fit and proper persons procedure · 2020. 9. 16. · are fit and proper persons both on recruitment...

FIT AND PROPER PERSONS PROCEDURE

Approved By: Policy and Guidelines Committee Date Approved: 20 May 2016 Trust Reference: B17/2016 Version: 3 Supersedes: 2 – May 2017 Author / Originator(s):

Kam Chouhan, Recruitment Services Manager Lesley Austick, PA to Director of Workforce and OD

Name of Responsible Committee/Individual: Hazel Wyton, Director of Workforce and OD

Latest Review Date 16 March 2018 – Policy and Guideline Committee Next Review Date: March 2021

CONTENTS

Section Page 1 Introduction and Overview 3 2 Policy Scope – Who the policy applies to and any Specific

Exemptions 4

3 Definitions and/or Abbreviations. 4 4 Roles - Who does what. 5 5 Compliance on Recruitment 5 6 Assessment of Continued Compliance 5 6 Education and Training 14 7 Process for Monitoring Compliance 14 8 Equality Impact Assessment 15 9 Supporting References, Evidence Base and Related Policies 15 10 Process for Version Control, Document Archiving and Review 15

Appendices: Page 1. Fit and Proper Person Requirements Key Documents 6 Form 1 Letter to Current Directors 7 Form 2 Personal File Checklist 11 Form 3 Amendment to Contract 13 Form 4 Pre-Employment Checklist 16 Form 5a Reference Request (Longer form) 19 Form 5b Reference Request (Shorter form) 23 Form 6 Director Offer Letter 27 Form 7 Annual Self Declaration 30 Form 8 UHL Actions to Comply with FPPR 31

REVIEW DATES AND DETAILS OF CHANGES MADE DURING THE REVIEW

September 2018- Form 4b has been updated and form 6b has been added into the policy March 2018 – V2 of this policy was completely re-written to take into account the changes to NHSLA requirements, UHL’s Divisional structure and the experiences of the UHL Policies & Guidelines Committee in implementing the Policy recommendations.

May 2017 – V1 of this Policy was written and subsequently revised in 2017.

September 2011 – V3, a further review was carried out to incorporate the changes made to the trust’s archiving system of policies and guidelines and also to include explicit guidance on ‘associated documents’ and ‘supporting references’ in line with the NHSLA standard Fit and Proper Persons Policy of 45 V3 Approved by Policy and Guideline Committee on 16 March 2018 Trust Ref: B17/2016 Next Review: March 2021

NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents

April 2012 – V4, following the NHSLA Assessment for Level 1, the Policy has been again reformatted to incorporate the changes suggested by the NHSLA Assessor

October 2016 – V5 following consultation the policy has been revised to change format requirements and strengthen governance.

KEY WORDS

Policy for Policies

Developing and Approving Policies

Policy and Guidelines Policy

P&G Policy

PAGL

Writing policies

Writing guidelines

Fit and Proper Persons Policy of 45 V3 Approved by Policy and Guideline Committee on 16 March 2018 Trust Ref: B17/2016 Next Review: March 2021


1 INTRODUCTION AND OVERVIEW

1.1 This Procedure has been developed in response to the requirements placed on NHS

providers, following the introduction of the Care Quality Commission’s new regulatory standards for the Fit and Proper Person Requirements (FPPR) of Directors.

1.2 Care Quality Commission- The regulations give the Care Quality Commission powers to assess whether Executive and Non-Executive Directors are fit to carry out their role and whether providers have in place adequate and appropriate arrangements to ensure directors are fit and proper persons both on recruitment and whilst in posts.

In undertaking inspections, the Commission will assess compliance as part of the well-led domain. Where compliance cannot be demonstrated this will be addressed as appropriate through the regulatory process.

1.3 All provider organisations must ensure that Director level appointments meet the ‘fit and proper persons test’ and the regulations place a duty on NHS providers not to appoint a person or allow a person to continue to be an Executive Director or Equivalent or Non-Executive Director under given circumstances.

1.4 This regulation has been integrated into the Care Quality Commission’s (CQC) registration requirements and falls within the remit of their regulatory and inspection approach.

1.5 Providers must not appoint to a qualifying post unless appointees are

• Of good character

• Have the necessary qualifications, skills and experience

• Are able to perform the work they are employed for after reasonable adjustments are made

• Can provide information as set out in the regulations

1.6 Guidance issued by the CQC emphasises the importance of the FPPR in ensuring the accountability of Directors of NHS bodies. NHS bodies have a responsibility to ensure the requirements are met with the CQC’s role being to monitor and assess how well this responsibility is discharged.

1.7 The FPPR lists categories of persons who are prohibited from holding office and for whom there is no discretion.

1.8 There is an expectation of senior leaders to set the tone and culture of the organisation that leads to staff adopting a caring and compassionate attitude. As such, in making Directors appointments, Boards should take account of the values of the organisation and the candidate’s fit to these values.

1.9 This procedure presents a summary of the standards Executive, Non-Executive Directors and other Board level posts must comply with Policy and the Trust’s process for monitoring and record keeping.

2 POLICY SCOPE

2.1 Where permanent or interim Directors are in place, assurance will be required from the providing organisation/agency that the FPPR Test has been completed in line with best practice. Where procured directly, contractual arrangements with the individual should include a stipulation to demonstrate they meet the requirements



3 DEFINITIONS AND ABBREVIATIONS- IN ALPHABETICAL ORDER

3.1 Good Character: The Care Quality Commissions definition of ‘good character’ is not the objective test of having no criminal convictions but rather a judgement to be made as to whether a person’s character is such that they can be relied upon to do the right thing under all circumstances.

4. ROLES – WHO IS RESPONSIBLE FOR WHAT

4.1 The Director of Workforce and Organisational Development 4.1.1 The Director of Workforce and Organisational Development shall be the named

Executive Lead and will ensure that:-

1. Through the Recruitment Services Department, pre-employment checks in line with NHS Employers pre-employment check standards, take place for each relevant appointment.

2. Evidence of compliance is maintained on the personal files of qualifying postholders. 3. An annual self-declaration process is undertaken for all relevant post holders. 4. An annual check of the Disqualified Director’s Register and credit and bankruptcy

register.

4.1.2 The Director of Workforce and Organisational Development, in conjunction with the Chairman and the Remuneration Committee will also ensure immediate action in the event of non-compliance of the procedure by any qualifying postholder.

4.2 Board Postholders within the Scope of the FPPR 4.2.1 Non-Executive Directors and Executive Directors and other Board level posts must

ensure they comply with and continue to comply with the requirement of the FPPR Test and this procedure.

