Fit and Proper Person Test Policy

Introduction

The Fit and Proper Persons Regulations (FPPR) were introduced in response to concerns raised following investigations into Mid Staffordshire NHS Foundation Trust and Winterbourne View Hospital.

The Regulations stipulate that NHS organisations must not appoint or have in place directors unless they meet the FPPR standards. To assess individuals, the Fit and Proper Person Test (FPPT) was introduced in 2014 via Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

In 2019, Tom Kark KC made recommendations to revise the existing FPPT assessment process in his review into its scope, operation and purpose. In response to these recommendations, NHS England (NHSE) published a Fit and Proper Person Test Framework in August 2023 to support NHS organisations’ compliance with the regulations and ensure directors satisfy the regulatory requirements. The Framework also takes into account the requirements of the Care Quality Commission (CQC) in relation to directors being fit and proper for their roles.

The Framework is not retrospective and is intended to be used from 30 September 2023 onwards with full implementation by 31 March 2024.

By way of a formal assessment, Integrated Care Boards are required to demonstrate compliance with the FPPR on an annual basis.        

Purpose

The purpose of this policy is to outline how NHS Hertfordshire and West Essex Integrated Care Board (hereafter referred to as the ICB) will apply the FPPT assessment process to ensure it complies with FPPR requirements.

Current Fit and Proper Person Regulations

The FPPT applies to directors and those performing the functions of, or functions equivalent or similar to the functions of, a director in all NHS organisations registered with the CQC. ICBs and NHSE are within the scope of the Framework.

The FPPR requires that:

1. The individual is of good character.
2. The individual has the necessary qualifications, competence, skills and experience.
3. The individual is able by reason of their health, after reasonable adjustments are made, of properly performing tasks that are intrinsic to the office or position for which they are appointed or to the work for which they are employed.
4. The individual has not been responsible for, contributed to or facilitated any serious misconduct or mismanagement (whether unlawful or not) while carrying out a regulated activity or providing a service elsewhere which, if provided in England, would be a regulated activity.
5. 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:

1. 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.
2. 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.
3. 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.
4. The person has made a composition or arrangement with, or granted a trust deed for, creditors and not been discharged in respect of it.
5. 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.
6. 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.

The good character requirements referred to above in Regulation 5 are specified in Part 2 of Schedule 4 to the Regulated Activities Regulations, and relate to:

1. 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
2. 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.

FPPT Framework

The framework introduces a means of retaining information relating to testing the requirements of the FPPT, a set of standard competencies, a new way of completing references and extension of applicability to ICBs, NHS England and the CQC.

The Framework sets out:

• When the full FPPT assessment is needed, which includes self-attestations.
• New appointment considerations.
• Additional considerations in specific situations such as joint appointments, shared roles and temporary absences.
• The role of the Chair in overseeing the FPPT.
• The FPPT core elements to be considered in evaluating board members.
• The circumstances in which there will be breaches to the core elements of the FPPT.
• The requirements for a board member reference check.
• The requirements for accurately maintaining FPPT information on each board member in ESR.
• The record retention requirements.
• Dispute resolution.
• Quality assurance over the Framework.

Applicability

The Framework applies to the board members of NHS organisations. NHS England’s definition of “board members” is:

• both executive directors and non-executive members (NEMs), irrespective of voting rights.
• interim (all contractual forms) as well as permanent appointments.
• those individuals who are called ‘directors’ within Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
• those individuals who by virtue of their profession are members of other professional registers, such as the General Medical Council (GMC) or Nursing and Midwifery Council (NMC), should still be assessed against this Framework if they are a board member at an NHS organisation.

5.2       The Framework is designed to assess the appropriateness of an individual to effectively discharge their duties in the capacity of a board member. However, the framework does allow organisations to extend FPPT assessments to other key roles for example – those who may regularly attend board meetings or otherwise have significant influence on board decisions.

The FPPT requirement applies on an individual basis, rather than in relation to the board as a whole.

Individuals fall under the requirements of the Regulated Activity Regulations regardless of whether they undertake the above role via a temporary, secondment or interim basis.

