Trust Board Reservation of Powers and Scheme of Delegation 2022 -2023

Document Reference To be assigned by Corporate Records Manager
Document Status Draft
Version:  
DOCUMENT CHANGE HISTORY


Initiated by Date Author (s)
Executive changes, external review, restructuring of committees February 2022 Linda Gove, Head of Corporate Governance

Document Owner

Head of Governance

Recommended at

Audit Committee

Date

 02 March 2022

Approved at

 Board

Date

 

Valid Until Date  March 2023
 Linked Documents  

Standing Orders

Reservation of Powers

Delegation of Powers

Committee Terms of Reference

Standing Financial Instructions

Board Governance Assurance Framework

Dissemination requirements

Cascade to Board members and Senior Leaders and forms part of Board level induction pack 

Part of Trust’s publication scheme

 Yes
SECTION ITEM PAGE
1.0 Introduction 4
Appendix A Reservation of Powers to the Board 5
Appendix B Powers Delegated in Standing Orders 8
Appendix C Powers Delegated by the Board to the Chief Executive and Officers 10
  1. Introduction
    1. NHS Trusts are required by law to adopt Standing Orders, Standing Financial Instructions, Reservation of Powers to the Board and a Scheme of Delegation of Powers which regulate the way in which the proceedings and business of the Trust will be conducted.
    2. This document sets out the powers reserved to the Board and the Scheme of Delegation, recognising that the Board remains accountable for all of its functions, including those which have been delegated.
    3. All powers of the Trust which have not been retained as reserved by the Board or delegated to a Committee authorised by the Board, shall be exercised on behalf of the Board by the Chief Executive. The Scheme of Delegation identifies functions which the Chief Executive will perform personally and those delegated to other directors or officers. All powers delegated by the Chief Executive can be re-assumed by the Board as required.
    4. The Scheme of Delegation shows only the “top level” of delegation by the Board to Committees and Directors or Officers (Appendix B) and the Detailed Scheme of Delegation, (Appendix C) covers other specific matters referred to in the Standing Financial Instructions and Standing Orders. The Scheme of Delegation is to be used in conjunction with the system of budgetary control and other established procedures within the Trust.
    5. Decisions taken on the basis of this document should also have regard to the relevant Trust policies and procedures. The Chief Executive will establish appropriate management arrangements to ensure that Officers pursue the Trust’s policies in a corporate manner.
    6. In the absence of a Director or Officer to whom powers have been delegated those powers shall be exercised by the person acting on behalf of that Officer in his/her absence and to whom authority has been delegated.

Appendix A

Reservation of Powers to the Board

General Enabling Provision

  1. The Board may determine any matter, for which it has delegated or statutory authority, it wishes in full session within its statutory powers.

Regulation and Control

  1. Approval, suspension, variation or amendment of Standing Orders, Standing Financial Instructions, Schedule of Matters Reserved to the Trust Board, and the Scheme of Delegation of Powers from the Board.
  2. Specification of financial and performance reporting arrangements.
  3. Requiring and receiving the declaration of Directors’ interests which may conflict with those of the Trust and determining the extent to which that Director may remain involved with the matter under consideration.
  4. To receive reports from Committees, including those which the Trust is required by the Secretary of State for Health and Social Care or other regulation to establish, and to take appropriate action thereon.
  5. Ratifications of any urgent decisions taken by the Trust Chair.
  6. Approval of arrangements relating to the discharge of the Trust’s responsibilities as a corporate trustee for funds held on Trust.
  7. Continuous appraisal of the affairs of the Trust by means of the provision to the Board, as the Board may require from Directors, Committees, and Officers of the Trust as set out in policy statements.
  8. Approve and delegate authority from the Board to Committees, Officers and other bodies.
  9. Adopt the organisation structures, processes and procedures to facilitate the discharge of business by the Trust and to agree modifications thereto.
  10. To approve any changes to the Trust’s Corporate Governance Framework.
  11. To approve the appointment of professional advisors where such approval is required in accordance with Standing Orders.

Appointments

  1. Appointment and agreement of the terms of reference of Board Committees.
  2. Appoint, appraise, discipline and dismiss individuals directly accountable to the Board.
  3. Appoint Vice Chair of the Board.
  4. Approve proposals of the Nomination, Remuneration and Terms of Service Committee regarding directors and senior employees and proposals of the Chief Executive for staff not covered by the Nomination, Remuneration and Terms of Service Committee.

Strategy and Plans

  1. Define the strategic aims and objectives of the Trust.
  2. Approve the Trust’s policies and procedures for the management of risk.
  3. Approve annually the Trust’s proposed organisational development proposals
  4. Approve the actions and implementation of the Fit for the Future programme as recommended by the Fit for the Future Steering Group, notwithstanding the individual Committee delegations.
  5. Responsible for the development of a consistent culture where people feel safe and supported

Financial and Performance Reporting

  1. Approval of the Trust’s Annual Report, including the Annual Accounts and Annual Governance Statement, prior to submission to Department of Health.
  2. Approve the Trust's forward plan and budget in respect of each financial year setting out the application of available financial resources.
  3. Approval of the Trust’s Quality Account, prior to submission to Department of Health.
  4. Receipt and approval of the Annual Report(s) for funds held on trust.
  5. Agreement of action on litigation against or on behalf of the Trust.
  6. Approval of loans taken out with repayment periods in excess of one year.
  7. Approval of the acquisition, disposal or change of use of land and/or buildings as specified in the table of financial limits as delegated within the Scheme of Delegation.
  8. To approve such business plans, budgeted and capital programmes submitted by the Chief Executive on at least an annual basis, including the approval of Cost Improvement Programmes.

Audit

  1. Approve the appointment (and where necessary dismissal) of External Auditors appointed by The Trust.
  2. Receive the annual management letter from the external auditor and agreement of proposed action, taking account of the advice, where appropriate, of the Audit Committee.

