Date formulated: April 1st 2019
Date to be reviewed: April 1st 2021
Reviewee: Martin Clitheroe
Physio 33 Ltd is committed to ensuring that, as far as it is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on the basis of their age, disability, gender, race, religion/belief or sexual orientation. Should a member of staff or any other person require access to this policy in another language or format (such as Braille or large print) we will do our best to provide this in a format the user is able to access. Physio 33 Limited will do its utmost to support and develop equitable access to all policies. The Director is responsible for ensuring staff are aware of Physio 33 Ltd policies and that staff adhere to them. It is also the Director’s responsibility to keep staff up to date with new policy changes. Staff are responsible for ensuring they are familiar with policies, know where to locate the documents within clinic, and seek out every opportunity to keep up to date with them. Independent contractors are expected to identify a lead person to be responsible for ensuring staff employed within their place of work are aware of Physio 33 Limited
All staff should be aware of the Nolan Principles of Conduct in Public Life and apply them in their dayto-day practice.
The principles are:
1. Selflessness – Holders of public office should take decisions solely in terms of the public interest. They should not to do to gain financial or other material benefits for themselves, their family or their friends.
2. Integrity – Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might influence them in the performance of their official duties.
3. Objectivity – In carrying out public business, including making public appointments, awarding contracts or recommending individuals for rewards and benefits, holders of public office should make choices on merit.
4. Accountability – Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office.
5. Openness – Holders of public office should be as open as possible about all the decisions and actions they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands.
6. Honesty – Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest.
7. Leadership – Holders of public office should promote and support these principles by leadership and example. For advice and support regarding corporate governance issues, staff should
For advice and support regarding corporate governance issues, staff should speak with the Director.
Standards of Business Conduct Policy
Staff should comply with the Trust’s Standards of Business Conduct policy in relation to the acceptance and declaration of gifts and hospitality, pharmaceutical collaboration, commercial sponsorship, declaration of interests, and outside/additional employment.
Under the Standards of Business Conduct Policy, staff should:
• Only accept gifts of less than £25, or £6 if offered by a supplier of medicinal products.
• Declare offers of gifts in excess of £25 (which must be declined), or several small gifts worth a total of over £100 received from the same or closely related source in a 12 month period.
• Only accept hospitality offered in the course of a working day (e.g. lunch) that is incidental to the business activity and not the main purpose, and is of a commensurate value to that which the Trust would provide in similar circumstances.
• Make their line manager aware of any controlling or financial interests that they or their close relative or associate holds in a business (including a private company, public sector organisation, other NHS employer and/or voluntary organisation) or in any other activity or pursuit, which may compete for an NHS contract to supply either goods or services to the Trust. All staff should declare such interests either on starting employment or on acquisition of the interest.
• Not engage in outside employment which may conflict with their Physio 33 Limited work or be detrimental to it. All staff should notify the Director with details of any outside/additional employment if there is any doubt as to whether it does conflict or would potentially conflict with their work for the Trust.
Codes of Conduct Professional codes
Staff should follow the values and procedures contained with any relevant professional or managerial codes of conduct, such as the Chartered Society of Physiotherapy Code of Conduct.
Code of Conduct for NHS Managers
The Code of Conduct for NHS Managers sets out the core standards of conduct expected of NHS managers. As a provider of services to the NHS and the private sector Physio 33 Limited employees will all observe the following principles:
• Make the care and safety of patients my first concern and act to protect them from risk
• Respect the public, patients, relatives, carers, Physio 33 Limited staff and partners in other agencies
• Be honest and act with integrity
• Accept responsibility for my own work and the proper performance of the people I manage
• Show my commitment to working as a team member by working with all my colleagues in the Physio 33 Limited and the wider community
• Take responsibility for my own learning and development
Responsibilities
The Director holds all financial responsibilities.