5 RECRUITMENT COMPLIANCE

The Trust has in place robust processes with regard to recruitment to posts within the scope of this procedure. The recruitment checks undertaken are shown at Appendix 1, Form 4 of this Procedure.

5.1 Assessment for continued compliance

The Trust is responsible for ensuring the continued ‘fitness’ of those persons to whom the Requirements apply. This requirement will be fulfilled through a number of processes shown within Appendix 1 including:-

• An on-going duty to include in contracts of employment

• The completion of an annual self-declaration by individuals within the scope of the procedure.

• Annual checks for credit, bankruptcy and registration to be undertaken by the Personal Assistant to the Director of Workforce and Organisational Development

• Formal appraisal processes addressing the Fit and Proper Persons Requirements.

• Maintenance of the register of declared interests.

• Where a Board member no longer meets the Fit and Proper Persons Requirements, appropriate action will be taken.



6 EDUCATION AND TRAINING FOR THIS POLICY

6.1 Education and training on this policy will be provided to all members of the Recruitment Services and regular updates provided. Recruiting Managers attending the Recruitment and Selection Course will be provided with training on the principles outlined in this policy. This policy is also available on Insite.

7 PROCESS FOR MONITORING COMPLIANCE

7.1 The audit criteria for this policy and the process to be used for monitoring compliance are given in the table below: Element to be monitored

Lead Tool Frequency Reporting arrangements

Ensuring Pre-Employment Checks are carried out according to NHS Employment Check Standards

Resoucing Lead

Personal Files, TRAC and ESR

Weekly Regular Spot checks of personal files by Recruitment Team Managers/ Officers, Quarterly Audit carried out by Recruitment Manager/ Medical Staffing Managers. These will be logged

Compliance with the terms of this policy

Resourcing Lead

TRAC and ESR Question and answer sessions with recruitment services employees

1 mthly To Recruitment Services Manager

8 EQUALITY IMPACT ASSESSMENT

The Trust recognises the diversity of the local community it serves. Our aim therefore is to provide a safe environment free from discrimination and treat all individuals fairly with dignity and appropriately according to their needs.

As part of its development, this policy and its impact on equality have been reviewed and no detriment was identified.

9 SUPPORTING REFERENCES, EVIDENCE BASE AND RELATED POLICIES

This policy has been written in line with and in accordance with the requirements of the following:

Legislation

• Equality Act 2010

• Data Protection Act 1998

• Safeguarding Vulnerable Groups Act 2006 (as amended by the Protection of Freedoms Act 2012)

• The Rehabilitation of Offenders Act (1974) and Exemptions Order (1975)

National Guidance Fit and Proper Persons Policy of 45 V3 Approved by Policy and Guideline Committee on 16 March 2018 Trust Ref: B17/2016 Next Review: March 2021


• NHS Employment Check Standards July 2013

• CQC, (Care Quality Commission)

• DoH (Department of Health Policy)

• NHS Care Records Service

• Access to the NHS Care Record Service

• Information Governance and Assurance Standards

Key UHL Policies

• Registration Checks UHL Policy (B64/2008)

• Disclosure & Barring Service Policy (B2/2006)

• Recruitment & Selection Policy (B43/ 2009)

10 PROCESS FOR VERSION CONTROL, DOCUMENT ARCHIVING AND REVIEW

This document will be uploaded onto SharePoint and available for access by Staff

through INsite. It will be stored and archived through this system.



Appendix 1 University Hospitals of Leicester NHS Trust FPPR Key Documents

Form 1 Letter to Current Directors

Form 2 Personal File Checklist

Form 3 Amendment to Contract

Form 4a Pre-Employment Checklist for Directors and Director-Level Equivalents

Form 4b Pre-Employment Checklist for Non-Executive Directors (NED’s)

Form 5a Reference Request (longer form)

Form 5b Reference Request (shorter form)

Form 6 Director Offer Letter

Form 6a Director Offer Letter- Trust Group Holdings

Form 7 Annual Self Declaration

Form 8 UHL Actions to Comply with FPPR



Director of Workforce & Organisational Development Direct Dial: 0116 258 8903 Date: Dear Re: Regulation 5: Fit and Proper Persons Regulations: Directors There were discussions at the Trust Board regarding the Care Quality Commission (CQC) published guidance on the Fit and Proper Persons Regulations and duty of candour which came into force for all NHS providers from 27 November 2014. This requires a number of actions to be completed and/or noted:-

1. In order to comply with these Regulations, this letter confirms that with immediate effect you are to note that your contract is varied to include the attached wording at Appendix A.

2. In addition, the Trust requires you to complete, sign and return an Annual Declaration at

Appendix B and return this to Lesley Austick, PA to Director of Human Resources no later than xxxxx

Finally, Lesley is also reviewing your personal file to ensure that the information held is in line with the Fit and Proper Person Regulations. Lesley will be contacting within the next few weeks should you be required to submit further information.

If you have any queries, please let me know. Yours sincerely, Director of Human Resources

Form 1

Leicester Royal Infirmary Leicester

LE1 5WW



Amendment to Contracts of Employment for Director and Director Level Equivalents (For FPPR)

“Regulated Activities Regulations” means The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; Terms and Conditions of Service 1.0 It is a condition of your employment that you agree to the public disclosure of information by

the Trust in relation to your employment in accordance with the National Health Service Act 2006, and/or any other legal or regulatory requirements that may be imposed on the Trust from time to time. If information is requested to be withheld this should be discussed with the Director of Corporate and Legal Affairs and Chief Executive.

2.0 You are required to confirm in writing in such form as may be prescribed by the Trust, on appointment and thereafter on demand, that:

2.1 you are not subject to any restrictions which would prevent you from holding the office of Director of the Trust;

2.2 you do not fall within the definition of an “unfit person” as specified in Part 1 of Schedule 4 of the Regulated Activities Regulations which are:-

(a) the person is an undischarged bankrupt or a person whose estate has had sequestration awarded in respect of it and who has not been discharged;

(b) the person is the subject of a bankruptcy restrictions order or an interim bankruptcy restrictions order or an order to like effect made in Scotland or Northern Ireland;

(c) the person is a person to whom a moratorium period under a debt relief order applies under Part VIIA (debt relief orders) of the Insolvency Act 1986;

(d) the person has made a composition or arrangement with, or granted a trust deed for, creditors and not been discharged in respect of it;

(e) the person is included in the children’s barred list or the adults’ barred list maintained under section 2 of the Safeguarding Vulnerable Groups Act 2006, or in any corresponding list maintained under an equivalent enactment in force in Scotland or Northern Ireland;

(f) the person is prohibited from holding the relevant office or position, or in the case of an individual for carrying on the regulated activity, by or under any enactment.