Appendix B

Powers Delegated in Standing Orders

Delegated Authority Delegated to SO
1 Final authority in the interpretation of Standing Orders Trust Chair 2.2
2 If difficulties arise regarding the interpretation or application of any of the Standing Orders Head of Governance 2.3
3 Any variation to financial limits in Standing Orders, Schedule of Decisions Reserved for the Trust Board and the Scheme of Delegated Authorities Board 6.2
4 Non-Compliance with Standing Orders Audit Committee 7.1
5 Standing Orders shall be reviewed annually Audit Committee 8.1
6 Appointment of the Chief Executive

Trust Chair and the Non-Executive

11.2
7 Appointment of Executive Directors Directors, overseen by NHSE/I 11.3
8 Appointment of Vice- Chair Trust Chair, the Non-Executive Directors and the Chief Executive Board 13.1
9 When the Chair is unable to perform their duties Vice-Chair 13.3
10 Appoint Associate Non-Executive Directors  Board  14.1
11 Responsibility for the operation of the Board and chair all Board meetings  Trust Chair  17.1
12

Responsibility for the overall performance of the executive functions of the Trust in line with the requirements of the Accountable Officer Memorandum for Trust Chief Executives.

 Chief Executive  17.3
13 Responsible for the provision of financial advice to the Trust, the supervision of financial control and accounting systems and the discharge of obligations under relevant Financial Directions.  Director of Finance  17.4
14 To call a meeting of the Board at any time. Trust Chair  18.3
15 A notice of the meeting, specifying the business proposed to be transacted, shall be posted before each meeting of the Trust Board. This notice shall be signed. Trust Chair, or by an Officer of the Trust authorised by the Chair to sign on their behalf  21.2
16

Responsible for deciding whether a vote is required and what form this will take

Responsible for deciding whether a vote is required and what form this will take 28.1
17 A second or casting vote  Trust Chair  28.2
18 A properly received petition shall be included as an item for the agenda of the next Trust Board meeting  Trust Chair  29.1
19 Standing Orders may in emergency be exercised  Chief Executive and the Chair acting jointly  34.3
20 Preparation of a Scheme of Delegation  Chief Executive  34.6
21 Appoint Committees of the Trust  Board  35.1
22 Declaration of Interests All Staff and Board  46.1
23 Register of Interests to be established and maintained Head of Governance  46.13
24 Take reasonable steps to make arrangements for the Register of Interests to be made available to the public and open to inspection if required Trust Chair and Chief Executive  51.1
25 Determine that a matter dealt with by the Board or Committee, or brought before it, is confidential. Chair 51.1
26 The Common Seal of the Trust shall be kept in a secure place Chief Executive or a nominated Officer 54.1
27

Register of Sealing to be established and maintained

Chief Executive or a nominated Officer 55.1
28 By resolution of the Board, to sign on behalf of the Trust any agreement or other document not required to be executed as a deed Chief Executive or nominated directors 56.2

Appendix C

Powers Delegated by the Board to the Chief Executive and Officers

Delegated matters in respect of decisions which may have a far-reaching effect must be reported to the Chief Executive. The delegation shown below is the lowest level to which authority is delegated by the Board. Delegation to lower levels is only permitted with written approval of the Chief Executive who will, before authorising such delegations, consult with other senior officers as appropriate. All items concerning Finance must be carried out in accordance with Standing Financial Instructions and Standing Orders.

Forward Plans, Budgets, Budgetary Control and Monitoring
1.0   Preparation & Approval of Forward Plans and Budgets 3.1
  1.1 Compilation and submission to Board a forward plan in respect of each financial year. Chief Executive in conjunction with Director of Finance 3.1.1/3.1.3
  1.2 Implementation and performance monitoring of the Forward Plan

Executive Leadership Board

Director of Finance

 
  1.3 Preparation and submission of budgets for approval by the Board prior to start of financial year Director of Finance 3.1.2
  1.4 Monitor financial performance against budget and plan, and advise Board Director of Finance 3.1.3
  1.5 Provision of information to enable budgets to be compiled Budget Holders 3.14
  1.6 Budget holders to sign up to their allocated budgets at commencement of each financial year. Director of Finance 3.1.5
  1.7

Provision of adequate business planning and budget management training on an on-going basis to budget holders to help them manage successfully.

Director of Finance 3.1.6
2.0

Budgetary Delegation

          2.1 Responsibility for delegation of the management of revenue budget to permit the performance of a defined range of activities: Chief Executive

3.2.1 & 10.1.1

3.2.2 & 10.1.1

3.2.2 & 10.1.1

  1. Designation of budget holder Chief Executive
  2. Responsibility for management of revenue budget at individual budget level Budget Holder
  3. Responsibility for the totality of activities covered by each Corporate or Operational Directorate Chief Executive or in their absence relevant Executive Director
  4. Responsibility for all other revenue budgetary areas, e.g., reserves, non-recurring budgets Director of Finance 3.2.4
2.2 Responsibility for delegation of the management of capital budget in line with the approved Capital Programme Chief Executive 3.4 & 12 & 3.4



  1. Designation of Budget Holder Chief Executive
  2. Responsibility for management of the capital budget Director of Finance
  3. Responsibility for management of capital budget at individual level Capital Budget Holder
3.0 Accounts and Reports
   3.1 Preparation and submission of financial reports in accordance with the accounting policies, guidance and timetable prescribed and approved by the Department of Health Director of Finance 4.1
3.2 Preparation and publication of annual report and audited accounts and presentation to Board and to the Annual Public Meeting of the Trust. Chief Executive 4.2
4.0 Bank and Treasury Management Policy
              4.1 Compilation and submission of Treasury Management Policy to Board Director of Finance 5.1.1
4.2 Monitoring of Treasury Management Policy and provision of advice to Board Director of Finance 5.1.1
4.3 Monitoring compliance with Department of Health’s guidance on level of cleared funds Director of Finance 5.1.1
4.4 Responsibility for bank and Government Bank Accounts including preparation of detailed instructions for operation. Director of Finance 5.2 & 5.3
4.5 Review commercial banking arrangements of the Trust to reflect best practice and ensure through market testing (at least every 5-years) value for money. Director of Finance 5.4
4.6 Approval of banking arrangements Board 5.1.2
4.7 Opening of bank accounts Director of Finance 5.3.2
4.8  