The individual does not have to be an employee of the ICB to fall within the scope of this policy. A documented, full FPPT assessment by the ICB is required in the following circumstances:

1. New appointments in board member roles, whether permanent or temporary, where greater than six weeks, this covers:
   a.  new appointments that have been promoted within an NHS organisation
   b. temporary appointments (including secondments) involving acting up into a board role on a non-permanent basis
   c. existing board members at one NHS organisation who move to another NHS organisation in the role of a board member
   d. individuals who join an NHS organisation in the role of board member for the first time from an organisation that is outside the NHS.
2. When an individual change’s role within their current NHS organisation (for instance, if an existing board member moves into a new board role that requires a different skillset, e.g., Chief Finance Officer).
3. Annually of the date of the previous FPPT to review for any changes in the previous 12 months.

Notes:

• for points 1a – 1b above (new appointments) the full FPPT will also include a board member reference check.
• for points 2 and 3 above, the board member reference check will not be needed.

The FPPR does not apply to a person who has left the board or ICB, or once a board is dissolved. If the individual applies for a new job with a new employer, it is the new employer’s responsibility to assure itself that the candidate is fit and proper.

Duties

ICB Chair

• Ultimately responsible for ensuring the ICB has proper systems and processes in place to comply with the FFPT requirements.
• Ensure an appropriate programme is in place to identify and monitor the development needs of board members.
• On appointment of a new board member, consider the specific competence, skills and knowledge of board members to carry out their activities, and how these fits with the overall board.
• Conclude whether the board member is fit and proper.
• Complete an annual self-attestation that they themselves are in continued adherence with the FPPT requirements.
• Confirm, on an annual basis, that all board members have completed their own FPPT self-attestation.
• Ensure that for any board member approved to commence work or continue in post despite there being concerns about a particular aspect of the FPPT, they document the reason(s) as to why there has been an issue.

ICB Deputy Chair

• Complete an annual self-attestation that they themselves are in continued adherence with the FPPT requirements.
• Confirm, on an annual basis, that the Chair has completed their own FPPT self- attestation.
• Conclude whether the Chair is fit and proper and provide “sign off” for the annual submission.

Chief Executive

• Ensure that the executive director references/pre-employment checks (where relevant) and full FPPT (including the annual self-attestation) are complete and adequate for each individual.
• Ensure an appropriate programme is in place to identify and monitor the development needs of executive directors.
• On appointment of a new executive director, consider the specific competence, skills and knowledge required to carry out their activities and, where appropriate, how these fits with the board.
• Conclude whether the executive director is fit and proper and provide “sign off” for the annual submission.
• Complete an annual self-attestation that they themselves are in continued adherence with the FPPT requirements.
• Ensure that for any executive director approved to commence work or continue in post despite there being concerns about a particular aspect of the FPPT, they document the reason(s) as to why there has been an issue.

Those within scope of FPPR:

• Hold and maintain suitability for the role they are undertaking.
• Respond promptly to any requests for information or evidence of their ongoing suitability.
• Disclose any issues which may call into question their suitability for the role they are undertaking.

Recruitment Team

• Undertake all recruitment checks and ensure results are recorded on ESR.
• Arrange for DBS and Social Media checks to be undertaken by external companies at recruitment and for annual checks.
• Forward all supporting evidence/documentation to the HR team (VSM filing) and Corporate Governance (board and partner member filing) to be saved on local records.
• Notify HR and Corporate Governance of any issues identified.
• Provide information and reports in relation to the FPPT as required.
• Support internal FPPT audits including preparation and presentation of evidence and development and implementation of any recommendations.
• Support CQC in their inspection and provide evidence where required.

Human Resources

• Ensure the full FPPT assessment has been completed before executive directors are appointed.
• Undertake annual FPPT checks for all executive directors (at VSM grade), ensure check results are entered on ESR and any supporting documentation is saved on the relevant personnel file.
• Support internal FPPT audits including preparation and presentation of evidence and development and implementation of any recommendations.
• Support CQC with their inspection and provide evidence where required.
• Where required, support to the Chair in ensuring a robust FPPT system and processes are in place.

