Scheme of Delegation and Matters Reserved
Reservation of Powers to the Board of Directors and Council of Governors
and
Schedule of Decisions/Duties Delegated by the Board of Director
Responsible: Chief Executive
Prepared by: Associate Director for Corporate Governance
Ratified by: Board of Directors
Date: July 2024
Next review: July 2026
SECTION 1 – INTRODUCTION
NHS England’s Code of Governance for NHS Provider Trusts (October 2022) requires there to be a formal document setting out the Reservation of Powers to the Board of Directors and a Schedule of Decisions/Duties Delegated by the Board of Directors.
The purpose of this document is to define those powers specifically reserved to the Board of Directors, while at the same time detailing those delegated to the appropriate level. However, the Board of Directors remains accountable for all of its functions, including those delegated to the Chair of the Trust, individual directors or officers in the Trust, and will establish ways in which it will receive information about the exercise of those delegated functions to enable it to maintain a monitoring role.
All matters which are not reserved for the Board of Directors or delegated to its committees shall be exercised by the Chief Executive. In turn, the Chief Executive will delegate as he/she sees fit to members of the Executive Management Team. All powers delegated by the Chief Executive can be reassumed by him/her should the need arise.
It should be noted (in accordance with the provisions of the emergency Powers Section of Annex 8 paragraph 4.2 of the Constitution that in an emergency the powers that the Board of Directors has retained to itself may be exercised by the Chief Executive and the Chair of the Trust after having consulted at least two non-executive directors. The exercise of such powers by the Chief Executive and the Chair of the Trust shall be reported to the next formal meeting of the Board of Directors for approval.
This document also includes a schedule of Reservation of Powers to the Council of Governors which is set out in Section 4; and these include those matters for which it has responsibility set out in the NHS Act 2006 (as amended by the Health and Social Care Act 2012).
ABBREVIATIONS USED IN SECTIONS OF THIS DOCUMENT:
- BoD = Board of Directors
- Code of G = Code of Governance
- CoG = Council of Governors
- Const = Constitution
- FP = Financial Procedures
- MHA = Mental Health Act
- SFIs = Standing Financial Instructions
- SO = Standing Orders
SECTION 2 – PORTFOLIOS OF EXECUTIVE DIRECTORS
All the powers of the Trust that have not been retained by the Trust Board or delegated to a committee will be exercised on behalf of the Board by the Chief Executive. They will in turn delegate some of these duties to the executive directors. Below if a high-level list of the duties that fall into each of the portfolios of the executive directors (greater detail of individual responsibilities is set out in directors’ job descriptions).
| Directorate functions | |
| Chief Financial Officer and Deputy Chief Executive | · Financial leadership, standards and governance with expert professional advice to the Board of Directors and the Council of Governors
· Financial performance delivery · Contracting · Estates and facilities including security management · Commercial activities including the North of England Commercial Procurement Collaborative (NoE CPC). · Supplies and procurement · Internal audit and counter fraud · Health and safety · Informatics and Information Management and Technology · Capital development · Management of the Programme Management Office which oversees the delivery of the Trust’s strategic programmes |
| Director of Nursing and Professions / Director of Infection and prevention and control (DIPC) | · Nursing, social work and AHP leadership, standards, governance and revalidation with expert professional advice to the Board of Directors and Council of Governors
· Quality review and assurance · Professional leadership and strategies · Clinical governance · Safer staffing and practice placement facilitation, new professional roles · Risk management including oversight of risk registers and Datix reporting · Serious incident reporting and learning from incidents · Safeguarding children and adults · Infection prevention and control · Physical health · Patient experience and carer involvement · Smoking cessation · Complaints/PALs and claims · CQC compliance · Chaplaincy |
| Medical Director | · Medical leadership, standards and governance, including revalidation with expert professional advice to the Board of Directors and Council of Governors
· Research and development · Improvement & knowledge · Medicines management · Caldicott guardian · Mortality review · Quality review · Compliance with NICE / national clinical standards · Andrew Sims Centre and events management · Accountable for clinical leadership (clinical directors / clinical leads) · Clinical quality supported by others · Mental Health Legislation |
| Chief Operating Officer | · Management and leadership across Care Services
· Service Delivery · Resource deployment · Care services financial management · Emergency Preparedness, Response and Resilience · Clinical Services Strategic Plan and delivery of service developments · Performance management and delivery of performance standards · Partnership development · Service Integration · Service development · Quality delivery |
|
Director of People and Organisational Development |
· Organisational development and HR function, leadership standards and governance with expert professional advice to the Board of Directors and Council of Governors
· Workforce planning and workforce information/systems · Recruitment · Strategic resourcing · Employment practice · Learning and development, including compulsory training · Temporary Workforce, including clinical and non-clinical staff bank · Workforce Equality, Diversity and Inclusion · Employee Engagement, reward and recognition · Employee health and wellbeing, including Occupational Health services · Partnership Working · Workforce data and analytics |
SECTION 3 – RESERVATION OF POWERS TO THE BOARD OF DIRECTORS
The Board of Directors must determine those matters on which decision are reserved unto itself. These reserved matters are set out below:
MATTERS RESERVED TO THE BOARD OF DIRECTORS |
|
General Enabling ProvisionThe Board of Directors shall exercise all powers of the Trust as set out in the NHS Act 2006 (as amended by the Health and Social Care Act 2012), subject to any restrictions by its license, or as delegated in accordance with this Scheme. The Board at a full session may determine any matter it wishes in within its statutory powers. |
|
1. Regulations and Control |
|
| 1.1 | Approve the Reservation of Powers to the Board of Directors and Council of Governors, Schedule of Decisions/Duties Delegated by the Board of Directors (BoD SO 4.5). |