Designation of authorised panel officers, by resolution of the Board for signing of cheques for cash, other cheques and authorisation of Government Banking Services and BACS payment schedules

Cheques or other orders drawn upon the main exchequer bank account with

Director of Finance 5.3.3

1.Value below £5,000

One signature from the First Officer Panel  5.3.4
 2.Value of £5,000 or more  Two signatures, one from the First Officer Panel and the other from the Second Officer Panel 5.3.5 
4.9  

Cheques or other orders drawn upon the main charitable fund bank account with:

   
 1.Value below £5,000  One signature from the First Officer Pane  5.3.6

 2. Value over £5,001

Two signatures, one from the First Officer Panel and the other from the Second Officer Panel  5.3.6
5.0 Income, Fees and Charges and Security of Cash, Cheques and Other Negotiable Instruments
  5.1 Income
    5.1.1 Design, maintain and ensure compliance with income and expenditure systems for prompt banking of all monies Director of Finance

6.1.1 &

6.1.2

    5.1.2 Approval and regular review of the level of all fees and charges, other than those determined by the Secretary of State or statute Director of Finance  6.2
    5.1.3 Responsibility for debt recovery and associated procedures Director of Finance  6.3
    5.1.4 Security of cash, cheques, and other negotiable instruments Director of Finance  6.4
  5.2        
     5.2.1  Monitoring of money laundering regulations Director of Finance  6.5
     5.2.2  Reporting of any cash payments in excess of €15,000 (approximately £10,000) in respect of any single transaction to the Director of Finance All Employees  6.5
 6.0 Tendering and Contracting Regulations     
  6.1   Legislation and Guidance Covering Public Procurement
      Monitoring compliance with Public Contract Regulations 2015 and relevant Procurement Policy Notices relating to public procurement. Director of Finance 7.2
  6.2   E-Auctions
    6.2.1 Monitoring of future expansion into e-auction activity Director of Finance 7.3
  6.3   Capital Investment
    6.3.1 Monitor compliance with the requirements of guidance published on capital investment and estate and property transactions Director of Finance 7.4
   6.4   Quotations, Tendering, Leasing and Contract Procedures (Applicable to all goods and services including healthcare services)
    6.4.1 Quotation and Tendering Limits (all limits quoted include VAT):    
      1.Obtain one written or two verbal quotations for goods/services up to £4,999 at Procurement Department’s discretion Budget Holder in conjunction with Procurement Department 7.7.2
      2. Competitive sourcing either through the Trust’s electronic tendering systems or by obtaining a minimum of two written quotations for goods/services between £5,000 and £19,999 at Procurement Department’s discretion Budget Holder in conjunction with Procurement Department 7.7.2
      3. Competitive sourcing either through the Trust’s electronic marketplace system or by obtaining a minimum of three written quotations for goods/services from £20,000 to £50,000 Budget Holder in conjunction with Procurement Department 7.7.2
      4. Execute formal tender procedures and obtain minimum of three written competitive tenders (if feasible) for goods/services over £50,000.   Appropriate Head of Department or General Manager /Executive Director and Director of Finance in conjunction with Procurement Departmen  
      5. (UK Public Procurement Rules apply:  Thresholds routinely change and the Trust will apply these as published. Applicable thresholds from 1 January 2020 to 31st August 2021 are: Goods and Services £122,976;Works and Concessions £4,733,252 and Light Touch Regime £663,540)    
   6.5    List of Approved Firms    
    6.5.1 Compilation and maintenance of approved list of firms for tendering Director of Finance 7.5.5 & 7.6.8
    6.5.2 Responsibility for ensuring all suppliers aware of the Trust’s Terms and Conditions of Contract Director of Finance 7.6.8
    6.5.3 Responsibility for ensuring financial standing and technical competence of approved contractors Director of Finance 7.6.8 & 10.1.3
    6.5.4 Responsibility for ensuring technical/medical competence of approved contractors for clinical governance purposes Director of Finance  
    6.5.5 Variation to use of approved firms/individuals or if a list does not exist for whatever reason, responsibility for ensuring appropriate checks are carried out for technical and financial capability of those first invited to tender    
   6.6    Invitation to Tender    
     6.6.1 Issue of all tenders for goods, materials, services, building, engineering works and disposals with appropriate Terms and Conditions regulating the conduct of the tender and appropriate Terms and Conditions on which Contract to be awarded

Director of Finance and/or Head of Procurement and /or Procurement Manager

 7.6.1
   6.7    Receipt and Safe Custody of Tenders  
     6.7.1  Receipt and safe custody of all tenders  Director of Finance and/or Head of Procurement and /or Procurement Manager  7.6.2
  6.8   Tender Opening/Evaluation/Acceptance/Recording
    6.8.1 Opening Tenders:  £50,000 and over or if conducted using the eProcurement system, view tender submissions via tender portal and grant access to the tender portal as appropriate Director of Finance and/or Head of Procurement and /or Procurement Manager 7.6.3
    6.8.2 Preparation and submission of formal written Tender Evaluation Report Designated Lead for tender process as defined by Head of Department or General Manager or Executive Director together with Finance Manager and other internal specialist advisor(s) (e.g., Procurement Manager, estates, service users, as appropriate) 7.6.6
    6.8.3 Review of formal written Tender Evaluation Report required for (in accordance with Scheme of Delegation 10.3)   7.8
      1.Formal Tenders up to £100,000 (Average annual contract term cost, including VAT) Maximum initial contract term of 3 years only Head of Department or Head of Operations countersigned by Executive Director.  
      2. Formal Tenders from £100,001 to £500,000 (Average annual contract term cost, including VAT) Maximum initial contract term of 3 years only

Head of Department /Executive Director/

Director (as appropriate/designated) with countersignature by Director of Finance/Chief Executive (or designated deputy in their absence