2.3 you satisfy the requirements of Regulation 5(3) of the Regulated Activities Regulations; i.e. the Regulations provide that health service bodies must not appoint or have in place an individual as a Director or equivalent unless:-

Appendix A



(a) the individual is of good character;

(b) the individual has the qualifications, competence, skills and experience which are necessary for the relevant office or position or the work for which they are employed;

(c) the individual is able by reason of their health, after reasonable adjustments are made, of properly performing tasks which are intrinsic to the office or position for which they are appointed or to the work for which they are employed;

(d) the individual has not been responsible for, privy to, contributed to or facilitated any serious misconduct or mismanagement (whether unlawful or not) in the course of carrying on a regulated activity or providing a service elsewhere which, if provided in England, would be a regulated activity; and

(e) none of the grounds of unfitness specified in Part 1 of Schedule 4 apply to the individual

2.4 you do not meet any of the criteria for disqualification as a director outlined within the

Regulated Activities Regulations i.e.

(a) they are a member of the council of governors, or a governor or director of an NHS body or another NHS foundation trust;

(b) they are a member of the patients’ forum of an NHS organisation;

(c) they are the spouse, partner, parent or child of a member of the board of directors of the Trust;

(d) they are a member of a local authority’s scrutiny committee covering health matters;

(e) they have been adjudged bankrupt or their estate has been sequestrated and in either case they have not been discharged;

(f) they have made a composition or arrangement with, or granted a Trust deed for, their creditors and have not been discharged in respect of it;

(g) they have within the preceding five years been convicted in the British Islands of any offence, and a sentence of imprisonment (whether suspended or not) for a period of three months or more (without the option of a fine) was imposed;

(h) they are the subject of a disqualification order made under the Company Directors Disqualification Act 1986;

(i) in the case of a non-executive director, they are no longer a member of the public constituency;

(j) they are a person whose tenure of office as a Chair or as a member or director of a health service body has been terminated on the grounds that their appointment is not in the interests of the health service, for non-attendance at meetings, or for non-disclosure of a pecuniary interest;

(k) they have had their name removed, other than by reason of resignation, from any list prepared under sections 91, 106, 123 and 146 of the 2006 Act and have not subsequently had their name included on such a list;

(l) they have within the preceding two years been dismissed, otherwise than by reason of redundancy, from any paid employment with a health service body;



(m) in the case of a non-executive director they have refused to fulfil any training requirement established by the Board of Directors; or

(n) they have refused to sign and deliver to the Secretary a statement in the form required by the Board of Directors confirming acceptance of the code of conduct for directors.

2.5 You shall notify the Trust as soon as practicable (and in any event within 7 days) of any

change in circumstances that means the written confirmation that you have provided in accordance with clause 2.4 above is no longer accurate.

2.6 You warrant that you are entitled to work in the United Kingdom without any additional approvals and you will notify the Trust immediately if you cease to be so entitled during your employment.

2.7 Failure to provide the confirmation or notification described in clauses 2.1 to 2.6 (inclusive) above without good reason within 14 days of such confirmation or notification being requested or required shall be referred to the Chief Executive and Director of Workforce and Organisational Development and is likely to be considered a disciplinary matter.



Regulation 5: Fit and Proper Person Requirements Directors Annual Self Declaration Form

On 20 November 2014, the Care Quality Commission (CQC) published guidance on the Fit and Proper Person Requirements and duty of candour which came into force for all NHS providers from 27 November 2014. These regulations play a major part in ensuring the accountability of Directors of NHS bodies and outline the requirements for robust recruitment and employment processes for Board level appointments. As part of the assurance against the new Fit and Proper Person Requirements for existing Board members, you are required to answer the following questions, sign, date and return. Have you got the qualifications, competency, skills and experience which are necessary for your current position at UHL?

Yes No

Are you able by reason of health (after reasonable adjustments are made) of properly performing tasks which are intrinsic to the office or position for which you are employed at UHL?

Yes No

Have you been subject to a formal conduct or capability investigation in the preceding five years?

Yes No

Have you been responsible for, been privy to, contributed to or facilitated any serious misconduct or mismanagement (whether lawful or not) in the course of carrying on a regulated activity or providing a service elsewhere which, if provided in England would be a regulated activity?

Yes No

Have you been the subject of any of the following?:- • Undischarged bankrupt or a person whose estate has had sequestration awarded in

respect of it and who has not been discharged Yes No

• Subject of a bankruptcy restrictions order or an interim bankruptcy restrictions order or an order to like effect made in Scotland or Northern Ireland

Yes No

• A moratorium period under a debt relief order applies under Part V11A (debt relief orders) of the Insolvency Act 1986

Yes No

• A composition or arrangement with, or granted a trust deed for, creditors and not been discharged in respect of it

Yes No

• Included in the children’s barred list or the adults’ barred list maintained under section 2 of the Safeguarding Vulnerable Groups Act 2006, or in any corresponding list maintained under an equivalent enactment in force in Scotland or Northern Ireland

Yes No

• Prohibited from holding the relevant office or position, or in the case of an individual from carrying on the regulated activity, by or under any enactment

Yes No

Have you been convicted in the United Kingdom of any offence or been convicted elsewhere of any offence which, if committed in any part of the United Kingdom, would constitute an offence?

Yes No

Have you been erased, removed or struck-off a register of professionals maintained by a regulator of health care or social work professionals? Yes No

Have you ever been found not to be a fit and proper person for the purposes of Regulation 5? Yes No I hereby agree that the above is accurate Name Position

Signed Date

Countersigned by Chief Executive (or Chairman for the Chief Executive)

Appendix B



Name Position

Signed Date

Please return this form to Lesley Austick, PA to Director of Workforce and Organisational Development, Level 3, Chief Executive’s Department Leicester Royal Infirmary, Leicester. LE1 5WW

Regulation 5: Fit and Proper Person Requirements

Directors and Non-Executive Directors – Information Requirements: Personal File Checklist

Name

Post Title

Evidence supplied of Right to Work in the UK Yes No Proof of Identity including a recent photograph Yes No Enhanced/Standard DBS check and/or barring information under the Safeguarding Vulnerable Groups Act 2006

Yes No

Satisfactory evidence of conduct in previous employment concerned with the provision of services relating to health or social care, or children of vulnerable adults

Yes No

Where a person has been previously employed in a position whose duties involved work with children or vulnerable adults, satisfactory verification, so far as reasonably practicable, of the reason why that person’s employment in that position ended