Counter Fraud Policy and Response Plan
Physio 33 Limited is committed to identifying and stopping fraud, whether committed in Physio 33 Limited or against Physio 33 Limited
Normally, concerns over fraud or suspected fraud should be raised in the first instance with the Director. If you do not feel able to talk to anyone in Physio 33 Limited you can contact the NHS Fraud hotline:
NHS Fraud Hotline – 0800 028 4060 (freephone)
For free advice on the Publc Interest Disclosure Act, fraud or other serious malpractice, contact the Public Concern at Work Charity:
Public Concern at Work Charity – 020 7404 6609
Security Management In line with their responsibilities, the Trust Chief Executive will monitor and ensure compliance with good practice regarding security management.
ALLOCATIONS, PLANNING, BUDGETS, BUDGETARY CONTROL, AND MONITORING
The Director will formulate a business plan.
The Business Plan will contain:
(a) A statement of the significant assumptions on which the plan is based;
(b) Details of major changes in workload, delivery of services or resources required to achieve the plan.
The Director may delegate the management of a budget to permit the performance of a defined range of activities. This delegation must be in writing and be accompanied by a clear definition of:
(a) the amount of the budget;
(b) the purpose(s) of each budget heading;
(c) individual and group responsibilities;
(d) authority to exercise virement;
(e) achievement of planned levels of service;
(f) the provision of regular reports. Delegated budget holders must not exceed the budgetary total limit set by the Director.
The adminstrator for Physio 33 Limited will be used to keep accounts, and in respect of each financial year, prepare annual accounts for review by an independent accountant.
The Director is responsible for managing Physio 33 Limited banking arrangements.
Fees and Charges
All employees must inform the Director of Finance promptly of money due arising from transactions which they initiate/deal with, including all contracts, leases, tenancy agreements, private patient undertakings and other transactions.
Debt Recovery
The Director is responsible for the appropriate recovery action on all outstanding debts.
Building and Engineering Construction Works
All decisions relating to construction works will be made by the Director alone.
Asset Registers
The Director is responsible for the maintenance of registers of assets, concerning the form of any register and the method of updating, and arranging for a physical check of assets against the asset register to be conducted once a year. Additions to the fixed asset register must be clearly identified to the Director
Security of Assets
The overall control of fixed assets is the responsibility of the director. Asset control procedures (including fixed assets, cash, cheques and negotiable instruments, and also including donated assets) must be approved by the Director.
This procedure shall make provision for:
(a) recording managerial responsibility for each asset;
(b) identification of additions and disposals;
(c) identification of all repairs and maintenance expenses;
(d) physical security of assets;
(e) periodic verification of the existence of, condition of, and title to, assets recorded;
(f) identification and reporting of all costs associated with the retention of an asset;
(g) reporting, recording and safekeeping of cash, cheques, and negotiable instruments.
All discrepancies revealed by verification of physical assets to fixed asset register shall be notified to the Director.
Whilst each employee and officer has a responsibility for the security of property of the Trust, it is the responsibility of the director to apply such appropriate routine security practices in relation to Physio 33 Limited.
Any breach of agreed security practices must be reported in accordance with agreed procedures. Any damage to Physio 33 Limited’s premises, vehicles and equipment, or any loss of equipment, stores or supplies must be reported by Board members and employees in accordance with the procedure for reporting losses.
13.2.2 The responsibility for security arrangements and the custody of keys for any stores and locations shall be clearly defined in writing by the director.
The Director shall set out procedures and systems to regulate the stores including records for receipt of goods, issues, and returns to stores, and losses.
Stocktaking arrangements shall be agreed with the Director and there shall be a physical check covering all items in store at least once a year.
Where a complete system of stores control is not justified, alternative arrangements shall require the approval of the Director.
INFORMATION TECHNOLOGY
Responsibilities and duties of the Director
The Director, who is responsible for the accuracy and security of the computerised financial data Physio 33 Limited shall:
(a) devise and implement any necessary procedures to ensure adequate (reasonable) protection of Physio 33 Limited’s data, programs and computer hardware for which the Director is responsible from accidental or intentional disclosure to unauthorised persons, deletion or modification, theft or damage, having due regard for the Data Protection Act 1998;
(b) ensure that adequate (reasonable) controls exist over data entry, processing, storage, transmission and output to ensure security, privacy, accuracy, completeness, and timeliness of the data, as well as the efficient and effective operation of the system;
(c) ensure that adequate controls exist such that the computer operation is separated from development, maintenance and amendment;
(d) ensure that an adequate management (audit) trail exists through the computerised system and that such computer audit reviews as the Director may consider necessary are being carried out.