Corporate Governance

• Ensure all board members and executive directors have returned a signed self- attestation form annually.
• Ensure the full FPPT assessment is completed before board members are appointed.
• Undertake annual FPPT checks for all board members, ensure results are recorded on ESR and ensure any supporting documentation is saved on the relevant personnel file.
• Support the Chair in discharging their duties in relation to the FPPR.
• Prepare reports for presentation to the board in public.
• Support CQC inspection and provide evidence where required.
• Support internal FPPT audits including preparation and presentation of evidence and development and implementation of any recommendations.
• Maintain the FPPT Policy.

ESR Support team

• Ensure ESR fields are configured correctly for NWICB.
• Enter the outcome of FPPT tests on ESR – at recruitment and on behalf of the HR Team and Corporate Governance teams for annual checks.
• Provide technical support and guidance to the ICB where required.
• Provide information and reports in relation to the FPPT as required.
• Support the ICB with ongoing validation of FPPT information within ESR.
• Support audits where required.

Recruitment agencies and agency providers

• Ensure the necessary checks have been completed as outlined in this policy.
• Report any issues in a timely manner to the ICB’s recruiting manager.
• Promptly provide scanned copies of any evidence of checks undertaken/supporting documentation.

CQC

• Ensure the ICB has a robust process in place to adequately perform the FPPT assessments, and to adhere to the requirements of Regulation 5 of the Regulations.

Roles and responsibilities relating to the FPPT process are shown in a checklist in Appendix 1.

FPPT Assessment

The Chair is ultimately responsible for ensuring the ICB can evidence that appropriate systems and processes are in place to ensure that all new and existing board members and executive directors are, and continue to be, fit and proper. Such systems and processes include (but are not limited to) recruitment, induction, training, development, appraisal, governance committees, disciplinary and dismissal processes.

The annual assessment will be made as part of the well-led review key question “Is there the leadership capacity and capability to deliver high-quality, sustainable care? With the related prompt “Do leaders have the skills, knowledge, experience and integrity that they need – both when they are appointed and on an ongoing basis?”.

The FPPT assessment process covers the following:

FPPT checks are undertaken in addition to the standard NHS pre-employment checks.

Where an individual is deemed ‘not fit and proper’ and disagrees with the outcome of the FPPT assessment, the following options are available:

• For NHS England-appointed board member roles (Chair) – the matter should be escalated to the NHS England Appointments team for investigation in accordance with extant policy and procedure. ‒ Where this results in a board member being terminated from their appointed role, a BMR** must be completed and retained by the local organisation in accordance with the Framework.
• For Non-NHS England-appointed roles (executive and non-executive) – local policy and constitution arrangements should be followed first. At any point, employees have the right to take the matter to an employment tribunal*.

* Chair and non-executive board members cannot take their organisation to employment tribunal unless in relation to discrimination, although they can choose to instigate civil proceedings.

** Exit BMR to be drafted by the Chair for non-executive members (with support from the NHS England Appointments team as needed), and by the NHS England Appointments team for Chairs.

For NHS England-appointed Chairs, a copy of the exit BMR will also be retained by the NHS England Appointments team.

Appointments

The ICB is required to demonstrate that appointments have been made via a robust and thorough appointment process.

No new appointments should be made (to the post of board member or executive director (VSM) until the full FPPT assessment is complete and any issues have been resolved and documented.

In addition, for the Chair role, approval is also required from the NHS England Appointments Team before commencing in role.