 
      3. Formal Tenders from £500,001 to £999,999 (Average annual contract term cost, including VAT) Maximum initial contract term of 3 years only Chief Executive/Director of Finance  
      4. Formal Tenders of £1M and over (Average annual contract term cost, including VAT) (To be recorded in the Minutes of the Board) Maximum initial contract term of 3 years only Board 7.6.7 & 7.8
      5. All formal tenders with a contract of greater than 3 years and a total contract value less than £3M. Executive Leadership Board  
      6. All formal tenders with a contract of greater than 3 years and a total contract value greater than £3M. Board  
      7. Tenders accepted that are not lowest expenditure or highest income to be reported to the Audit Committee Director of Finance  
    6.8.4  Approval of expenditure over agreed tender/quotation budget:  Director of Finance  
  6.9     Register of Tenders  
    6.9.1 Maintenance of Tender Register Director of Finance  
  6.10   Quotation/Tender Waiver or Single Tender Action   7.5.3 & 7.9
    6.10.1 Tender waiver requests for Orders under £25,000 Head of Procurement, following Waiver Process  
    6.10.2 Orders over £25, 000 up to Public Contract Regulation limits: the request will be forwarded to the CEO and DOFC for determining on the recommendation of the Head of Procurement. Chief Executive Officer and Director of Finance  
    6.10.3 Approval of formal written report for the waiver of tenders or requests for single tender action over £50,000 (report to Audit Committee) Chief Executive and Director of Finance upon advice of procurement  
    6.10.4 Public Contract Regulation   Threshold Limits (see Scheme of Delegation 6.4.1 (IV)) – No Waiver/Single Tender Action Permitted No Delegated Authority  
   6.11   Private Finance for Capital Procurement  
    6.11.1 Approval of PFI capital procurement Board 7.10
  6.12   Compliance Requirements for All Contracts
    6.12.1 All contracts, being legally binding, shall comply with best costing practice and devised to manage contractual risk, whilst optimising the Trust’s opportunity to generate income.  Approval of all contracts entered into on behalf of the Trust. (See overlap with 7.2) See 7.2 7.11 & 8.4
  6.13   Procurement of In-House Services
    6.13.1 Determination of in-house services to be subject to competitive tendering Board 7.14.2
    6.13.2 Delegation of lead officer(s) to oversee and manage the process and contract on behalf of the Trust Chief Executive  
  7.0     Contracting for Provision of Services (Income)  
      7.1  Regular review of capacity and capability of the Trust to provide its mandatory goods and services  Board  8.1
     7.2 All contracts, being potentially legally binding, shall comply with best costing practice and devised to manage contractual risk, whilst optimising the Trust’s opportunity to generate income.  Approval of all contracts entered into on behalf of the Trust.   7.11 & 8.6 
       (a) Approval of Existing Business/Contract Rollover/New Business/ Diversification:    
      (i) Average Annual Contract Value up to £500,000. Initial contract term up to a maximum of 3 years. Director of Finance following recommendation from Executive Leadership Board approval  
      (ii) Average Annual Contract Value Between £500,001 to £999,999. Initial contract term up to a maximum of 3 years Chief Executive and/or Director of Finance following Executive Leadership Board approval  
     

(iii) Average Annual Contract Value over £1m.  Initial contract term up to a maximum of 3 years.

(To be recorded in the Minutes of the Board)

Board following recommendation from Executive Leadership Board

Contract signature by Chief Executive or nominated deputy in their absence

 
      (iv) Contract term over 3 years with a contract value of less than £3M Executive Leadership Board  
      (v) Contract term over 3 years with a contract value of greater than £3M Board  
       (b) Contract Signing following approvals given at 7.2 (a) above:  As per the delegated officers and values defined at 7.2 (a) (i), (ii), (iii) and (iv) above  
  7.3     Reporting on actual and forecast service activity income.  Director of Finance  8.9
 8.0     Terms of Service and Payment of Directors and Employees  
  8.1    Funded Establishment    
    8.1.1  Agree workforce plans within annual budget  Board  9.2.1
    8.1.2   Authority to change establishment within Board of Director’s agreed financial budget financial budget  Director of People Services and Director of Finance  
    8.1.3 Authority to authorise temporary variations to pay rates within standard Agenda For Change Terms and Conditions Chief Executive and Director of Finance with Executive Leadership Board approval  
    8.1.4 Authority to fill funded post on the establishment within area of operational/corporate responsibility. Head of HR and Head of Finance (being vacancy panel) for approval, reported to Executive Leadership Board  
    8.1.5 1.Authority to permanently appoint staff to posts above the formal budgeted establishment (i.e., increasing overall revenue cost to the Trust of £500,000 per annum) Chief Executive and Director of Finance, following recommendation from Executive Leadership Board 9.2.2
      2. Authority to permanently appoint staff to posts above the formal budgeted establishment (i.e., increasing overall revenue cost to the Trust above £500,001 per annum) Chief Executive and Director of Finance, after approval with Board  
    8.1.6 The granting of additional increments to newly appointed staff within budget and regulations Head of HR and Head of Finance (being vacancy panel) for approval, reported to ELB 9.3.1
    8.1.7  Authority to grant additional increments to existing or newly appointed staff above the formal budgeted position (i.e., increasing overall revenue cost to Trust) Head of HR and Head of Finance (being vacancy panel) for recommendation to ELB for approval    
    8.1.8 All requests for upgrading/re-grading shall be dealt with in accordance with Trust procedures Director of People Services  
    8.1.9 Additional staff to the agreed establishment with specifically allocated finance Appropriate Head of Department or Head of Operations or Director with Director of Finance 9.3.1
  8.2   Engagement of Staff not on the Establishment    
     8.2.1 Authority to engage Non-medical consultancy staff – having regard to guidance an approval requirement from NHS Improvement Director of People Services or nominated deputy   
    8.2.2  Booking of Bank, Locum or Agency Staff (Medical Locums, Nursing & Clerical) Excluding EOC within budget allocation – see 8.2.3 below Authority to design and implement standing data forms affecting pay, new starters, variations, and leavers   
    8.2.3  Authority to complete and authorise negative/positive reporting forms Budget Holders/Managers/ Head of Department or Head of Operations/Directors/ Chair (as appropriate)  
    8.2.4 Authority to authorise overtime within Agenda for Change Terms and Conditions  Head of Department or Head of Operations (or nominated deputy) /Executive Directors (as appropriate)  
  8.4     Contract of Employment   9.5 
    8.4.1   Authority to issue contract of employment in a form approved by the Board Director of People Services or nominated Deputy  
    8.4.2 Authority to vary terms and conditions of employment within budget and regulations Director of People Services or nominated Deputy  
    8.4.3 Authority to vary terms and conditions of employment not within budget and regulations (i.e., increasing overall revenue cost to Trust Chief Executive and Director of Finance, after recommendation from the Executive Leadership Board  
      Renewal of fixed term Contract Head of HR and Head of Finance (being vacancy panel) for approval, reported to ELB for approval  
     