Yes No

In so far as it is reasonably practicable to obtain, satisfactory documentary evidence of any qualification relevant to the duties for which the person is employed or appointed to perform

Yes No

A full employment history, together with a satisfactory written explanation of any gaps in employment

Yes No

Two detailed references have been received (one from the most recent employer) Include FPPT Declaration Form for each referee

Yes No

Satisfactory information about any physical or mental health conditions which are relevant to the person’s capability, after reasonable adjustments are made, to properly perform tasks which are intrinsic to their employment or appointment for the purposes of the regulated activity

Yes No

Such other information as is required to be kept by the service provider under any enactment which is relevant to that individual

Yes No

Other Supporting Information Annual Self-Declaration Form Yes No Model DBS Declaration A or B Yes No Declaration of Interest Form/Declaration of Financial Interest (From Corporate and Legal Affairs submission) Yes No

Appraisal Documentation Yes No Membership Body and Number (if applicable) Yes No Signed Contract of Employment Yes No Job Description on file Yes No

Information Requirements completed by: Name Position

Signed Date

Fit and Proper Person Regulation Compliance Confirmed :

Form 2



Name Position

Signed Date

Amendment to Contracts of Employment for Director and Director Level

Equivalents (For FPPR) “Regulated Activities Regulations” means The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; Terms and Conditions of Service 1.0 It is a condition of your employment that you agree to the public disclosure of information by

the Trust in relation to your employment in accordance with the National Health Service Act 2006, and/or any other legal or regulatory requirements that may be imposed on the Trust from time to time. If information is requested to be withheld this should be discussed with the Director of Corporate and Legal Affairs and Chief Executive.

2.0 You are required to confirm in writing in such form as may be prescribed by the Trust, on appointment and thereafter on demand, that:

2.1 you are not subject to any restrictions which would prevent you from holding the office of Director of the Trust;

2.2 you do not fall within the definition of an “unfit person” as specified in Part 1 of Schedule 4 of the Regulated Activities Regulations which are:-

(a) the person is an undischarged bankrupt or a person whose estate has had sequestration awarded in respect of it and who has not been discharged;

(b) the person is the subject of a bankruptcy restrictions order or an interim bankruptcy restrictions order or an order to like effect made in Scotland or Northern Ireland;

(c) the person is a person to whom a moratorium period under a debt relief order applies under Part VIIA (debt relief orders) of the Insolvency Act 1986;

(d) the person has made a composition or arrangement with, or granted a trust deed for, creditors and not been discharged in respect of it;


Form 3




2.3 you satisfy the requirements of Regulation 5(3) of the Regulated Activities Regulations; i.e. the Regulations provide that health service bodies must not appoint or have in place an individual as a Director or equivalent unless:-

(a) the individual is of good character;




(e) none of the grounds of unfitness specified in Part 1 of Schedule 4 apply to the individual

2.4 you do not meet any of the criteria for disqualification as a director outlined within the

Regulated Activities Regulations i.e.

(a) they are a member of the council of governors, or a governor or director of an NHS body or another NHS foundation trust;

(b) they are a member of the patients’ forum of an NHS organisation;

(c) they are the spouse, partner, parent or child of a member of the board of directors of the Trust;

(d) they are a member of a local authority’s scrutiny committee covering health matters;

(e) they have been adjudged bankrupt or their estate has been sequestrated and in either case they have not been discharged;

(f) they have made a composition or arrangement with, or granted a Trust deed for, their creditors and have not been discharged in respect of it;

(g) they have within the preceding five years been convicted in the British Islands of any offence, and a sentence of imprisonment (whether suspended or not) for a period of three months or more (without the option of a fine) was imposed;

(h) they are the subject of a disqualification order made under the Company Directors Disqualification Act 1986;

(i) in the case of a non-executive director, they are no longer a member of the public constituency;

(j) they are a person whose tenure of office as a Chair or as a member or director of a health service body has been terminated on the grounds that their appointment is not in the interests of the health service, for non-attendance at meetings, or for non-disclosure of a pecuniary interest;



(k) they have had their name removed, other than by reason of resignation, from any list prepared under sections 91, 106, 123 and 146 of the 2006 Act and have not subsequently had their name included on such a list;

(l) they have within the preceding two years been dismissed, otherwise than by reason of redundancy, from any paid employment with a health service body;

(m) in the case of a non-executive director they have refused to fulfil any training requirement established by the Board of Directors; or

(n) they have refused to sign and deliver to the Secretary a statement in the form required by the Board of Directors confirming acceptance of the code of conduct for directors.

2.5 You shall notify the Trust as soon as practicable (and in any event within 7 days) of any

change in circumstances that means the written confirmation that you have provided in accordance with clause 2.4 above is no longer accurate.

2.6 You warrant that you are entitled to work in the United Kingdom without any additional approvals and you will notify the Trust immediately if you cease to be so entitled during your employment.

2.7 Failure to provide the confirmation or notification described in clauses 2.1 to 2.6 (inclusive) above without good reason within 14 days of such confirmation or notification being requested or required shall be referred to the Chief Executive and Director of Workforce and Organisational Development and is likely to be considered a disciplinary matter.



PRE-EMPLOYMENT CHECKLIST FOR DIRECTOR AND DIRECTOR-LEVEL EQUIVALENTS

Name: Post Title:

Address: Contact Details

Email:

Telephone:

Standard Date

Evidence Received/Comment

Photocopy taken and Placed on Personal File

Yes/No

SARS Check 1 (shortlisting)

Job Description & Specification

Application Form & Interview Notes/Scoring Include Evidence of Values Based Questions

Mandatory Questions - Signed

Declaration Form Received A or B

Conditional Offer Letter Sent – Include paragraph for FPPT

Completed Self-Declaration Non Confidential OH Form – Action any Concerns

Form 4a



Confidential Immunisation and Screening Form Sent to OH

IAT Request from Previous NHS Trust

DBS Processed – Enhanced with adults and children’s barred lists

2 References Requested – Include FPPT Declaration Form

Gaps in Employment History Form Completed

Conditional Signed Offer Letter Received

Satisfactory Clearance Received

Evidence of Right to Work in the UK

Verification of Identity ( photograph included)

Confirmation of DBS Certificate Number and Satisfactory Clearance

Detailed review of Full Employment History Taken to Include Review of External Information as Necessary

Comments:

Minimum of Two References to Cover Satisfactory Evidence of Conduct/Performance/Capability

Must Include: Reason for Leaving Most Recent Position and completed paragraph for FPPT