Breaches, Investigations and Dispute Resolution

Breaches

The Regulation will be breached if a board member or executive director:

• Is unfit on the grounds of character, such as:
  • an undischarged conviction
  • being erased, removed or struck-off a register of professionals maintained by a regulator of healthcare, social work professionals or other professional bodies across different industries
  • being prohibited from holding a relevant office or position.
• Is also unfit on the grounds of character if they have been responsible for, contributed to or facilitated any serious misconduct or mismanagement (whether lawful or not) in the course of carrying out a regulated activity.
• Is unfit should they fail to meet the relevant qualifications or fail to have the relevant competence, skills and experience as deemed required for their role.
• A board member is unfit on grounds of financial soundness, such as a relevant undischarged bankruptcy or being placed under a debt relief order.
• An NHS organisation does not have a proper process in place to make the robust assessments required by the Regulations.
• On receipt of information about a board member’s fitness, a decision is reached on the board member that is not in the range of decisions a reasonable person would be expected to reach.

Exceptions

• If a board member or executive director is deemed competent but does not hold the relevant qualifications, there should be a documented explanation approved by the Chair, as to why the individual in question is deemed fit to be appointed, or fit to continue in role if they are an existing board member or executive director. This should be recorded in the annual return to the NHS England regional director.
• Where an individual is deemed unfit (that is, they failed the FPPT) for a particular reason (other than qualifications) but the ICB appoints them or allows them to continue their current employment there should be a documented explanation as to why the individual is unfit and the mitigations taken, which is approved by the Chair. This should be submitted to the relevant NHS England regional director for review, either as part of the annual FPPT submission for the NHS organisation, or on an ad hoc basis as a case arises.

In the event of a breach, the following process will be followed:

Investigations

Investigations will be undertaken in line with the ICB’s Disciplinary Policy.

Dispute resolution

Where a board member or executive director identifies an issue with data held about them in relation to the FPPT, they should email [email protected] to request a review.

Where this does not lead to a satisfactory resolution, the following options are available:

• For Chairs – the matter should be escalated to the NHS England Appointments Team.
  • For all other board members and executive directors (including NHS England- appointed board members where the above processes have not led to a satisfactory conclusion), the options could include:
• referring the matter to the ICO
• (for executive director roles only*) taking the matter to an employment tribunal.
• instigating civil proceedings.

Self-Attestation

These form part of the full FPPT assessment and each board member and executive director is required to complete a self-attestation at initial recruitment and annually thereafter.

The annual attestation should be completed at the same time as the annual appraisal process.

Assessment of competence against the six competency domains (see section 11) will also be used to guide the board member’s development plan for the coming year.

A copy of the standard self-attestation form is included in Appendix 2.

NHS Leadership Competency Framework (LCF)

The LCF sets out six competency domains which should be incorporated into all senior leader job descriptions and recruitment processes and built into national leadership programmes and support offers. It should also form the core of board appraisal frameworks, alongside appraisal of delivery against personal and corporate objectives.

The six LCF domains are:

1. Setting strategy and delivering long term transformation
2. Leading for equality
3. Driving high quality, sustainable outcomes
4. Providing robust governance and assurance
5. Creating a compassionate and inclusive culture

Line managers are required to capture stakeholder feedback as part of the appraisal process and summarise competence against each of the six competency domains.

Appraisals

Appraisals should be carried out at the same time as the annual FPPT checks and individuals should be asked to confirm whether there have been any changes to their FPPT status since the last annual review.

The outcome of the FPPT assessments for board members and executive directors (relevant evidence, ESR dashboard etc) will be provided by the HR and Chief of Staff Governance teams to the Chair and Chief Executive to consider as part of the appraisal meetings.

For joint appointments, the host/employing NHS organisation should lead on conducting the joint appraisal and ensure adequate input from the other contracting NHS organisation.

References

The Board Member Reference (BMR) template (see appendix 4) is based on the standard NHS reference template, applies to all board members and executive directors and is a mandatory requirement from 30 September 2023.

The BMR process for new appointments and leavers is set out in Appendix 5 and further information on references is set out in section 3.0 of the Framework.

New Appointments

Board member references will be requested in writing before appointment, as part of the FPPT assessment, for new board and executive director appointments – either internal to a NHS organisation, internal with the ICB or external to the NHS. This applies whether permanent or temporary where greater than six weeks; specifically:

1. New appointments that have been promoted within an NHS organisation.
2. Existing board members at one NHS organisation who move to another NHS organisation in the role of a board member.
3. Individuals who join an NHS organisation in the role of board member for the first time from an organisation that is outside of the NHS.
4. Individuals who have been a board member in an NHS organisation and join another NHS organisation not in the role of board member, that is, they take a non-board level role.