| 1.2 | Approve the Standing Financial Instructions which set out the responsibilities of individuals (BoD SO 2.5) |
| 1.3 | Approve the Standing Orders for the Board of Directors as set out in the Constitution (BoD SO 15.1). |
| 1.4 | Suspend Standing Orders pertaining to the Board of Directors BoD SO 3.10). |
| 1.5 | Approve variations or amendments to the Constitution (including the Standing Orders) in conjunction with the Council of Governors (Const 44.1.2). |
| 1.6 | At the next formal meeting of the Board of Directors ratify any urgent decisions taken by the Chair of the Trust and Chief Executive (BoD SO 4.2) |
| 1.7 | At any point during discussions at a Board of Directors’ meeting require and receive the declaration of interests of any member of the Board of Directors that may conflict with those of the Trust; and determining the extent to which that Board member may remain involved with the matter under consideration (BoD SO 6.6). |
| 1.8 | Approval of the format for the Declaration of Interests’ form (BoD SO 7.2) |
| 1.9 | Determine the independence of the non-executive directors. (Code of G. A.3.1) |
| 1.10 | Regularly review and at all times maintain and ensure the capacity and capability of the Trust to provide the mandatory goods and services as per the Provider Licence. (SFIs para 7.1) |
| 1.11 | Establish and disband the sub-committees that are directly accountable to the Board of Directors (BoD SO 5.1.1) |
| 1.12 | Receive reports from its sub-committees including those that the Trust is required to establish and take appropriate action. |
| 1.13 | Confirm the recommendations of the Trust’s sub-committees where they do not have the power to make such a decision. (Where sub-committees made a decision which is within their delegated power this will be regarded as having been made by the Board of Directors) |
| 1.14 | Ratify the terms of reference and reporting arrangements of all sub-committees that are formally established by the Board of Directors (BoD SO 4.3). |
| 1.15 | At its next formal meeting receive a report of the application of the Trust seal since the last report to the Board of Directors (BoD SO 11.3.1). |
| 1.16 | Ratify, or otherwise, instances of non-compliance with the Board of Directors’ Standing Orders and the justification for such non-compliance (BoD SO 4.7) |
| 1.17 | Ratify a memorandum of understanding between the Chair of the Trust and the Chief Executive setting out a division of responsibilities, review any modifications to that memorandum (BoD SO 2.6) |
| 1.18 | Approve the wording of any statement of the Board of Directors pertaining to a dispute between the Council of Governors and the Board of Directors (BoD SO 10.3). |
| 1.19 | Decide on whether the Trust will insure through the risk pooling schemes administered by the NHS Resolution (SFIs para 20.2) |
| 1.20 | Make any arrangements it considers appropriate to the provision of indemnity insurance or similar arrangements for the benefit of the Trust or directors to meet all or any liability which are properly the liability of the Trust recognising the Public Benefit Corporation status (BoD SO 2.13.2) (SFIs para 20.4) |
| 1.21 | Approve any recording by members of the public of any public Board of Directors’ meeting (BoD SO 3.2.5). |
| 1.22 | Resolve to exclude members of the public from any meeting or part of a meeting (BoD SO 3.1.2) |
| 1.23 | Determine that certain matters appear on each agenda of the Board of Directors’ meeting (BoD SO 3.4.1) |
| 1.24 | Provide permission that governors, directors, officers or any employee or representative of the Trust in attendance at a private meeting or private part of a meeting of the Board of Directors may disclose the contents of the papers or any discussion (BoD SO 3 1.9) |
| 1.25 | Send a copy of the agenda of the meeting of the Board of Directors to the Council of Governors (BoD SO 3.4.3) |
| 1.26 | Send a copy of the minutes of the public Board of Directors’ meeting to the Council of Governors (BoD SO 3.9.5) |
| 1.27 | Determine the times and places for the meetings of the Board of Directors (BoD SO 3.2) |
| 1.28 | Approval of the Trust’s banking arrangements. (SFIs para 5.1.2) |
| 1.29 | Approve arrangements relating to the discharge of the Trust’s responsibilities as a Corporate Trustee for funds held on Trust |
| 1.30 | Approve arrangements relating to the discharge of the Trust’s responsibilities as Bailee for patient’s monies |
| 1.31 | Grant delegated authority to the Chair or other directors to carry out actions on its behalf |
2. Appointments / Dismissal / Terms and Conditions |
|
| 2.1 | Ratify any changes to the overall number of non-executive directors and executive directors (BoD SO 2.8). |
| 2.2 | Appoint one of the independent non-executive directors as the Senior Independent Director (BoD SO 2.10.4). |
| 2.3 | Advise a partner organisation of concerns regarding any individual that an organisation may appoint to the Council of Governors (i.e. an appointed governor) (Const para 11.5). |
| 2.4 | Approve the appointment of any advisor to assist or advise the Council of Governors. (Const para 11.6) |
| 2.5 | Appoint, discipline and dismiss the Trust Secretary (BoD SO 2.11) |
| 2.6 | Consider and approve proposals presented by the Chief Executive for setting remuneration and conditions of service for those employees and officers not covered by the Remuneration Committee. (SFIs 9.1.4) |
| 2.7 | Approve procedures presented by the Chief Executive for the determination of commencing pay rates, condition of service etc for employees. (SFIs para 9.3.2) |
| 2.8 | Approve the directors’ Code of Conduct |
3. Strategy, Business Plans, Budgets and Statutory returns |
|
| 3.1 | Define and set the aim, goals and strategic objectives of the Trust (i.e. the Trust Strategy). |
| 3.2
|
Approve any supporting (underpinning) strategies (Clinical Services, Estates, IT, Quality, and People Plan). Note: for clarity the approval of all other strategies are delegated to the Executive Management Team to be approved. |
| 3.3 | Approve the capital programme (FP 4.3). |
| 3.4 | Approve any outline and final business cases for capital investments of £1m or more (or a linked series of projects for which the combined value would exceed £1m). |
| 3.5 | Approve any long-term borrowing and ensure this is consistent with the plans outlined in the annual plan (SFIs para 11.2.3) |
| 3.6 | Ratify proposals for acquisition, disposal or change of use of land and/or buildings of £1m or more (or a linked series of acquisitions, disposals or change of use of land for which the combined value would exceed £1m) |
| 3.7 | Approve any new PFI contract and / or significant changes to PFI contracts (for avoidance of doubt this would include any refinancing agreements). |