The Director shall need to ensure that new financial systems and amendments to current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. Where this is undertaken by another organisation, assurances of adequacy must be obtained from them prior to implementation.
Contracts for Computer Services with other health bodies or outside agencies
The director shall ensure that contracts for computer services for financial applications with another health organisation or any other agency shall clearly define the responsibility of all parties for the security, privacy, accuracy, completeness, and timeliness of data during processing, transmission and storage. The contract should also ensure rights of access for audit purposes.
Where another health organisation or any other agency provides a computer service for financial applications, the director responsible for Information Technology services shall periodically seek assurances that adequate controls are in operation.
Risk Assessment
The director responsible for Information technology shall ensure that risks to Physio 33 Limited arising from the use of IT are effectively identified and considered and appropriate action taken to mitigate or control risk. This shall include the preparation and testing of appropriate disaster recovery plans.
Requirements for Computer Systems which have an impact on corporate financial systems
Where computer systems have an impact on corporate financial systems the Director shall need to be satisfied that:
(a) systems acquisition, development and maintenance are in line with corporate policies such as an Information Technology Strategy;
(b) data produced for use with financial systems is adequate, accurate, complete and timely, and that a management (audit) trail exists;
(c) such computer audit reviews as are considered necessary are being carried out.
PATIENTS’ PROPERTY
Physio 33 Limited has a responsibility to provide safe custody for money and other personal property (hereafter referred to as “property”) handed in by patients, in the possession of unconscious or confused patients.
The Director is responsible for ensuring that patients or their guardians, as appropriate, are informed before entering the premises by:
– notices and information booklets; (notices are subject to sensitivity guidance)
– oral advice of administrative and physiotherapy staff, that Physio 33 Limited will not accept responsibility or liability for patients’ property brought into Physio 33 Limited’s premises.
Staff should be informed, on appointment, by the appropriate departmental or senior manager of their responsibilities and duties for the administration of the property of patients.
RETENTION OF RECORDS
The Director shall be responsible for maintaining archives for all records required to be retained in accordance with Department of Health guidelines.
The records held in archives shall be capable of retrieval by authorised persons.
Records held in accordance with latest Independent Regulator guidance shall only be destroyed at the express instigation of the Director. Detail shall be maintained of records so destroyed.
RISK MANAGEMENT AND INSURANCE
Programme of Risk Management
The Director shall ensure that Physio 33 Limited has a programme of risk management, in accordance with current Independent Regulator requirements (if any), which must be approved and monitored by the Board.
The programme of risk management shall include:
a) a process for identifying and quantifying risks and potential liabilities;
b) engendering among all levels of staff a positive attitude towards the control of risk;
c) management processes to ensure all significant risks and potential liabilities are addressed including effective systems of internal control, cost effective insurance cover, and decisions on the acceptable level of retained risk;
d) contingency plans to offset the impact of adverse events;
e) audit arrangements including; Internal Audit, clinical audit, health and safety review;
f) a clear indication of which risks shall be insured; g) arrangements to review the Risk Management programme.
The existence, integration and evaluation of the above elements will assist in providing a basis to make a Statement on the effectiveness of Internal Control (SIC) within the Annual Report and Accounts as required by current guidance.
INSURANCE
The Director is to ensure that the business insurance is to the required level. She will ensure all practicing physiotherapists are members of The Chartered Society of Physiotherapists and Health Professions Council. This will provide £5 million for Medical Professional Liability claims (with an annual limit of £10 million for all claims in any insurance year). The Director will ensure employers liability, Public Liability and Assets/Equipment liability are renewed annually.