References for a potential candidate applies irrespective of how the previous employment ended, for instance, resignation, redundancy, dismissal or fixed term work or temporary work coming to an end.

Obtaining references:

For board members/executive directors:

• The ICB will obtain a minimum of two board member references (using the BMR template) where the individual is from outside the NHS, or from within the NHS but moving into the board role for the first time.
• These two references should come from different employers, where possible.

For an individual who moves from one NHS board role to another NHS board role, across NHS organisations:

• Where possible one reference from a separate organisation in addition to the board member reference for the current board role will suffice. This is because their BMR template should be completed in line with the requirements of the framework so that
• NHS organisations can maintain accurate references when a board member departs

For a person joining from another NHS organisation:

• The new employing/appointing NHS organisation should take reasonable steps to obtain the appropriate references from the person’s current employer as well as previous employer(s) within the past six years.
• These references should establish the primary facts as per the board member reference template.

Where an employee is entering the NHS for the first time or coming from a post which was not at board/executive director level:

• The new employing NHS organisation should make every practical effort to obtain such a reference which fulfils the board member reference requirements.
• In this scenario, the NHS organisation will determine their own reasonable steps to satisfy themselves they have pursued relevant avenues to obtain the information on potential incoming individuals through alternative means.
• For example, if a Chief Finance Officer is joining from financial services, they can check the financial services register, or request for a mandatory reference under the financial services regulations.

Settlement Agreements

References will not ask for specific information on settlement agreements or non- disclosure agreements but will request any further information and concerns about an applicant’s fitness and propriety, relevant to the FPPT to fulfil the role as a director, be it executive or non-executive.

If the ICB becomes aware that a settlement agreement may be in place, the ICB may make some further enquiries.

Further, if there is a historical settlement agreement/non-disclosure agreement already in place which includes a confidentiality clause, the ICB will seek permission from all parties prior to including any such information in a board member reference.

The existence of a settlement agreement does not, in and of itself determine that a person is not fit or proper to be a board member.

Investigations

Investigations (irrespective of reason for discontinuance) will be limited to those which are applicable and relevant to the FPPT for example:

• Relating to serious misconduct, behaviour and not being of good character.
• Reckless mismanagement which endangers patients.
• Deliberate or reckless behaviour
• Dishonesty
• Suppression of the ability of people to speak up about serious issues in the NHS, e.g., allowing bullying or victimisation of those who speak up or blow the whistle, or any harassment of individuals.
• Any behaviour contrary to the professional Duty of Candour which applies to health and care professionals, e.g., falsification of records or relevant information.

Discontinued investigations are included in the reference request to identify issues around serious misconduct and mismanagement and to deliberately separate them from issues around qualifications, competence, skills, and experience and health, unless such competence and/or health issues could potentially lead to an individual not meeting the requirements of the FPPT.

Providing references

The HR team will aim to provide a reference to another NHS organisation within 14 days of the date that the request is received for VSM’s (past or present).

The standard Board Member Reference template will be used for VSM and board member references. References relating to board Members (past or present) will be completed by HR and the Chair.

Where a current board member moves between different NHS organisations, a board member reference form following a standard format will be completed by the employer and signed off by the Chair of that NHS organisation.

A board Member Reference must be completed for all leavers (VSMs and board members) whether or not a reference has been requested. This should be retained on the personnel file and forwarded to another organisation as requested.

Revising References

If an NHS organisation has provided a reference to another NHS organisation about an employee or former employee, and has subsequently:

• become aware of matters or circumstances that would require them to draft the reference differently.
• determined that there are matters arising relating to serious misconduct or mismanagement.
• determined that there are matters arising which would require them to take disciplinary action.
• concluded there are matters arising that would deem the person not to be ‘fit or proper’ for the purposes of Regulation 5 of the Regulations,

The NHS organisation that provided the reference should make reasonable attempts to identify if the person’s current employer is an NHS organisation and, if so, provide an updated reference/additional detail within a reasonable timeframe.