| 3.8 | Approve proposals in individual cases for the write-off of losses or making of special payments of £500k or more and all those of a novel or contentious nature. (SFIs para 14.2.8) |
| 3.9 | Approve the introduction or discontinuance of any significant activity or operation in relation to the Trust. An activity or operation shall be regarded as significant where it is of a novel or contentious nature, or if it has a gross annual income in excess of £1m per annum. |
| 3.10 | Approve the introduction or discontinuation of any significant activity or operation relating to the areas of responsibility for those Committees in Common established by the Board, where this has gross annual income or cost to the Trust in excess of £500k per annum. |
| 3.11 | Approve the level of non-pay expenditure on an annual basis (SFIs para 10.1.1) |
| 3.12 | Approve orders for items of expenditure in respect of service directorate and corporate budgets where the value is for £1m or more. (FP 4.1) |
| 3.13 | Approve the Care Quality Commission Registration Declaration. |
| 3.14 | Approve the Trust’s Quality Report. |
| 3.15 | Approve any monitoring returns prior to submission to NHS England, ensuring these are submitted at such frequency as is required (SFIs para 3.5.1) |
| 3.16 | Approve the Trust’s forward plan prior to submission to NHS England, ensuring that it has regard to the views of the Council of Governors |
| 3.17 | Receipt and adoption of the Trust’s Annual Report and Annual Accounts. |
| 3.18 | Where applicable receive recommendations from the evaluation team on matters regarding in-house services that are subject to competitive tendering. (SFIs para 8.9.4) |
| 3.19 | Receive reports from the Chief Financial Officer on financial performance against budget and plans. |
4. Audit |
|
| 4.1 | Approve the annual Letter of Representation to the external auditors. |
| 4.2 | Receive from the External Auditor any Public Interest Report. (SFIs para 2.4.7) |
5. Monitoring |
|
| 5.1 | Receive such reports as the Board sees fit from sub-committees in respect of their exercise of delegated powers, including an annual report of activities undertaken by the sub-committees |
| 5.2 | Continuous appraisal of the affairs of the Trust by means of reports to the Board, in whatever format the Board determines |
| 5.3 | Receive performance reports against agreed internal, local, contractual and national targets and standards |
| 5.4 | Receive and approve key reports as required including reports to and from NHS Improvement in regard to compliance |
6. Emergency Preparedness Resilience and Response |
|
| 6.1 | Receive and ratify the EP-0005 – Business Continuity and EPRR Policy and Business Continuity Management System Procedure |
| 6.2 | Receive and approve the EPRR Annual Report |
| 6.3 | Receive and confirm the EPRR assurance declaration annually |
SECTION 4 – RESERVATION OF POWERS TO THE COUNCIL OF GOVERNORS
MATTERS RESERVED TO THE COUNCIL OF GOVERNORS |
|
| 1.1 | Approve changes to the Trust’s Constitution in conjunction with the Board of Directors (Const para 44.1) |
| 1.2 | Appoint and/or disband the committees that are directly accountable to the Council of Governors and approve their Terms of Reference. (CoG SO 6.1) |
| 1.3 | Receive the annual report and accounts and any related auditors’ reports. (Const para 41) (SFIs para 4.1.3) |
| 1.4 | Appoint or remove the Chair of the Trust and other non-executive directors and decide their remuneration, allowances and other terms and conditions. (Const para 24.1) (SFIs para 9.1.5) |
| 1.5 | Approve the appointment of the Chief Executive. (Const para 27.2) |
| 1.6 | Appoint the Deputy Chair of the Trust. (Const para 26) |
| 1.7 | Appoint or remove the Trust’s external auditors. (Const para 37.2) (SFIs para 2.4.2) |
| 1.8 | Hold the non-executives, individually and collectively, to account for the performance of the Board (Const para 15.1.1). |
| 1.9 | Receive from the External Auditor any Public Interest Report. (SFIs para 2.4.7) |
| 1.10 | Require one or more of the directors to attend a meeting to obtain information about the Trust’s performance, or information about how the directors have performed their duties in order to determine if there is a need to vote on issues concerning that performance. (CoG SO 4.1.9.2) |
| 1.11 | Resolve to exclude members of the public from any formal meeting or any part of a meeting of the Council of Governors (CoG SO 4.1.2) |
| 1.12 | Determine times and places of Council of Governors’ meetings having regard for the accommodation of the public at those meetings (CoG SO 4.1.7 and 4.1.8) |
| 1.13 | Give permission for governors, directors or officers to disclose the content of a paper or discussion taken in a private meeting of the Council of Governors (CoG SO 4.2.2) |
| 1.14 | Determine that certain matters should appear on each Council of Governors’ agenda (CoG SO 4.6.1) |
| 1.15 | Approve by majority vote the implementation of any proposals to increase by 5% or more the proportion of total income in any financial year derived from non-NHS activities. (Const para 40.7) |
| 1.16 | Approve by majority vote entering into a significant transaction (a significant transaction is defined in the Constitution). (Const para 46.1) |
| 1.17 | Approve by majority vote an application to NHS England (one of our regulators) for a merger with or the acquisition of another foundation trust or NHS trust. (Const para 45) |
| 1.18 | Approve by majority vote an application to NHS Improvement for the separation and dissolution of the foundation trust. (Const para 45) |
| 1.19 | Determine whether the provision of activities other than the provision of goods and services for the purpose of health services in England will to any significant extent interfere with the fulfillment of the Trust’s principal purpose (Const para 40.6.1) |
| 1.20 | Be consulted on the appointment of the Senior Independent Director. (BoD SO 2.10.4) |
| 1.21 | Agree a clear process for the appointment of the Chair of the Trust and the other non-executive directors. (Code of G C.1.4) |
| 1.22 | Agree a process for the evaluation or appraisal of the Chair of the Trust and the other non-executives, including the outcomes of the evaluation of the Chair of the Trust and the non-executive directors. (Code of G D.2) |
| 1.23 | Receive a report on the outcome of the evaluation or appraisal of the Chair of the Trust or the other non-executive directors, particularly where this is linked to a re-appointment process. (ToR for CoG) |
| 1.24 | Represent the interests of the members of the Trust as a whole and the interests of the public. (Const para 15.1.2) |
| 1.25 | At the next formal meeting of the Council of Governors approve any urgent decisions taken by the Chair of the Trust on behalf of the Council of Governors. (CoG SO 5.1) |