Satisfactory Original Documentary Evidence of Qualifications Checks

Membership Body and Number:

Occupational Health Clearance including any Reasonable Adjustments Required



Approval of Absences Declared in Non-Confidential Health Questionnaire

Satisfactory Search of Disqualified Director’s Register

http://wck2.companieshouse.gov.uk//dirsec

Satisfactory Search of Insolvency and Bankruptcy Registerhttps://www.insolvencydirect.bis.gov.uk/eiir/

Self-Declarations of Fitness including Explanation of Past Conduct/Character Issues

Corporate/ Local Induction

Recruitment Services File Sign-off Name: Signature:

Date File Sent to Chief Executive:

Fit and Proper Person Regulation Compliance Confirmed

Name: Signature

Signed Copy of Contract Returned and Placed on File



http://wck2.companieshouse.gov.uk/dirsec

https://www.insolvencydirect.bis.gov.uk/eiir/

PRE-EMPLOYMENT CHECKLIST FOR NON-EXECUTIVE DIRECTORS (NED’s)

Name: Post Title:

Address: Contact Details

Email:

Telephone:

Standard Responsible Individual

Date Evidence Received/Comment

Photocopy taken and Placed on Personal File.

Yes/No

Job Description & Specification NHS Improvement

Application Form & Interview Notes/Scoring Include Evidence of Values Based Questions

NHS Improvement

Declaration Form Received A or B UHL

Conditional Offer Letter Sent – Include paragraph for FPPT

UHL

Form 4b



Completed Self-Declaration Non Confidential OH Form – Action any Concerns

UHL

Confidential Immunisation and Screening Form Sent to OH

UHL

IAT Request from Previous NHS Trust (if applicable) UHL

DBS Processed – Standard UHL

2 References Requested – Include FPPT Declaration Form

NHS Improvement

Gaps in Employment History Form Completed UHL

Conditional Signed Offer Letter Received NHS Improvement

Satisfactory Clearance Received

Evidence of Right to Work in the UK UHL

Verification of Identity ( photograph included) UHL

Confirmation of DBS Certificate Number and Satisfactory Clearance printed for file

UHL

Detailed review of Full Employment History Taken to Include Review of External Information as Necessary

Comments:

NHS Improvement

Minimum of Two References to Cover Satisfactory Evidence of Conduct/Performance/Capability

Must Include: Reason for Leaving Most Recent Position and completed paragraph for FPPT

NHS Improvement

Satisfactory Original Documentary Evidence of Qualifications Checks

Membership Body and Number:

UHL



Occupational Health Clearance including any Reasonable Adjustments Required

UHL

Approval of Absences Declared in Non-Confidential Health Questionnaire

UHL

Satisfactory Search of Disqualified Director’s Register

http://wck2.companieshouse.gov.uk//dirsec

NHS improvement

Satisfactory Search of Insolvency and Bankruptcy Registerhttps://www.insolvencydirect.bis.gov.uk/eiir/

NHS Improvement

Self-Declarations of Fitness including Explanation of Past Conduct/Character Issues

UHL

Corporate /Local Induction UHL

Expenses/ IPAD UHL

Recruitment Services File Sign-off Name: Signature:

Date File Sent to Chief Executive:

Fit and Proper Person Regulation Compliance Confirmed

Name: Signature

Signed Copy of Contract Returned and Placed on File



http://wck2.companieshouse.gov.uk/dirsec



REFERENCE REQUEST FORM – DIRECTOR LEVEL EQUIVALENT

References are non-confidential and may be disclosed to the applicant upon request. URGENT – Please note that we are unable to make a formal offer of employment to this candidate until satisfactory references have been received. References are requested to be returned in 2 working days. PLEASE EMAIL/RETURN TO: Name: Address: Tel. No:- Email Address:- DATE: REFEREE DETAILS: Name: Address: CANDIDATE DETAILS: Name: Post applied for:

IF VERBAL REFERENCE: Please read ** to referee if taking verbal reference Name of person obtaining verbal reference: Tel: Email: Date verbal reference taken: Signature:

** The above named has applied for the above post and has given your name as a referee. I would be obliged if you would complete the following questionnaire so that we may assess the applicant’s suitability for this post. I will note your comments in each section on the level of performance then put a cross ( X ) in the appropriate box. I will continue your comments on a separate sheet if

Form 5a



necessary. If you are a friend or colleague please advise me and I will note your comments on a separate sheet at the end of our conversation. At the end of the conversation, I may ask you to review and sign that the notes I have taken down are accurate 1. PLEASE COMMENT ON THE CANDIDATE’S :-

2. PROFESSIONAL SKILLS/ABILITIES

Please give your impression of the candidate’s professional abilities and an indication of their personality and interpersonal relationships, reliability, initiative, quality of work and any other information which you consider relevant.

3. Please indicate the number of occasions and days absent in the previous

two years Of these, please indicate the number of occasions and days absent in the last 12 months


two years as a result of sickness


12 months as a result of sickness

6. Please indicate this person’s level of reliability and punctuality

Comment: V Good Good Acceptable Poor 8. Are there any outstanding disciplinary warnings/unresolved issues against this person?

Occasions Days



Comment: Yes No 9. Do you know of any reason why the candidate should not be permitted to work in a hospital? Comment: Yes No 10. Would you re-employ this person at the same or higher level? Same Yes No Higher Yes No The Health and Social Care Act 2008 (Regulated Activities) Regulations 2008 state that the Trust must not appoint or have in place an individual as a director, or who performs the functions of or equivalent or similar functions of a director if they do not fulfil the following requirements: To your knowledge do you know if:- (a) the individual is of good character;




None of the grounds of unfitness specified in Part 1 of Schedule 4 apply to the individual. The grounds of unfitness specified in Part 1 of Schedule 4 to the Regulated Activities Regulations are: (a) the person is an undischarged bankrupt or a person whose estate has had sequestration

awarded in respect of it and who has not been discharged; (b) the person is the subject of a bankruptcy restrictions order or an interim bankruptcy

restrictions order or an order to like effect made in Scotland or Northern Ireland; (c) the person is a person to whom a moratorium period under a debt relief order applies under

Part VIIA (debt relief orders) of the Insolvency Act 1986; (d) the person has made a composition or arrangement with, or granted a trust deed for,

creditors and not been discharged in respect of it;





If Yes, please give details . START DATE: END DATE: (if applicable) JOB TITLE: HOW LONG KNOWN: ANY FURTHER COMMENTS:- Please complete in BLOCK CAPITALS SIGNATURE: NAME: POSITION: TELEPHONE NO: ORGANISATION: EMAIL ADDRESS: RELATIONSHIP TO CANDIDATE:

Yes No

Please confirm the dates that this person was employed in your organisation and in what capacity. Please indicate how long you have known this person in this capacity and for how long you have been in a position to assess them



REFERENCE REQUEST FORM – DIRECTOR LEVEL EQUIVALENT

References are non-confidential and may be disclosed to the applicant upon request. URGENT – Please note that we are unable to make a formal offer of employment to this candidate until satisfactory references have been received. References are requested to be returned in 2 working days. PLEASE EMAIL/RETURN TO: Name: Address: Tel. No:- Email Address:- DATE: REFEREE DETAILS: Name: Address: CANDIDATE DETAILS: Name: Post applied for:

IF VERBAL REFERENCE: Please read ** to referee if taking verbal reference Name of person obtaining verbal reference: Tel: Email: Date verbal reference taken: Signature:

** The above named has applied for the above post and has given your name as a referee. I would be obliged if you would complete the following questionnaire so that we may assess the applicant’s suitability for this post. I will note your comments in each section on the level of performance then put a cross ( X ) in the appropriate box. I will continue your comments on a separate sheet if necessary. If you are a friend or colleague please advise me and I will note your comments on a separate sheet at the end of our conversation. At the end of the conversation, I may ask you to review and sign that the notes I have taken down are accurate 7. PLEASE COMMENT ON THE CANDIDATE’S :-

8. PROFESSIONAL SKILLS/ABILITIES

Please give your impression of the candidate’s professional abilities and an indication of their personality and interpersonal relationships, reliability, initiative, quality of work and any other information which you consider relevant.




two years Of these, please indicate the number of occasions and days absent in the last 12 months


two years as a result of sickness


12 months as a result of sickness

12. Please indicate this person’s level of reliability and punctuality

Comment: V Good Good Acceptable Poor 8. Are there any outstanding disciplinary warnings/unresolved issues against this person? Comment: Yes No 9. Do you know of any reason why the candidate should not be permitted to work in a hospital? Comment: Yes No 10. Would you re-employ this person at the same or higher level? Same Yes No Higher Yes No The Health and Social Care Act 2008 (Regulated Activities) Regulations 2008 state that the Trust must not appoint or have in place an individual as a director, or who performs the functions of or equivalent or similar functions of a director if they do not fulfil the following requirements:

Occasions Days



To your knowledge do you know if:- (a) the individual is of good character;




None of the grounds of unfitness specified in Part 1 of Schedule 4 apply to the individual.The grounds of unfitness specified in Part 1 of Schedule 4 to the Regulated Activities Regulations are: (a) the person is an undischarged bankrupt or a person whose estate has had sequestration

awarded in respect of it and who has not been discharged; (b) the person is the subject of a bankruptcy restrictions order or an interim bankruptcy

restrictions order or an order to like effect made in Scotland or Northern Ireland; (c) the person is a person to whom a moratorium period under a debt relief order applies under

Part VIIA (debt relief orders) of the Insolvency Act 1986; (d) the person has made a composition or arrangement with, or granted a trust deed for,

creditors and not been discharged in respect of it; (e) the person is included in the children’s barred list or the adults’ barred list maintained under

section 2 of the Safeguarding Vulnerable Groups Act 2006, or in any corresponding list maintained under an equivalent enactment in force in Scotland or Northern Ireland;


If Yes, please give details . START DATE: END DATE: (if applicable) JOB TITLE: HOW LONG KNOWN: ANY FURTHER COMMENTS:- Please complete in BLOCK CAPITALS SIGNATURE:

Yes No

Please confirm the dates that this person was employed in your organisation and in what capacity. Please indicate how long you have known this person in this capacity and for how long you have been in a position to assess them



NAME: POSITION: TELEPHONE NO: ORGANISATION: EMAIL ADDRESS: RELATIONSHIP TO CANDIDATE:

Director of Workforce & Organisational Development Direct Dial: 0116 258 8903 Direct Fax: 0116 258 8943 Email: [email protected] Date: PERSONAL AND CONFIDENTIAL XX Dear XX DIRECTOR OFFER OF APPOINTMENT- XX UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST I am delighted to be writing to you to confirm the offer of the post of xxxxxxx at University Hospitals of Leicester NHS Trust. Clearly, this is a crucial appointment for UHL and we are looking forward to you joining us in this role. This offer is subject to:-

• Satisfactory Health Clearance

• Satisfactory searches of the insolvency and bankruptcy register

• Search of disqualified directors register

• Professional Qualification Check

• Verification of Identify Check

• Right to Work in the UK Check

• Satisfactory References

• Satisfactory Disclosure and Barring (formerly CRB) check

The post is subject to the Fit and Proper Person Requirements and duty of candour which came into force for all NHS providers from 27 November 2014. These regulations play a major part in ensuring the accountability of Directors of NHS bodies and outline the requirements for robust recruitment and employment processes for Board level appointments. In order to process the formalities, please can you complete and return the attached non confidential health questionnaire to myself by return).

Leicester Royal Infirmay Leicester

LE1 5WW

Tel: 0300 303 1573 Fax: 0116 258 7565

Minicom: 0116 287 9852

Form 6



mailto:[email protected]

Thank you for confirming that you will start with us on xxxx. (Name), the Director of Workforce and OD will be in touch to discuss the content of your induction programme and to ensure appropriate support is in place for your initial period with us. As we discussed, I confirm your starting salary will be £xxxx per annum. (We also agreed a relocation package of up to £8,000 to assist your move to Leicester. I have attached the Trust’s Relocation Policy, please can you liaise with the Director of Workforce and Organisational Development in relation to the relocation package). In relation to your other terms and conditions of service, your annual leave entitlement is 32 days and your annual leave year will run from your date of commencement. Your continuous NHS start date remains unchanged. The period of notice which you will be entitled to receive will be six months and the period of notice you will be required to give is six months. Your hours of work will be a minimum of 37.5 per week and you will also participate in the Directors On-Call Rota which requires, out of hours working/availability and some weekend working for which time back will be given. I would be grateful if you could confirm your acceptance of the post, by signing and returning one copy of this letter. I will ensure that your contract of employment is sent to you as soon as your employment checks are complete. May I take this opportunity to congratulate you on your appointment. We have many exciting challenges and opportunities at UHL and I look forward to working with you over the coming years to take UHL forward. Kind regards. Yours sincerely, John Adler Chief Executive c.c. Director of Workforce and OD Fit and Proper Persons Policy of 45 V3 Approved by Policy and Guideline Committee on 16 March 2018 Trust Ref: B17/2016 Next Review: March 2021


