Conflict of Interest, Relationships & Gifts Declaration (HR-F038) CONFLICT OF INTEREST / RELATIONSHIPS AT WORK DECLARATION (HR-F038) Newsletter CONFLICT OF INTEREST / RELATIONSHIPS AT WORK DECLARATION Conflict of Interest, Relationships & Gifts Declaration (HR-F038)SECTION 1: EMPLOYEE BASELINE DATATitle- Select -MrMrsMissMsMxOtherStaff Member NameStaff_IDJob TitleCare Worker / Support WorkerComplex Care WorkerSenior Care Worker / MentorField SupervisorCare Coordinator / Rota SchedulerClinical LeadQuality Assurance / Compliance OfficerHR / Recruitment AdministratorImplementation ResearcherDeputy Care ManagerRegistered Care ManagerOperating Local Authority- Select -HaringeyIslingtonBarnetWaltham ForestCamdenHackneyBrentHarrowRedbridgeNewhamCity of LondonWestminsterTower HamletsBarking and DagenhamHaveringKensington and ChelseaHammersmith and FulhamEalingHillingdonHounslowSouthwarkLambethLewishamGreenwichWandsworthRichmond upon ThamesMertonKingston upon ThamesSuttonBexleyBromleyCroydonOtherDeclaration Type- Select -Annual ReviewNew AppointmentChange in CircumstancesSECTION 2: INTERNAL RELATIONSHIPS AT WORKDo you have a current or former close personal relationship with another staff member?- Select -YesNoName of Staff MemberNature of Relationship- Select -Spouse/PartnerSibling/ParentFormer PartnerClose Friend/FlatmateDoes this individual have authority over your pay, leave, or performance auditing?- Select -YesNoIndividual has authority- Select -Immediate mandatory reassignment of supervisory duties to a neutral third partySECTION 3: PRE-EXISTING RELATIONSHIPS WITH SERVICE USERSDo you have a pre-existing relationship (Family, Friend, Former Colleague, Neighbour) with anyone currently receiving care from us?- Select -YesNoName of Service UserRelationship Type- Select -Immediate Family Member (Spouse, Child, Parent, Sibling)Extended Family Member (Aunt/Uncle, Cousin, In-law)Close Personal FriendNeighbour (Immediate local vicinity)Former Colleague / EmployerAcquaintance (Via community, religious, or social groups)Boundary Agreement- Select -I agree I will not be rostered to this individual, nor will I access their digital care records (Nourish/Birdie) or participate in their care reviews.SECTION 4: EXTERNAL BUSINESS & FINANCIAL INTERESTSDo you, or an immediate family member, hold a financial interest, directorship, or employment with another domiciliary care provider?- Select -YesNoDo you have any interest in a business supplying goods or services (e.g., PPE, Training, Agency) to Mutima Care?- Select -YesNo"I confirm I will not use Mutima Care proprietary systems or data to benefit any external business interest.- Select -YesNoSECTION 5: GIFTS, HOSPITALITY & GRATUITIESHave you been offered any gift or financial gratuity (£ value) from a service user or family in the last 12 months?- Select -YesNoGift Category- Select -Confectionery / Consumables (e.g., chocolates, biscuits, flowers)Cash / Vouchers / Gift Cards (Strictly regulated/usually prohibited)Physical Goods (e.g., clothing, jewelry, ornaments)Hospitality (e.g., event tickets, meals out)Bequest / Will / Legacy inclusion (Requires immediate Director escalation)Estimated Value Bracket- Select -Under £10 (Token gesture)£10 - £20£21 - £50 (Requires Registered Manager approval)Over £50 (Prohibited threshold - Requires immediate return or Director intervention)Unknown / Not Applicable (e.g., named in a Will)Aggregation Rule:- Select -I confirm I have not accepted multiple 'small' gifts from this same source that exceed £50 in total over the last 12 monthsOutcome- Select -DeclinedAccepted (Under £10)Donated to CharityPending ApprovalSECTION 6: MANAGER’S RISK ASSESSMENT & ROTA MITIGATIONConflict Grading- Select -LowMediumHighCriticalRequired Mitigations (Select all that apply)- Select -Forbidden PairingData FirewallSupervisory duties moved to an independent manager.Secondary employment/interest reviewed for WTD and Conflict compliance.Registered Manager Authorization- Select -I have reviewed these risks and confirm that the digital and operational mitigations are active in our rostering and care systems.Manager's Justification for Outcome- Select -Mitigation Adequate; No direct supervisory overlap or care provision link exists.Mitigation Applied; System locks engaged to separate staff member from service user care/records.Mitigation Applied; Line management restructured to ensure independent auditing and compliance.Mitigation Applied; Gift logged and returned/donated in strict accordance with the Anti-Bribery Policy.Escalation Required; Conflict deemed Critical; referred to Board of Directors for structural review/disciplinary action.Employee Declaration- Select -I confirm this is a full and accurate disclosure of all actual, potential, or perceived conflicts. I understand that failure to disclose is a breach of the Code of Conduct and may result in summary dismissal. I also acknowledge my duty to report any suspected undisclosed conflicts involving others via the Whistleblowing/FTSU policy.Next Review Date:SUBMIT FORM