| 1.26 | Suspend the Standing Orders pertaining to the Council of Governors. (CoG SO 4.13.1) |
| 1.27 | Approve the wording of any statement of the Council of Governors pertaining to a dispute between the Council of Governors and the Board of Directors. (CoG SO 10.3) |
| 1.28 | Inform NHS England that in the Council of Governors’ opinion the Board of Directors has not responded constructively to concerns of the Council of Governors. (CoG SO 10.9) |
| 1.29 | Nominate the Lead Governor. |
| 1.30 | Approve any recording of a public Council of Governors’ meeting by any member/s of the public. (CoG SO 4.1.5) |
| 1.31 | Agree the remit of any individual to whom the Council of Governors has delegated responsibility to that individual. (CoG SO 5.3) |
| 1.32 | Appoint or disband a sub-committee of the Council of Governors. Agree the Terms of Reference of any such sub-committee and agree the membership and determine the chair of the sub-committee (CoG SO 6.5) |
| 1.33 | Authorise the delegation of any powers of a sub-committee to any other committee (CoG SO 6.4) |
| 1.34 | Receive any report of non-compliance with Council of Governors Standing Orders at a formal meeting and determine action or ratification (CoG SO 11.1) |
SECTION 5 – SCHEDULE OF DECISIONS/DUTIES DELEGATED BY THE COUNCIL OF GOVERNORS AS SET OUT IN ANNEX 7 OF THE CONSTITUTION (The Standing Orders of the Council of Governors)
STANDING ORDER REF |
DELEGATED TO |
DECISION / DUTY DELEGATED AS SET OUT IN THE STANDING ORDERS OF THE COUNCIL OF GOVERNORS |
| 1.1 | Chair of the Trust | Final authority in the interpretation of Annex 7 of the Constitution (Council of Governors’ Standing Orders) in respect of the Council of Governors. |
| 3.3 | Chair of the Trust | Has responsibility for the leadership of the Council of Governors. |
| 3.2 and 3.4 | Chair of the Trust | Has responsibility for chairing the Council of Governors’ meetings. |
| 4.1.4 | Chair of the Trust | May exclude any member of the public from a meeting of the Council of Governors if they are interfering with or preventing the proper or reasonable conduct of that meeting. |
| 4.1.6 & 4.1.10 | Chair of the Trust | Invite members of the public to ask questions or otherwise participate in a meeting of the Council of Governors. |
| 4.3.1 | Chair of the Trust | In exceptional circumstances call a meeting of the Council of Governors at any time. |
| 4.3.3 | Chair of the Trust | Chair any meeting of the Council called by governors |
| 4.3.3 | Trust Secretary | Attend any meeting of the Council called by governors |
| 4.4.1 | Chair of the Trust or Authorised Officer | Sign a notice of business to be conducted at public meetings of the Council of Governors. |
| 4.4.1 | Chair of the Trust | Agree any agenda papers that are to follow the main agenda and papers going out |
| 4.4.3 | Chair of the Trust | Waive notice of a meeting of the Council of Governors. |
| 4.4.4 | Governors | Those governors calling a meeting in default of the chair shall sign a notice of business to be transacted at that meeting. |
| 4.5.2 | Governors | Send apologies to the Trust Secretary should they not be able to attend a formal Council meeting |
| 4.6.2 | Chair of the Trust | Decide if an agenda item received less than 12 days before a meeting will be included on the agenda |
| 4.6.3 | Chair | Decide those items that are to be on the agenda of the Council of Governors |
| 4.7.1 | Deputy Chair of the Trust | In the absence of, incapacity of, or exclusion of the Chair of the Trust, chair the meetings of the Council of Governors. |
| 4.8.1 | Chair of the Trust | Include on the agenda all notice of motions received |
| 4.8.2 | Chair of the Trust | Give a final ruling for requests to permit emergency motions |
| 4.7.3 | Governor | In the absence of, incapacity of, or exclusion of the Chair of the Trust and the Deputy Chair of the Trust, chair the meetings of the Council of Governors. |
| 4.9.1 | Chair of the Trust | Give a final ruling in questions of order, relevancy and regularity of matters pertaining to governors’ statements |
| 4.10.1 | Chair of the Trust | Have a second or casting vote. |
| 4.11.1 | Chair of the Trust | Sign the minutes of the meetings of the Council of Governors. |
| 4.11.2 | Chair of the Trust | To agree where it is appropriate for discussions to take place in respect of the minutes of the meeting |
| 4.13.5 | Audit Committee | Review every decision to suspend Standing Orders of the Council of Governors. |
| 5.1 | Chair of the Trust and five elected Governors | The powers which the Council of Governors has retained to itself within these Standing Orders may in emergency be exercised by the Chair of the Trust after having consulted at least five elected Governors. |
| 7.1 and 7.4 | Governors | Declare relevant and material interests |
| 7.7 | Governors | Inform the Trust Secretary within 7 days of becoming aware of a relevant or material interest |
| 8.1 & 8.2 | Trust Secretary | Establish and maintain a Register of Interests for Governors. |
| 10.2 | Chair of the Trust | Endeavour to resolve any dispute between the Council of Governors and the Board of Directors through discussion in the initial stages. |
| 10.3 | Chair of the Trust | Ensure a draft Dispute Statement is included on the next agenda of the formal meeting of either the Board of Directors or the Council of Governors for approval. |
| 10.4 | Chair of the Trust | Ensure the approved Dispute Statement is included on the next agenda of the formal meeting of either the Board of Directors or the Council of Governors as appropriate. That meeting shall agree the precise wording of a Response to Disputes Statement. |
| 10.5 | Chair of the Trust | Communicate the outcome of any Dispute Statement to the other party and deliver the written Response to Disputes Statement. |
| 10.6 | Chair of the Trust | Communicate to the other party where there is no prospect of full or partial resolution and advise accordingly. |
| 11.2 | All Governors and staff | Duty to disclose any non-compliance with Annex 7 of the Constitution in respect of the Council of Governors. |
| 13.2 | All Governors | Disclose to the Board Secretary any relationship with a candidate who is applying for any staff appointment within the Trust, when the candidate makes the application. (For clarity “relationship” shall be defined as spouse or co-habiting partner, or close family member). |
SECTION 6 – SCHEDULE OF DECISIONS/DUTIES DELEGATED BY THE BOARD OF DIRECTORS AS PER ANNEX 8 OF THE CONSTITUTION (the Standing Orders of the Board of Directors)
STANDING ORDER REF |
DELEGATED TO |
DECISION/ DUTY DELEGATED AS SET OUT IN THE STANDING ORDERS OF THE BOARD OF DIRECTORS |
| 1.1 | Chair of the Trust | Final authority in the interpretation of Annex 8 of the Constitution (Standing Orders for the Board of Directors). |
| 1.1 | Chief Executive or Trust Secretary | Advise the Chair on the interpretation of the Standing Order for the Board of Directors. |