DATE PRIVATE & CONFIDENTIAL ADDRESS Dear XX OFFER OF APPOINTMENT – EXECUTIVE DIRECTOR TRUST GROUP HOLDINGS I am delighted to be writing to confirm the offer of appointment as an Executive Director of Trust Group Holdings. Clearly, this is a crucial appointment and we are looking forward to you joining us. This offer is subject to:-

• Satisfactory Health Clearance

• Satisfactory searches of the insolvency and bankruptcy register

• Search of disqualified directors register

• Professional Qualification Check

• Verification of Identify Check

• Right to Work in the UK Check

• Satisfactory References

• Satisfactory Disclosure and Barring (formerly CRB) check

As we discussed, (include pay details or allocated hours of expected work). In relation to your other terms and conditions of service, your annual leave entitlement is XX days. The period of notice which you will be entitled to receive for this post will be six months and the period of notice you will be required to give is six months. Your hours of work will be a minimum of 37.5 per week and you will also participate in the Directors On-Call Rota, which requires, out of hours working/availability and some weekend working for which time back will be given. I have attached a draft contract for

Form 6a



your information which will be finalised once all your employment checks are complete and we have a start date. In order to comply with recent guidance on fair pay in the public sector, you will be subject to a requirement to meet agreed performance objectives. These objectives will be based on delivery of core objectives, agreed in advance. Accordingly, 10% of your base salary will be put at risk each month, pending an annual review of your performance against the objectives set. Should you not have met the agreed performance objectives, your base salary may be reduced by an appropriate amount in the 12 month period following the performance review. Should you have met the agreed performance objectives, you will qualify to ‘earn-back’ the 10% of your base salary put at risk each month and it will not be recouped. The post is subject to the Fit and Proper Person Requirements and duty of candour which came into force for all NHS providers from 27 November 2014. These regulations play a major part in ensuring the accountability of Directors of NHS bodies and outline the requirements for robust recruitment and employment processes for Board level appointments. I would be grateful if you could confirm your acceptance of the post, by signing and returning one copy of this letter to Michelle Robinson, HR Business Partner, Level 3, Knighton Street Offices, Leicester Royal Infirmary, Infirmary Square, Leicester. LE1 5WW. May I take this opportunity to congratulate you on your appointment. We have many exciting challenges and opportunities at Trust Group Holdings and I look forward to working with you over the coming years to take TGH forward. Yours sincerely Andrew Johnson Chairman ______________________________________________________ PLEASE DO NOT DETACH I confirm my acceptance of the above offer of appointment SIGNED:____________________________________DATE:_______________________ PRINT NAME:____________________________________________________________



To: Director of Workforce and OD University Hospitals of Leicester NHS Trust Chief Executive’s Department Leicester Royal Infirmary Leicester LE1 5WW Dear Post of: xx I write to confirm my acceptance of the post outlined in your letter dated xxx Signed

Date



Regulation 5: Fit and Proper Person Requirements Directors Self Declaration Form

On 20 November 2014, the Care Quality Commission (CQC) published guidance on the Fit and Proper Person Requirements and duty of candour which came into force for all NHS providers from 27 November 2014. These regulations play a major part in ensuring the accountability of Directors of NHS bodies and outline the requirements for robust recruitment and employment processes for Board level appointments. As part of the assurance against the new Fit and Proper Person Requirements Board members are required to answer the following questions, sign, date and return.

Have you got the qualifications, competency, skills and experience which are necessary for your current position at UHL?

Yes No

Are you able by reason of health (after reasonable adjustments are made) of properly performing tasks which are intrinsic to the office or position for which you are employed at UHL?

Yes No

Have you been subject to a formal conduct or capability investigation in the preceding five years?

Yes No

Have you been responsible for, been privy to, contributed to or facilitated any serious misconduct or mismanagement (whether lawful or not) in the course of carrying on a regulated activity or providing a service elsewhere which, if provided in England would be a regulated activity?

Yes No

Have you been the subject of any of the following?:- • Undischarged bankrupt or a person whose estate has had sequestration

awarded in respect of it and who has not been discharged Yes No

• Subject of a bankruptcy restrictions order or an interim bankruptcy restrictions order or an order to like effect made in Scotland or Northern Ireland

Yes No

• A moratorium period under a debt relief order applies under Part V11A (debt relief orders) of the Insolvency Act 1986

Yes No

• A composition or arrangement with, or granted a trust deed for, creditors and not been discharged in respect of it

Yes No

• Included in the children’s barred list or the adults’ barred list maintained under section 2 of the Safeguarding Vulnerable Groups Act 2006, or in any corresponding list maintained under an equivalent enactment in force in Scotland or Northern Ireland

Yes No

• Prohibited from holding the relevant office or position, or in the case of an individual from carrying on the regulated activity, by or under any enactment

Yes No

Have you been convicted in the United Kingdom of any offence or been convicted elsewhere of any offence which, if committed in any part of the United Kingdom, would constitute an offence?

Yes No

Have you been erased, removed or struck-off a register of professionals maintained by a regulator of health care or social work professionals? Yes No

Have you ever been found not to be a fit and proper person for the purposes of Regulation 5 (future appointments)? Yes No

I hereby agree that the above is accurate

Form 7



Name Position

Signed Date

Countersigned by Chief Executive (or Chairman for the Chief Executive) Name Position

Signed Date

Please return this form to Lesley Austick, PA to Director of Workforce and Organisational Development, Level 3, Chief Executive’s Department Leicester Royal Infirmary, Leicester. LE1 5WW



Form 8

University Hospitals of Leicester NHS Trust

Compliance with Regulation 5 – Fit and Proper Persons Test

(*) indicates newly-introduced requirements to address the regulations:

Standard Assurance Evidence

1. The Individual is of Good Character

1.1 Providers should make every effort to ensure that all available information is sought to confirm that the individual is of good character as defined in Schedule 4, Part 2 of the regulations.

(Sch.4, Part 2: Whether the person has been convicted in the United Kingdom of any offence or been convicted elsewhere of any offence which, if committed in any part of the United Kingdom, would constitute an offence. Whether the person has been erased, removed or struck-off a register of professionals maintained by a regulator of health care or social work professionals.)

Employment checks are undertaken in accordance with NHS Employers pre-employment check standards and include:

Two references, one of which must be most recent employer

qualification and professional registration checks

right to work checks

identity checks

occupational health clearance

DBS checks ( An enhanced DBS check with adult and childrens barred list check)

In addition, Trust also carry out:

Declarations of fitness by candidates

Search of insolvency and bankruptcy register (*)

Search of disqualified directors register (*)

Fit and Proper Person Pre Employment Checklist (*)


1.2 Where a provider deems the individual suitable despite not meeting the characteristics outlined in Schedule 4, Part 2 of these regulations, the reasons should be recorded and information about the decision should be made available to those that need to be aware.