Revised references between NHS organisations should cover a six-year period from the date the initial board member reference was provided, or the date the person ceased employment with the NHS organisation, whichever is later.

Leavers

A reference will be completed when a board member or executive director leaves the ICB irrespective of whether a reference has been requested by a future employer and including in the circumstances of retirement. This can be completed as part of the exit interview and the individual has the right to have sight of any reference that has been written for them.

The competency domains in the LCF should be taken into account when the board member reference is written.

14.         Disclosure and Barring Service (DBS) Checks

There are three types of DBS checks. These are:

Basic check

To be eligible for a standard level DBS certificate, the position must be included in the Rehabilitation of Offenders Act (ROA) 1974 (Exceptions) Order 1975.

Enhanced checks

To be eligible for an enhanced level DBS certificate, the position must be included in both the ROA Exceptions Order and in the Police Act 1997 (Criminal Records) regulations.

Enhanced checks with children’s and/or adults’ barred list check(s)

To be eligible to request a check of the children’s or adults’ barred lists, the position held must be eligible for an enhanced level DBS check and undertake ‘regulated activities’ that are covered by the barred list. The regulated activities are contained in the Protection of Freedoms Act 2012, which can be accessed here.

Basic checks will be completed for all board members and executive directors (at VSM grade).

Enhanced checks will be completed for the Medical Director, Deputy Medical Director and Executive Director of Nursing.

All DBS checks will be conducted at initial recruitment by the recruitment team and then on a 3 yearly cycle thereafter.

Joint Appointments and Shared Roles

Joint appointments across different NHS organisations

Joint appointments may occur where two or more NHS organisations wish to create a combined role or want to employ an individual to work across the different NHS organisations in the same role.

The full FPPT assessment applies and should be completed by the designated host/employing NHS organisation. In concluding their assessment they will need input from the Chair of the other contracting NHS organisation to ensure that the board member is fit and proper to perform both roles.

The host/employing NHS organisation will then provide a ‘letter of confirmation’ (Appendix 6) to the other contracting NHS organisation to confirm that the board member in question has met the requirements of the FPPT.

Where a joint appointment results in a new board member, it constitutes a new appointment and as such, the host/employing NHS organisation should provide a ‘letter of confirmation’ to the other NHS organisation(s).

If the FPPT assessment at one organisation finds an individual not to be fit and proper the Chair should update their counterpart of any other NHS organisation(s) where the individual has a board-level role and explain the reason.

Shared roles within the same NHS organisation

Where two individuals share responsibility for the same board member role (e.g., a job share) within the same NHS organisation, both individuals should be assessed against the FPPT requirements.

Temporary absence

A temporary absence is defined as leave for a period of six consecutive weeks or less (e.g. sick leave, compassionate leave or parental leave) and where the ICB is leaving the role open for the same board member/executive director.

Where an individual is appointed as temporary/interim cover and is not already assessed as fit and proper, the ICB should ensure appropriate supervision by an existing board member/executive director.

The full FPPT assessment applies and should be completed for interim roles exceeding six weeks.

Where the period of temporary absence is extended beyond six weeks, the FPPT assessment should commence as soon as the ICB is aware of the extension.

Personal Data

Personal data relating to the FPPT assessment will be retained in local record systems (TRAC and HR personnel files) and specific data fields in the NHS Electronic Staff Record (ESR).

The information contained in these records will not routinely be accessible beyond an individual’s own organisation.

Personal data is exempt from the Freedom of Information Act (FOIA).

General Data Protection Regulation

NHS England has established that the most relevant lawful basis for processing the FPPT data contained in ESR is set out in Article 6(1)(e) UK GDPR. This is on the basis that the processing of personal data is necessary for the performance of a task carried out in the public interest or in the exercise of official authority vested in the controller.