| 2.4.3 | Chief Executive | Overall performance of the executive functions of the Trust. |
| 2.4.4 | Chief Financial Officer | Provision of financial advice and for the supervision of financial control and accounting systems. |
| 2.4.4 | Chief Executive and Chief Financial Officer | Ensuring the discharge of obligations under relevant Financial Directions. |
| 2.4.6 | Chair of the Trust | Operation of the Board of Directors and will chair all Board meetings when present. |
| 2.4.7 | Chair of the Trust | Have responsibility for the induction of the non-executive directors, their portfolios of interests and assignments and their performance. |
| 2.4.8 | Chair of the Trust and Chief Executive | Ensure the Board of Directors discusses key and appropriate issues. |
| 2.4.9 | Chair of the Trust | Leadership of the Board of Directors, ensuring the Board of Directors and Council of Governors work effectively together. |
| 2.10 | Chair of the Trust and the Non-Executive Directors | Appoint the Chief Executive. |
| 2.10 | Committee of Chair of the Trust, non-executive Directors and Chief Executive | Appoint members of the Executive Team. |
| 3.2.1 | Chair of the Trust | Call meetings of the Board of Directors |
| 3.1.4 | Chair of the Trust | Exclude any member of the public from a public Board of Directors’ meeting if they are interfering with or preventing the proper or reasonable conduct of the meeting. |
| 3.1.6 | Chair of the Trust | Decide whether any question from a member of the public will be put to the Board of Directors at a public meeting. |
| 3.3.1 | Chair of the Trust or Authorised Officer | Sign a notice of business to be conducted at public meetings of the Board of Directors. |
| 3.3.1 | Chair of the Trust | Agree that papers may be sent out late as “to follow”. |
| 3.5.1 | Chair of the Trust | Chair all Board of Directors’ meetings. |
| 3.5.2 | Deputy Chair of the Trust | Carry out the role of the Chair of the Board of Directors in the absence of the Chair. |
| 3.5.3 | Non-executive Director | Chair the Board of Directors’ meeting in the absence of both the Chair of the Trust and the Deputy Chair of the Trust. |
| 3.6.1 | Chair of the Trust | Include on the agenda all notices of motion received. |
| 3.6.2 | Chair of the Trust | Give final ruling to requests to permit emergency motions. |
| 3.7.1 | Chair of the Trust | Give final ruling in questions of order, relevancy and regularity of matters pertaining to directors’ statements. |
| 3.8.1 | Chair of the Trust | Have a second or casting vote |
| 3.9.1 | Chair of the Trust | Sign the minutes of the meeting of the Board of Directors. |
| 3.10.5 | Audit Committee | Audit Committee to review every decision to suspend Standing Orders (power to suspend Standing Orders is reserved to the Board of Directors) |
| 4.2 | Chair of the Trust and Chief Executive and two non-executive directors | The powers which the Board of Directors has retained to itself within these Standing Orders may in emergency be exercised by the Chair of the Trust and Chief Executive after having consulted at least two non-executive directors. |
| 4.4 | Chief Executive | Carry out any function that is not reserved to the Board of Directors or delegated to an executive committee or Board committee. |
| 4.5 | Chief Executive | The Chief Executive shall prepare a Schedule of Decision/Duties Delegated by the Board of Directors and Council of Governors identifying his/her proposals that shall be considered and approved by the Board, subject to any amendment agreed during the discussion. |
| 4.7 | All | Disclosure of non-compliance with Standing Orders to the Chief Executive as soon as possible. |
| 6.1 & 6.4 | All Directors | Declare relevant and material interests and any pecuniary interest in any contract, proposed contract or other matter under discussion by the Board of Directors. |
| 7.1 | trust secretary | Establish and maintain Registers of Interests in line with the Trust’s Declaration of Interest Policy, and the Bribery Act 2010. |
| 7.2 | Trust Secretary | Keep the Register of Interests up to date adding new information as received. |
| 9.1 | All staff | Comply with national guidance on standards of business conduct for NHS staff. |
| 9.9 | All Directors including the chair of the trust | Disclose any relationship between themselves and a candidate for staff appointment in line with the Trust’s Anti-Bribery Policy and the Bribery Act 2010. (CE or nominated director to report the disclosure to the Board of Directors.) (For clarity “relationship” shall be defined as spouse or co-habiting partner, or close family member). |
| 10.2 | Chair of the Trust | Endeavour to resolve any dispute between the Board of Directors and the Council of Governors through discussion in the initial stages. |
| 10.4 | Chair of the Trust | Ensure any Dispute Statement is included on the next agenda of the formal meeting of either the Board of Directors or the Council of Governors as appropriate. |
| 10.5 &10.6 | Chair of the Trust | Communicate the outcome of any Dispute Statement to the other party and advise if there is no prospect of full or partial resolution. |
| 11.1.1 | Chief Executive or Nominated Officer | Keep the seal in a safe place and maintain a register of sealing. |
| 11.2.1 | chair of the trust and trust board secretary | The Board of Directors has delegated the witnessing of the application of the seal to the Chair of the Trust or in their absence the Deputy Chair and the Trust Board Secretary or in their absence their nominated officer. |
| 11.2.2 | Chief Financial Officer and Chief Executive | Approve any building, engineering, property or capital document prior to sealing. |
| 12.1 | Chief Executive/
Executive Director |
Approve and sign all documents which will be necessary in legal proceedings. |
| 12.2 | Chief Executive | The Board of Directors may authorise the Chief Executive, to sign on behalf of the Trust any agreement or other document not required to be executed as a deed, the subject matter of which has been approved by the Board of Directors or committee or sub-committee to which the Board of Directors has delegated appropriate authority. |
| 13.1 | Chief Executive | Ensure all existing and new Directors and officers are notified of and understand their responsibility within the Standing Orders, Standing Financial Instructions, Reservation of Powers and Schedule of Decision/Duties delegated to the Board of Directors. |
SECTION 7 – SCHEDULE OF DECISIONS/DUTIES DELEGATED BY THE NHS FOUNDATION TRUST ACCOUNTING OFFICER MEMORANDUM
(Taken from the NHS Foundation Trust Accounting Officers’ Memorandum August 2015)
Note: the use of the term Monitor in the context of this section refers to the statutory body ‘Monitor’ the duties of which have been subsumed into the role of NHS England.