1. Redundancy – Authorisation for employees up to Band 7 or a small group of redundancies (under 20 employees) 

Panel Comprising of: Chief Executive, Director of Finance and Director of People Services  
      2. Redundancy – Authorisation for employees 8a and above or a large group of redundancies (over 20 employees) Panel Comprising of: Chief Executive, Director of Finance and Director of People Services with approval from Remuneration Committee  
    8.4.5 MARS – Authorisation Director of People Services with Executive Leadership Board approval  
    8.4.6 Ill-Health Retirement – Decision to pursue retirement on grounds of ill health is an employee decision.  Activation of Trust Procedures. Head of Department or Deputy Director/Executive Director (as appropriate) & Occupational Health  
    8.4.7 Dismissal – Authorisation Director of People Services and authorised Directors/Managers (band 8c and above) or Remuneration Committee (as appropriate)  
  8.5   Leave Authority 10.2.6
    8.5.1 Study Leave – All study leave external to the UK and Ireland, including CME/professional leave Chief Executive or nominated Deputy following recommendation from Head of Department or Head of Operations /Director (as appropriate) and where appropriate in conjunction with the Medical Director or Director of Nursing (as appropriate)  
    8.5.2

Study Leave – All study leave involving hospitality. 

(Directorate required to obtain the necessary approval to study leave and maintain register and forward to the Head of Governance/Chief Executive for authorisation of any hospitality before acceptance).

Head of Department or Head of Operations /

Director (as appropriate) in conjunction with the Medical Director or Director of Nursing(as appropriate)

Chief Executive/Head of Governance

(for advance approval of hospitality)

 
  8.6   Relocation Expenses
    8.6.1 Authorisation of payment of relocation expenses incurred by officers taking up new appointments (in accordance with local policy);    
      1. Up to £8,000 Director of People Services or Remuneration Committee (as appropriate)  
      2. Over £8,001 Director of People Services and Chief Executive or Remuneration Committee (as appropriate)  
  8.7   Authorised Car and Mobile Phone Users
    8.7.1 Requests for new posts to be authorised as car users or re-designation of existing posts Director of Finance  
    8.7.2 Requests for authorised mobile phone status Budget Manager  
9.0     Facilities for Staff Not Employed by the Trust to Gain Practical Experience
  9.1   Professional recognition, honorary contracts, and insurance of medical staff Director of People Services or nominated deputy  
  9.2    Work experience students    
  9.3   Director of People Services or nominated deputy    
     9.3.1 Volunteer Car Drivers  Chief Operating Officer  
     9.3.2 Community First Responders Chief Operating Officer 10 
10.0      Non-Pay Expenditure    
  10.1    Approval of level of non-pay expenditure on an annual basis Board  10.1
  10.2    Determination of the level of delegation to budget managers  Director of Finance   
  10.3    Agree and maintain a list of managers authorised to place requisitions for the ordering and receipt of goods and services and authorisation of invoices (See overlap with Scheme of Delegation 16)  Director of Finance