This would be the subject of debate at the Appointments Committee and subsequently at the Remuneration Committee. The minutes should record such decisions.

The Chair will take advice from internal and external advisors as appropriate.

Appointment Committee notes

/Minutes of Remuneration Committee meetings.

2. Individual has the qualifications, competence, skills and experience




2.1 Where specific qualifications are deemed by the provider as necessary for a role, the provider must make this clear and should only employ those individuals that meet the required specification, including any requirements to be registered with a professional regulator.

This requirement is included within the job Person Specification for relevant posts and is checked as part of the pre-employment checks.

Person Specification

Fit and Proper Persons Recruitment Pre Employment Checklist (*)


2.2 The provider should have appropriate processes for assessing and checking that the individual holds the required qualifications and has the competence, skills and experience required, (which may include appropriate communication and leaderships skills and a caring and compassionate nature), to undertake the role; these should be followed in all cases and relevant records kept.

Employment checks include a candidate’s qualifications and employment references.

The recruitment process also includes qualitative assessment and values-based questions.

The Appointment Committee assessment is undertaken in line with the Person Specification for the role

Recruitment policy and procedure

Values-based questions





2.3 The provider may consider that an individual can be appointed to a role based on their qualifications, skills and experience with the expectation that they will develop specific competence to undertake the role within a specified timeframe.

Any such decision would be discussed by the Appointments Committee and should be minuted. Any subsequent actions required would be subject to follow-up as part of on-going review and appraisal.


Appraisal Paperwork

3. Health

3.1 When appointing relevant individuals the provider has processes for considering a person’s physical and mental health in line with the requirements of the role.

All post-holders are subject to clearance by occupational health as part of the pre-employment process.

Occupational health clearance as part of Recruitment pre-employment checks

3.2 Wherever possible, reasonable adjustments are made in order that an individual can carry out the role.

Pre Employment Health Screening would take place and process re adjustments is already included in the Trust’s Sickness Absence Policy.

Appropriate Occupational Health Report and Sickness Absence Policy

4. Check of Persons Prevented from holding office




4.1 The provider has processes in place to assure itself that the individual has not been at any time responsible for, privy to, contributed to, or facilitated, any serious misconduct or mismanagement in the carrying on of a regulated activity; this includes investigating any allegation of such potential behaviour. Where the individual is professionally qualified, it may include fitness to practise proceedings and professional disciplinary cases.

(“Responsible for, contributed to or facilitated” means that there is evidence that a person has intentionally or through neglect behaved in a manner which would be considered to be or would have led to serious misconduct or mismanagement.

“Privy to” means that there is evidence that a person was aware of serious misconduct or mismanagement but did not take the appropriate action to ensure it was addressed.

“Serious misconduct or mismanagement” means behaviour that would constitute a breach of any legislation/enactment CQC deems relevant to meeting these regulations or their component parts.”)

This has been incorporated as a specific declaration as part of the pre-employment process.

It is also incorporated into a revised reference request template for all director and director-equivalent posts.

References received that form part of the Fit and Proper Persons Pre-Employment Checklist (*)




4.2 Only individuals who will be acting in a role that falls within the definition of a “regulated activity” as defined by the Safeguarding Vulnerable Groups Act 2006 will be eligible for a check by the Disclosure and Barring Service (DBS).

As part of the recruitment/appointment process, providers should establish whether the individual is on a relevant barring list.

DBS checks are undertaken for those posts which fall within the definition of a “regulated activity” or which are otherwise eligible for such a check to be undertaken.

Eligibility for DBS checks will be assessed for each vacancy arising.

DBS Policy

DBS checks for eligible post-holders

4.3 The person is the subject of a bankruptcy restrictions order or an interim bankruptcy restrictions order or an order to like effect made in Scotland or Northern Ireland; The person is a person to whom a moratorium period under a debt relief order applies under Part VIIA (debt relief orders) of the Insolvency Act 1986(40); The person has made a composition or arrangement with, or granted a trust deed for, creditors and not been discharged in respect of it;

Search undertaken of Insolvency and Bankruptcy Register

Pre-Employment Checks

Screen print for Personal file

Fit and Proper Persons Recruitment Pre-Employment Checklist (*)




4.4 The person is prohibited from holding the relevant office or position, or in the case of an individual from carrying on the regulated activity, by or under any enactment;

Search undertaken of Disqualified DirectorsRegister – Company’s House

Pre-Employment Checks

Screen print for Personal file

Fit and Proper Persons Recruitment Pre-Employment Checklist (*)

5. On-going Checks

5.1 The fitness of directors is regularly reviewed by the provider to ensure that they remain fit for the role they are in; the provider should determine how often fitness must be reviewed based on the assessed risk to business delivery and/or the service users posed by the individual and/or role.

Post-holders undertake annual declarations of fitness to continue in post.

Checks of insolvency and bankruptcy register and register of disqualified directors to be undertaken each year as part of the declaration process. (*)

Annual Declaration (*)

5.2 The provider has arrangements in place to respond to concerns about a person’s fitness after they are appointed to a role, identified by itself or others, and these are adhered to.

The Disciplinary and Capability policies provide these arrangements, and revised contracts (for EDs and director-equivalents) and the Annual Declaration incorporate maintenance of fitness as a requirement (*)

Disciplinary and Capability Policies

Contracts of Employment




5.3 The provider investigates, in a timely manner, any concerns about a person’s fitness or ability to carry out their duties, and where concerns are substantiated, proportionate, timely action is taken; the provider must demonstrate due diligence in all actions.

This will be undertaken if concerns are identified and revised contracts provide for termination if individuals fail to meet necessary standards.

Disciplinary and Capability Policies

Revised employment contracts

5.4 Where a person’s fitness to carry out their role is being investigated, appropriate interim measures may be required to minimise any risk to service users.

This would be reviewed when concerns are identified. Disciplinary and Capabilities policies.

5.5 The provider informs others as appropriate about concerns/findings relating to a person’s fitness; for example, professional regulators, CQC and other relevant bodies, and supports any related enquiries/investigations carried out by others.

This would be completed if any concerns were identified. Referrals made to other agencies.

Component

(*) indicates newly-introduced requirements to address the regulations

In the table above, unless the contrary is stated or the context otherwise requires, “ED” means executive directors and director-equivalent