PARA REF |
DELEGATED TO |
DECISION/ DUTY DELEGATED AS SET OUT IN THE ACCOUNTING OFFICERS MEMORANDUM |
| 3 | Chief Executive (as Accounting Officer) | Duty to prepare the accounts in accordance with the NHS Act 2006. Duty to personally sign the accounts. Witness before the Committee of Public Accounts to deal with questions arising from the accounts or from any report made to Parliament by the Comptroller and Auditor General under the National Audit Act 1983. |
| 5 | Chief Executive (as Accounting Officer) | Responsible to Parliament for resources under his/her control. |
| 7 | Chief Executive (as Accounting Officer) | Responsible for the overall organisation, management and staffing of the NHS foundation trust and for its procedures in financial and other matters. The accounting officer must ensure that:
a) there is a high standard of financial management in the NHS foundation trust as a whole b) the NHS foundation trust delivers efficient and economical conduct of its business and safeguards financial propriety and regularity throughout the organisation c) financial considerations are fully taken into account in decisions by the NHS foundation trust. |
| 9 | Chief Executive (as Accounting Officer) | Required to:
a) personally sign the accounts and, in doing, so accept personal responsibility for ensuring their proper form and content as prescribed by Monitor in accordance with the Act b) comply with the financial requirements of the NHS provider licence c) ensure that proper financial procedures are followed and that accounting records are maintained in a form suited to the requirements of management, as well as in the form prescribed for published accounts (so that they disclose with reasonably accuracy, at any time, the financial position of the NHS foundation trust) d) ensure that the resources for which you are responsible as accounting officer are properly and well managed and safeguarded, with independent and effective checks of cash balances in the hands of any official e) ensure that assets for which you are responsible such as land, buildings or other property, including stores and equipment, are controlled and safeguarded with similar care, and with checks as appropriate f) ensure that any protected property (or interest in) is not disposed of without the consent of Monitor g) ensure that conflicts of interest are avoided, whether in the proceedings of the board of directors, or council of governors or in the actions or advice of the NHS foundation trust’s staff, including yourself h) ensure that, in the consideration of policy proposals relating to the expenditure for which you are responsible as accounting officer, all relevant financial considerations, including any issues of propriety, regularity or value for money, are taken into account, and brought to the attention of the board of directors. |
| 10 | Chief Executive (as Accounting Officer) | Ensure that effective management systems appropriate for the achievement of the Trust’s objectives, including financial monitoring and control systems, have been put in place. Ensure that managers at all levels:
a) have a clear view of their objectives, and the means to assess and, wherever possible, measure outputs or performance in relation to those objectives b) are assigned well-defined responsibilities for making the best use of resources (both those consumed by their own commands and any made available to organisations or individuals outside the NHS foundation trust), including a critical scrutiny of output and value for money c) have the information (particularly about costs), training and access to the expert advice which they need to exercise their responsibilities effectively. |
| 11 | Chief Executive (as Accounting Officer) | Ensure that their arrangements for delegation promote good management and that they are supported by the necessary staff with an appropriate balance of skills. |
| 12 | Chief Executive (as Accounting Officer) | Responsibility to see that appropriate advice is tendered to the Board of Directors and the Council of Governors on all matters of financial propriety and regularity, and more broadly, as to all considerations of prudent and economical administration, efficiency and effectiveness. Determine how and on what terms such advice should be tendered, and whether in a particular case to make reference to their own duty, as Accounting Officer, to justify to the Public Accounts Committee, transactions for which they are accountable. |
| 13 | Board of Directors | Act in accordance with the requirements of propriety or regularity. |
| 13 | Chief Executive (as Accounting Officer) | Make written objections to proposals by the Board of Directors, Council of Governors or Chair which he considers to infringe the requirement to act with the requirements of propriety or regularity. If the Board of Directors, Council of Governors or Chair decides to proceed, seek a written instruction to take the action in question, and inform Monitor of the position (if possible, before the decision is implemented). |
| 14 and 15 | Chief Executive (as Accounting Officer) | If a course of action is contemplated which raises an issue relating to his wider responsibilities for economy, efficiency and effectiveness, draw the relevant factors to the attention of the Board of Directors or Council of Governors and advise them in whatever way he deems appropriate. If his decision is overruled, and the proposal is one which he would not feel able to defend to the Public Accounts Committee as representing value for money, seek a written instruction before proceeding. Inform Monitor of such an instruction, if possible, before the decision is implemented. If there is no time to submit advice in writing due to extreme urgency, ensure that if the advice is overruled, both the advice and the instructions are recorded in writing immediately afterwards. |
| 16 | Chief Executive (as Accounting Officer) | Appear before the Public Account Committee from time to time to give evidence on the reports arising from examinations undertaken by the Comptroller and Auditor General, and answer questions concerning expenditure and receipts for which he/she is Accounting Officer. |
| 17 | Chief Executive (as Accounting Officer) | Furnish the Public Accounts Committee with explanations of any weaknesses in the matters covered in paragraphs 8-15 of the NHS Foundation Trust Accounting Officer Memorandum, to which his/her attention has been drawn by the Comptroller and Auditor General or about which they may wish to question to Accounting Officer. |
| 19 | Chief Executive (as Accounting Officer) | Ensure that he/she is adequately and accurately briefed on matters which are likely to arise at any hearing of the Public Accounts Committee. |
| 21 | Chief Executive (as Accounting Officer) | Ensure that he/she is generally available for consultation, and that in any temporary period of unavailability, there will be a senior officer in the Foundation Trust who can act on his behalf if required. |
| 22 | Board of Directors | Where it becomes clear that the Accounting Officer is so incapacitated that he/she will be unable to discharge his/her responsibilities over a period of four weeks or more, appoint an acting Accounting Officer (usually the Finance Director), until his/her return. |
| 23 | Acting Accounting Officer | Sign accounts where the Accounting Officer is unable to sign in time for printing. |
SECTION 8 – SCHEDULE OF DECISION/DUTIES DELEGATED BY THE BOARD OF DIRECTORS (AS PER THE STANDING FINANCIAL INSTRUCTIONS)
Standing Financial Instructions (SFIs) has within it details of duties that have been delegated to executive directors and other officers within the Trust. (As per the version dated March 2023). Please note that the duties reserved to the Board of Directors as set out in the SFIs are detailed in Section 3 of this document.