3.2.2 & 10.1.1

10.1.2 & 10.2.2

     10.3.1  Requisitioning and Ordering of Goods and Services and Authorisation of Invoices:    
      1. All requisitions/invoices up to £10,000 Budget Managers as designated by Budget Holders  
      2. All requisitions/invoices up to £25,00 Head of Department or Head of Operations  
      3. All requisitions/invoices between £25,001 and £100,000 Head of Department countersigned by Executive Director as designated  
      4. This SFI will be waived to one signature in the event of a Declared Major Incident.  The nominated staff member undertaking the role of Gold Commander shall be considered to have authorised delegated single signatory powers to the level of £100,000.  This is specifically limited to costs incurred in relation to the management of the declared Major Incident, as where possible, Gold Commanders should, where circumstances allow, follow normal SFI process rather than default to this emergency delegation.    
      5. All requisitions/invoices between £100,001 and £500,000 Head of Department/Executive Director/Director (as appropriate and designated) with countersignature by Director of Finance/Chief Executive (or Designated deputy in their absence)  
      6. All requisitions/invoices over £500,001 Chief Executive/Director of Finance  
    10.3.2 On-Line Requisitioning or Ordering of Goods and Services:    
      1. Inclusion of Supplies within OLR catalogue Band 8c Manager   following PSPG approval in conjunction with Head of Supplies  
      2. All OLR catalogue requisitions up to £25,000 OLR Designated Officer within Directorate  
      3. All OLR catalogue requisitions over £25,001 OLR Designated Officer with countersignature of Band 8c Manager or above  
    10.3.3 Medicines Management (In Accordance with Medicines Management Policy)    
      1. Controlled Drugs Accountable Officer and Accountable Officer for Medicines Management Medical Director  
      2. Determination of the medicines management strategy and the standards to be used for the administration of all medicines used by the Trust, including responsibility for the safe and secure handing of medicines Medical Director with specialist advice from the Trust’s Pharmaceutical Advisor and input from Medicines Management Group  
      3. Medicine stocks must be obtained from a supplier approved by the Medical Director, and against formal orders signed by an authorised Paramedic. Only those medicines appearing in the Trust’s formulary are authorised to be purchased  Medical Director and authorised Paramedic in accordance with Medicines Management Policy  
      4. Advisor to the Director of People Services on medicines management training requirements for all Trust clinicians.  Medical Director  
  10.4    Designation of authorised officers to issue of verbal orders in very exceptional circumstances (confirmation order required)  Director of Finance  10.2.6
  10.5   Development and maintenance of procedures on the seeking of professional advice regarding the supply of goods and services 10.1.2
    10.5.1 Responsibility for ensuring financial standing and technical competence of approved contractors Director of Finance 7.6.8 & 10.1.3
    10.5.2 Responsibility for ensuring technical/medical competence of approved contractors for clinical governance purposes Director of Finance 10.2.3
    10.5.3 Variation to use of approved firms/individuals or if a list does not exist for whatever reason, responsibility for ensuring appropriate checks are carried out for technical and financial capability of those first invited to tender   10.2.4
  10.6   System of Payment and Payment Verification    
    10.6.1 Responsibility for prompt payment of accounts, contract invoices and claims and that payments are only made once the goods and services are received and been appropriately certified Director of Finance 10.2.2 & 10.2.3
    10.6.2 Maintenance of register of employees (including specimens of their signatures) authorised to certify invoices Director of Finance 10.2.3
    10.6.3 Pre-payments only permitted where exceptional circumstances apply.  Authorisation of written report to permit pre-payment. Director of Finance 10.2.4
  10.7   Petty Cash Disbursements
    10.7.1 Authority to define restrictions in value and by type of purchase for petty cash disbursements and maintenance of record system. Director of Finance  
    10.7.2 Petty Cash Disbursement limits:  Expenditure up to £30 per transaction Budget Holder and Petty Cash Holder  
  10.8   Credit Cards
    10.8.1 Development and monitoring of Credit Card Procedure Director of Finance  
    10.8.2 Authorisation to issue credit cards Director of Finance  
    10.8.3 Definition of credit limit Director of Finance  
  10.9   Leases, Tenancy Agreements and Licences
    10.9.1 Approval of all new leases, tenancy agreements and licences, including any variation thereto: (N.B.  Values relate to total length of lease/tenancy agreement/licence)    
      1. Below £25,000 Head of Estates  
      2. Between £25,000 and £99,999 Head of Estates following recommendation from Executive Leadership Board  
      3. Between £100,000 – £500,000 Executive Leadership Board  
      4. Between £500,001 - £999,999 Director of Finance following Executive Leadership Board recommendation  
      5. Over £1M Board following recommendation from Executive Leadership Board  
    10.9.2 Approval of all renewals of leases, tenancy agreements and licences, including any variation thereto: (N.B.  Values relate to total length of lease/tenancy agreement/licence)    
      1. Below £25,000 Head of Estates  
      2. Between £25,000 and £99,999 Head of Estates following recommendation from Executive Leadership Board member  
      3. Between £100,000 and £500,000 Executive Leadership Board  
      4. Between £500,001 - £999,999 Director of Finance following Executive Leadership Board recommendation  
      5. Over £1M Board following recommendation from Executive Leadership Board  
      Letting of premises to outside organisations Head of Estates and Director of Finance  
    10.9.3 Approval of rent based on professional assessment Head of Estates and Director of Finance  
11.0     EXTERNAL BORROWING AND INVESTMENTS 11
  11.1   External Borrowing
    11.1.1 Preparation of detailed procedural instructions concerning applications for loans and overdrafts Director of Finance  
    11.1.2 Approval of Borrowings from Department of Health Director of Finance/ following recommendation from Board  
12.0     Capital Investment, Private Financial, Fixed Asset Registers and Security of Assets
  12.1   Capital Investment & Private Finance
    12.1.1 Approval of capital programme (including reserves list) as part of budget process. Board following recommendation from the Performance & Finance Committee  
    12.1.2 Approval of business cases and PFI Schemes including approval of variations:    
      1. Below £1m (Report to Executive Leadership Board) Executive Leadership Board following recommendation by Director of Finance & Capital Planning and Management Group  
      2. Over £1m (Report to Executive Leadership Board) Board following recommendation by the Executive Leadership Board  
    12.1.3 Selection of architects, quantity surveyors, consultant engineers and other professional advisors within the Public Contract Regulations 2015   and CONCODE (in accordance with Tendering Procedures) Director of Finance/Chief Executive following professional advice  
    12.1.4 Budgetary delegation for management of capital budget in line with approved capital programme Scheme of Delegation 3.21
    12.1.5 Financial monitoring and reporting on all capital scheme expenditure Director of Finance  
    12.1.6 Monitor compliance with the requirements of guidance published on capital investment and estate and property transactions Director of Finance 7.4
  12.2   Asset Registers
    12.2.1 Maintenance of Asset Register and responsibility for re-valuation of assets in accordance with the Capital Accounting Manual issued by the Department of Health Director of Finance 12.3.1 & 12.3.7
    12.2.2 Approval of asset disposals (all disposals must be reported to Director of Finance to enable the Asset Register to be updated)   12.3.4 & 13.2
      1. 'Protected Assets' as defined within the Trust’s Statutory Instrument and in accordance with the Capital Accounting Manual Board  
      2. Land and buildings Board 12.4
      3. Other – where the asset has a residual value less than £9,999 Head of Finance 12.4.1
      4. Other – where the asset has a residual value over £10,000 Director of Finance 12.4.2
  12.3   Security of Assets
    12.3.1 Overall control of fixed assets Chief Executive  
    12.3.2 Asset control procedures Director of Finance  
13.0     Stores and Receipt of Goods
  13.1   Management and control of stores:    
      1. General    
      2. Drugs    
      3. Fuel Deputy Director of Operational Support and Band 8b Manager or above  
14.0     Disposals and Condemnations, Losses and Special Payments
  14.1   Disposals and Condemnations of items included on the asset register Scheme of Delegation

14.1,

12.3.4 & 13.2

      Disposals and condemnations of items not included on the asset register up to a value of £25,000 Head of Department with notification going to Head of Finance  
      Disposals and condemnations of items not included on the asset register up to a value from £25,001 to £100,000. Head of Department countersigned by Executive Director as designated with notification going to Head of Finance  
  14.2   Losses and Special Payments Procedure
    14.2.1 Special Payments – compensation payments made under legal obligation (following written legal advice)    
      1. Under £100,000 + costs Director of Finance or Chief Executive plus 1 other Board Executive Director  
      2. Over £100,001 + costs