As special category data would be processed as part of the maintenance of the ESR FPPT data fields, controllers will also rely on one of the lawful bases for processing set out in Article 9 UK GDPR: Articles 9(2)(b) – employment; 9(2)(g) – statutory/public functions; and 9(2)(h) (read with Schedule 1, paragraph 2 of the Data Protection Act 2018). This covers processing that is ‘necessary for the management of the health service.’

Electronic Staff Record (ESR)

ESR will be used by the ICB to record that FPPR tests have been undertaken and to produce reports to support audit trails of completed testing, sign off and annual assessment.

Information held in ESR will only be accessible by a limited number of senior individuals within the ICB and Arden and GEM Commissioning Support Unit’s Recruitment Team.

ESR will be updated:

• For all new and existing board members/executive directors.
• Whenever there has been a change to relevant FPPT information held on ESR.
• For annual completion of the full FPPT.
• For annual completion of FPPT confirmed by Chairs.

As a minimum the ICB will conduct an annual review to verify that ESR is appropriately maintained.

Personal information recorded held on ESR includes details of the following:

• First name / surname
• National insurance number
• Organisation (current employer)
• Staff group
• Job title (current job description)
• Occupation code
• Position title
• Employment history
• Training and development
• References
• Last appraisal and date
• Disciplinary findings
• Date and type of DBS disclosed
• Date self-attestation form signed
• Social media checks
• Disqualified directors register check
• County Court Judgement check
• Date of medical clearance
• Date of professional register check
• Any ongoing and discontinued investigations relating to Disciplinary / Grievance / whistleblowing / Employee behaviour
• Insolvency check
• Employment tribunal judgement check
• Disqualification from being a charity trustee check
• Board member reference
• Sign-off by Chair/CEO.

The ICB’s Privacy Notice provides further information on how the ICB processes personal information.

Personal data of the applicant is exempt from the FOIA.

On appointment, the Corporate Governance (for board members) / HR team (for VSMs) will write to new board members and executive directors explaining what information is collected, how it will be stored and who will have access to it. By doing this, individuals will be afforded the opportunity to raise any concerns/objections regarding the proposed use of their data so that a review can be arranged.

Further information on data recorded on ESR can be found in section 3.10 of the Framework and in the FPPT for Board members: Guidance on electronic staff record.

Quality Assurance and Governance

To ensure compliance with the FPPR, quality assurance checks will be conducted by the Care Quality Commission (CQC), NHS England and an external/independent review.

CQC

Whilst it is the ICB’s duty to ensure that they have fit and proper persons in post, the CQC has the power to take regulatory action. against the ICB if it considers that it has not complied with the requirements of the FPPR. This may come about if concerns are raised to the CQC about an individual or during the annual review.

During its inspections, the CQC will consider the following:

• quality of processes and controls supporting the FPPT
• quality of individual FPPT assessments
• Board member references, both in relation to the new employing NHS organisation but also in relation to the NHS organisation which wrote the reference.
• collation and quality of data within the database and local FPPT records.

This may involve checking:

• personnel files of recently appointed directors (including internal appointments of existing staff)
• information or records about appraisal rates for executive and non-executive directors
• that the ICB is aware of the various guidelines on recruiting executives and that they have implemented procedures in line with this best practice.

NHS England

NHSE will quality assure the ICB through receipt and review of the annual submission to the regional director.

Internal Audit

The ICB’s FPPT assessment process will be considered by the Audit Committee, for example where there is a related internal or external audit review included in the audit programme.

Every 3 years, the ICB will undertake an internal audit/independent review of its FPPT processes, controls and compliance.

Board

A paper will be presented to the board in public at least annually.

Review

This policy will be reviewed on a three yearly basis or more frequently if changes are made to the FFPR or FPPT Framework.

Appendix

Fit and Proper Person Test – Appendix 1 (201kB)

Fit and Proper Person Test – Appendix 2 (96kB)

Fit and Proper Person Test – Appendix 3 (73kB)

Fit and Proper Person Test – Apendix_4 (155kB)

Fit and Proper Person Test – Appendix 5 (374kB)

Fit and Proper Person Test – Appendix 6 (102kB)