PARA REF |
DELEGATED TO |
DECISION/DUTY SET OUT IN THE STANDING FINANCIAL INSTRUCTIONS (SFIs) |
| 1.1.5 | Chief Financial Officer | Provide advice on matters regarding the interpretation or application of SFIs. |
| 1.1.7 | Chief Financial Officer | Receive notice of non-compliance with the SFIs from staff and members of the Board of Directors as soon as it is reasonably practicable. |
| 1.3.5 | Chief Financial Officer | Is required to:
(a) implement the Foundation Trust’s financial policies and co-coordinate any necessary amendments to the policies where appropriate (b) maintain an effective system of internal financial control (c) ensure that accurate financial records of financial transactions are regularly kept up to date and disclose the financial position of the Trust when required and within a reasonable time scale (d) (i) provide financial advice to the Board of Directors, Council of Governors and employees (ii) advise on the design, implementation and supervision of systems of internal financial control (iii) prepare and maintain the Trust Accounts, certificates, estimates records and reports. |
| 1.3.7 | Chief Executive (as Accounting Officer) | To ensure any contractor or their employees are aware of their duties within the SFIs. |
| 1.3.8 | Chief Financial Officer | Ensure that the manner by which the Board of Directors and employees carry out their financial function are of a satisfactory standard. |
| 2.1.1 | Board of Directors | Establish the Audit Committee consisting of at least three non-executives in accordance with the Constitution, with clearly defined terms of reference. |
| 2.1.3 | Chief Financial Officer | Ensure an adequate Internal Audit service is provided. |
| 2.1.3 | Audit Committee | Monitor arrangements and be involved in the selection process when / if an Internal Audit service provider is changed. |
| 2.2.1 | Chief Financial Officer | Is required to:
(a) ensure there are arrangements to review, evaluate and report on the effectiveness of internal control (b) ensure that the Internal Audit service is adequate and meets mandatory audit standards (c) provide advice on what stage to involve the police in cases of misappropriation of funds and other financial irregularities not involving fraud or corruption (d) ensure that the Annual Internal Audit Report is prepared for the consideration of the Audit Committee (e) ensure that at least every three years an internal audit plan a strategy plan for the forthcoming three years is submitted to the Audit Committee for consideration; and that an Internal Audit Annual Plan for the coming year is submitted to the Audit Committee for consideration. |
| 2.3.2 | Staff | Where matters concerning Trust property or suspected irregularity in the exercise of any function of a pecuniary nature the Chief Financial Officer must be notified and must comply with the relevant financial procedures. |
| 2.3.4 | Chief Financial Officer | He / she must agree the reporting system for Internal Audit with the Internal Audit representative and the Audit Committee. The agreement should be in writing and comply with the guidance on reporting contained in the Internal Audit Standards. The CFO must also review the reporting system at least every three years. |
| 2.3.5 | Chief Financial Officer | Identify a formal review process to monitor the extent to which staff comply with audit recommendations and report any failure to implement the recommendations within a reasonable timescale to the Audit Committee. |
| 2.5.1 | Chief Financial Officer and Chief Executive (as Accounting Officer) | Monitor and ensure compliance with all relevant laws, codes and contractual obligations governing the conduct of countering fraud and corruption. |
| 2.5.3 | Chief Financial Officer | Receive reports from the Local Counter Fraud Specialist and work with the staff from NHS Counter Fraud Authority in accordance with the NHS Anti-crime Manual. |
| 2.5.3 | Local Counter Fraud Specialist | Provide a report to the audit Committee at least annually. |
| 2.6.2 | Chief Executive (as Accounting Officer) | Overall responsibility for controlling and coordinating security. |
| 3.1.1 | Chief Executive (as Accounting Officer) | Compile and submit to the Board a Business Plan that takes into account financial targets and forecast limits of available resources. |
| 3.1.2 | Chief Financial Officer | Prepare and submit budgets for approval by the Board prior to the start of the financial year. |
| 3.1.3 | Chief Financial Officer | Monitor and review financial performance against the budget and business plan. Report the findings of the above review to the Board and Finance and Performance Committee, with any significant variances being reported to the Board of Directors as soon as possible. |
| 3.1.4 | Budget Holders | Provide the Chief Financial Officer with information as required to enable budgets to be compiled. |
| 3.1.6 | Chief Financial Officer | Ensure that budget holders are adequately trained on an ongoing basis. |
| 3.2.1 | Chief Executive (as Accounting Officer) | Delegate the management of a budget to permit the performance of a defined range of activities. |
| 3.3.1 | Chief Financial Officer | Devise and maintain systems of budgetary control. |
| 3.3.2 (c) | Chief Executive (as Accounting Officer) | Other than those staff provided for within the available resources and manpower establishments, the appointment of any permanent staff over and above this shall be approved by the Chief Executive. |
| 3.3.3 | Chief Executive (as Accounting Officer) | Ensure the best possible use of resources, both manpower and finances and for delivering value for money at all times. |
| 3.3.4 | Chief Executive (as Accounting Officer) | Identify and implement cost improvement plans and revenue generation initiatives in accordance with the requirements of the Annual Business Plan. |
| 4.1.2 | Chief Financial Officer | Ensure that the Foundation Trust prepares, each financial year, annual accounts in accordance with the Treasury and NHS England requirements. |
| 4.1.4 | Chief Executive (as Accounting Officer) | Ensure the Trust sends copies of the annual accounts and any report of the External Auditor on them to NHS England and once it has so done, lay a copy of those documents before Parliament |
| 4.1.5 | Chief Executive (as Accounting Officer) | Responsible for complying with the requirements relating to the form, preparation and presentation of the accounts |