Director of Finance or Chief Executive plus 1 other

Board Executive Director and 1 Audit Committee Member

 
    14.2.2 Special Payments within limits set by the Department of Health governing    
     

1. Extra contractual payments to contractors

2. Ex-gratia payments

3. Extra statutory and extra regulatory payments

   
      4. Maximum limit of £50,000 Director of Finance and Chief Executive  
      5. Over £50,001 Chief Executive with approval of the Executive Leadership Board  
    14.2.3

1. Cash

2. Fruitless Payments (including abandoned capital schemes)

3. Bad debts and claims abandoned.

4. Damage to buildings, fittings, furniture, equipment, loss of equipment, property, and stores

   
      5. Under £25,000 Director of Finance or Head of Finance  
      6. £25,001 to £50,000 Director of Finance and Chief Executive or nominated deputy in their absence  
      7. £50,001 to £249,999 Director of Finance following recommendation by Executive Leadership Board  
      8. Over £250,000 Chief Executive or Director of Finance and 1 other Executive Board Director and 1 Audit Committee Member  
    14.2.4 Novel, contentious, or repercussive losses or special payments Director of Finance to refer to Department of Health for approval  
    14.2.5 All write-offs and special payments and losses to be reviewed by the Audit Committee Director of Finance  
15.0     FINANCIAL SYSTEMS (IT)
  15.1   Responsibility for accuracy and security of computerised financial data of the Trust Director of Finance  
  15.2   Risk assessment and approval of all requirements for general applications impacting on corporate financial systems Director of Finance  
16.0          
  16.1   Provision of written instructions for the collection, safe custody, investment, recording and disposal of money and other personal property handed in by patients, or found in the possession of patients dying in hospital or dead on arrival Director of Finance  
  16.2   Operational management of patients’ property in accordance with patients’ property procedures Head of Department or General Managers  
17.0     Funds Held on Trust
  17.1    Corporate Trustee for the management of funds held in Trust  Board monitored through the Charitable Funds Committee  
  17.2     Nomination of Executive and Non-Executive Directors to discharge the Trust’s corporate trustee responsibilities  Board through appointment to the Charitable Funds Committee  
  17.3     Management of trust funds:    
      1. Executive Fundraising Lead Director of Finance  
      2. Accounts Management Director of Finance  
  17.4     Reporting on income and expenditure on funds held in Trust to Charitable Funds Committee (Audit Committee to sign off annual account)  Director of Finance  
  17.5    Approval to Fundraising/Appeal Launch:     
      1. Projected Fundraising up to £5,000 Head of Department and Director of Finance  
      2. Projected Fundraising between £5,001 - £300,000 Charitable Funds Committee following Head of Department or Director of Finance support  
      3. Over £300,000 Board following Charitable Funds Committee recommendation  
  17.6    Funds held in Trust - Expenditure    
       1. Under £1,500 per request  Head of Financial Services or Deputy Head of Financial Services  
      2. £1,501 to £5,000 per request Head of Finance  
      3. £5,001 to £25,000 per request Director of Finance  
      4. Requests over £25,001 Chief Executive, Director of Finance and Charitable Funds Committee Chair/Member  
 18.0      ANTI-BRIBERY    
  18.1    Nomination of Compliance Officer  Board  
  18.2   Development and maintenance of policy Compliance Officer (Director of Finance) in conjunction with Head of Governance  
19.0     ACCEPTANCE OF GIFTS BY STAFF/STANDARDS OF BUSINESS CONDUCT   18
  19.1   Development and maintenance of policy on standards of business conduct and acceptance of gifts and other benefits in kind by staff Head of Governance  
  19.2   Maintenance of Gifts and Hospitality Register Head of Governance  
  19.3   Approval of Acceptance of Gifts/Hospitality which exceeds the limit of £25. Director of Finance/Audit Committee  
  19.4   Annual Audit of Hospitality Register Head of Governance  
  19.5   Maintenance of Declaration of Interest Registers: Head of Governance  
20.0     Authorisation of Commercial Sponsorship, Advertising or Partnership Arrangements
  20.1   General Sponsorship, Advertising or Partnership Arrangements (including Charitable Fund Sponsorship) Chief Executive with the Director of Communications and Engagement & Director of Finance  
  20.2   Research & Development Sponsorship, Advertising or Partnership Arrangements Director of Communications and Engagement, after approval by the Medical Director/Chief Executive  

21.0

   

Retention of Documents/Data Protection

19

 

21.1

 

Compliance with Records Management – NHS Code of Practice

Chief Executive in conjunction with the Senior Information Risk Officer (SIRO)

 
 

21.2

 

Compliance with Access to Health Records

Medical Director (as Caldicott Guardian) in conjunction with the Senior Information Risk Officer

 
 

21.3

 

Compliance with the Data Protection and Freedom of Information Acts

Head of Governance in conjunction with the Senior Information Risk Officer

 
 

21.4

 

Caldicott Guardian

Medical Director

 

22.0

   

RISK MANAGEMENT AND INSURANCE

20

 

22.1

 

Risk Management

 
   

22.1.1

Administers programme of risk management, approved, and monitored by the Board

Chief Executive in conjunction with the Head of Governance

20.1

   

22.1.2

Integration and evaluation of the programme of risk management to provide a basis to make a statement on the effectiveness of internal control (Annual Governance Statement) within the Annual Report and Accounts as required by current Department of Health guidance


Chief Executive in conjunction with the Head of Governance


20.1

   

22.1.3

Review of Fire Precautions

Director of Nursing 

 
   

22.1.4

Review of all statutory compliance legislation pertaining to Health & Safety

Director of Nursing 

 
   

22.1.5

Review of compliance with environmental regulations, e.g., clean air and waste disposal

Infrastructure and Estates Programme Lead or Deputy Director of Operations Support and Head of Estates and Band 8b Manager or above 

 
   

22.1.6

Infection, Prevention & Control Responsibility

Director of Nursing 

 
   

22.1.7

Incident and Serious Incident Reporting

Director of Nursing (in conjunction with the appropriate external bodies and Trust’s Communications Team)

 
   

22.1.8

Infectious Diseases and Notifiable Outbreaks

Medical Director

 
   

22.1.9

Safeguarding

Director of Nursing 

 
   

22.1.10

Senior Information Risk Officer/Senior Responsible Owner

Chief Information Officer

 
   

22.1.11

Executive Responsibility for Maternity Services

Director of Nursing 

 
   

22.1.12

Security Management Director

Chief Executive in conjunction with Director of Nursing 

 
   

22.1.13

Sustainability Development

Chief Executive

 
   

22.1.14

Health and Safety Lead

Director of Nursing 

 
   

22.1.15

Emergency Planning (EPRR) Lead

Chief Operating Officer 

 
   

22.1.16

Child Protection and Vulnerable Persons Lead

Director of Nursing 

 
   

22.1.17

Resuscitation Officer

Medical Director

 
   

22.1.18

NHS Constitution Executive Lead

Chief Executive

 

23.0

   

Insurance

 
   

23.2.1

Approval of insurance policies and engagement of additional insurance over and above the NHS Resolution Scheme.

Director of Finance

 

24.0

   

Consultation

 
 

24.0

 

Formal Consultation

 
   

24.1.1

Compliance with Section 242 of the NHS Act 2006 and Regulation 4A of the Local Authority (Overview & Scrutiny Committee’s health scrutiny functions) Regulations 2002

Chief Executive in conjunction with the Director of Communications and Engagement, and the Head of Department

 
 

24.2

 

Media Liaison

 
   

24.2.1

All enquiries:

   
     
  1. within hours (Monday – Friday 9 am – 5 pm)

Director of Communications and Engagement and Communications Team in conjunction with Directors/ Managers (as appropriate)

 
     
  1. outside hours

On-call Communications Team in conjunction with Designated Duty Manager or Executive Director (as appropriate)

 

25.0

   

Engagement of Trust Solicitors

 
 

25.1

 

Award of Contract in accordance with tender procedures

Board

 
 

25.2

 

Referral of Trust Issues for Legal Opinion:

   
     

All requests for external legal advice will be routed through the Head of Governance or an Executive Director. The leads for each are detailed below

   
     
  1. Corporate Law

Head of Governance or Chief Executive

 
     
  1. Property, major transactions, commercial and associated contractual law

Director of Finance or Deputy Director for Operations Support or Head of Estates

 
     
  1. Clinical and Risk Management Law

Director of Nursing and Head of Governance (Risk)

 
     
  1. Contract or Commercial Law

Director of Finance 

 
     
  1. Employment Law

Director of People Services or Nominated Deputy

 
     
  1. R&D, Intellectual Property Law

Medical Director/or nominated deputy in conjunction with Research Manager

 

26.0

   

Patient Services



 

26.1

 

Patients’ and Relatives’ complaints management, including clinical negligence complaints

Director of Nursing and Quality

 
 

26.2

 

Variation of operating and clinical sessions within existing resources

Chief Operating Officer in conjunction with appropriate Head of Department (or nominated deputy) & Director of Nursing and Medical Director

 
 

26.3

 

Variation to changes in operational fleet allocation:

   
     
  1. Temporary Variation


Chief Operating Officer in conjunction with appropriate Head of Department or their nominated deputy

 
     
  1. Permanent Change

Chief Operating Officer in conjunction with Deputy Director of Operations Support

 

27.0

   

Extended Role Activities

 
   

27.1

Approval of staff to undertake extended professional clinical roles.



Chief Executive in conjunction with Medical Director or 

Director of Nursing (as appropriate)

 

28.0

   

Policies And Procedures

 
 

28.1

 

Approval of all non-clinical organisational/operational policies and procedures for and on behalf of the Board


The Chief Executive will have discretion to declare matters for specific consideration directly to the Board for approval.

Executive Leadership Board ratification following approval from Compliance and Risk Group after recommendation and consultation with relevant stakeholders

 

29.0

   

Attestation of Sealings and Register

 
 

29.1

 

Attestation of Sealings in accordance with Standing Orders of the Board

Chair and Chief Executive or nominated deputies

 
 

29.2

 

Maintenance of Register of Sealings

Head of Governance

 

30.0

   

RESEARCH & DEVELOPMENT 

 
 

30.1

 

Authorisation of Research and Development (subject to contract approvals) Delegation)

Chief Executive following recommendation from Clinical Best Practice Group

 
 

30.2

 

Authorisation of Clinical Trials (subject to contract approvals)

Chief Executive and Medical Director following recommendation from Clinical Best Practice Group

 

31.0

   

Clinical Products

 
 

31.1

 

Assessment and recommendation of clinical products

PSPG and/or Clinical Best Practice Group and Deputy Medical Director prior to recommendation to Senior Leadership Board

 

32.0

   

Medicines Inspectorate 

 
 

32.1

 

Review and implementation of Medicines and Healthcare products Regulatory Agency (MHRA) Regulations

Medical Director

 

33.0

   

Regulation of Medical Practitioners

 
 

33.1

 

Responsible Officer

Medical Director

 

34.0

   

External Auditor Services

 
 

34.1

 

Advise the organisation’s board on the selection and appointment of the external auditor 

Director of Finance and Auditor Panel

 
 

34.2

 

Advise the organisation’s board on the maintenance of an independent relationship with the appointed external auditor

Auditor Panel

 
 

34.3

 

Under the Audit Code, the External Auditor may provide the Trust with services which are outside the scope of the audit.   Application of the Trust’s “Provision of Additional Services by the External Auditor” should be applied to ensure no conflict of interest and ethical standards are applied.

Auditor Panel approval required before engagement.  If timing precludes this, the Auditor Panel Chair and Director of Finance may take action and report to next Auditor Panel meeting.

 

35.0

   

Emergency Preparedness, Resilience and Response compliance 

 
 

35.1

 

Responsible Officer for discharging the duties and responsibilities of the Trust as a category 1 responder


Chief Operating Officer 

 
 

35.2

 

Responsible Manager for attendance at Local Health Resilience Partnerships

Head of Operations for each area