| 4.2.1 | Chief Executive (as Accounting Officer) | Ensure the Trust prepares annual reports in accordance with the accounting policies and guidance given by NHS Improvement and sends these to NHS Improvement |
| 5.1.1 | Chief Financial Officer | Manage the Foundation Trust’s banking arrangements and advise on the provision of banking services and operation of accounts. |
| 5.2.1 | Chief Financial Officer | Is responsible for:
(a) commercial bank accounts and Government Banking Service (GBS) accounts; (b) establish separate bank accounts for the Foundation Trust’s non-exchequer funds; (c) ensure payments made from bank or GBS accounts do not exceed the amount credited to the account except where arrangements have been made; (d) reporting to the Board of Directors all arrangements made with the Foundation Trust’s bankers for accounts to be overdrawn when utilising a working capital facility. |
| 5.3.1 | Chief Financial Officer | Prepare delailed instructions on the operation of bank and GBS accounts. |
| 5.3.2 | Chief Financial Officer | Advise the Trust’s bankers in writing of the conditions under which each account will be operated. |
| 5.3.3 | Chief Financial Officer | Approve security procedures for any cheques issued without a hand-written signature e.g. lithographed. |
| 5.4.1 | Chief Financial Officer | Review the commercial banking arrangements of the Foundation Trust at regular intervals to ensure they reflect best practice. |
| 6.1.1 | Chief Financial Officer | Design, maintain and ensure compliance with systems for the proper recording, invoicing, collection and coding of all monies due. |
| 6.1.3 | Chief Financial Officer | Responsible for the prompt banking of all monies received. |
| 6.2.1 | Chief Financial Officer | Approve and regularly review the level of all fees and charges (other than those determined by the Department of Health or by Statute). |
| 6.2.2 | All Staff | Inform the Chief Financial Officer promptly of money due arising from transactions which they initiate / deal with, including all contracts, leases, tenancy agreements, private patient undertakings and other transactions. |
| 6.3.1 | Chief Financial Officer | Ensure appropriate recovery of all outstanding debts, including formal follow up procedure for all debtor accounts and ensure overpayments are detected and prevented where possible and recovery initiated. |
| 6.4.1 | Chief Financial Officer | Is required to approve the form of all receipt books, agreement forms, or other means of officially acknowledging or recording monies received or receivable, order and securely control stationery stocks, and provide adequate facilities and systems for employees whose duties include collecting and holding cash, including the provision of safes or lockable cash boxes, the procedures for keys, and for coin operated machines. |
| 6.4.3 | Chief Financial Officer | Approve any exceptional arrangements for disbursements to be made from any cash received. |
| 6.4.5 | Chief Financial Officer | Receive a report of any loss or significant trends of any loss or shortfall of cash, cheques or other negotiable instruments. |
| 7.2 | Chief Executive (as Accounting Officer) | Ensure the Foundation Trust enters into suitable legally binding contracts (LBC) with commissioners for the provision of NHS services. |
| 7.3 | Chief Executive (as Accounting Officer) | Ensure that the Foundation Trust works with all partner agencies involved in both the delivery and the commissioning of the service required. |
| 7.6 | Chief Executive (as Accounting Officer) | Set out and agree a written partnership agreement with other partner organisations as identified in the Regulations for section 75 partnership arrangements and demonstrate that the aim of any such agreement is to improve services for users by raising standards and improving the quality and responsiveness of services. |
| 8.3.1 | Chief Financial Officer | Approve procurement procedures where goods are not processed through NHS supply chain. |
| 8.3.3 | Chief Financial Officer | Where tender processes have been waived in respect of the provision of legal advice or services the Chief Financial Officer will ensure that any fees paid are reasonable and within commonly accepted rates for the costing of such work. |
| 8.3.3 | Chief Financial Officer | Report to the Auditors where the Head of Procurement has approved an extension to an existing contract rather than carrying out a competitive exercise. |
| 8.3.5 | Chief Financial Officer | Where it is decided that competitive tendering is not applicable and should be waived, the reasons should be documented in an appropriate record and he/she is required to report it to the Audit Committee in a formal meeting. |
| 8.3.8 | Chief Executive (as Accounting Officer) | Receive a report on those goods or services procured which were originally estimated to be below the limits for tender / quotation as set in the Standing Financial Instruction which subsequently are found to have a value above those limits. |
| 8.4.3 (i) | Chief Executive (as Accounting Officer) | Approve the awarding of any contract where this may appear not to be strictly competitive |
| 8.4.3 (ii) | Chief Financial Officer / Chief Executive | Where only one tender is sought and/or received, the Chief Financial Officer along with the Chief Executive, as far practicable, shall ensure that the price to be paid is fair and reasonable and will ensure value for money for the Trust. |
| 8.4.4 | Chief Executive (as Accounting Officer) | Consider if any tenders received after the due time and date, but prior to opening of other tenders should be included in the tendering process. |
| 8.4.5 (iii) | Chief Executive (as Accounting Officer) | Authorise the acceptance of tenders which will commit expenditure in excess of that which is allocated by the Trust. |
| 8.4.7 | Chief Financial Officer | Make or instigate any enquiries deemed appropriate concerning the financial standing and financial suitability of approved contractors. |
| 8.4.11 | Chief Executive (as Accounting Officer) / Chief Financial Officer
|
One of either the Chief Executive of Chief Financial Officer shall approve any quotation which commits expenses in excess of that allocated. |
| 8.5.1 | Chief Executive (as Accounting Officer) / Chief Financial Officer | Demonstrate that the use of private finance represents value for money and genuinely transfers significant risk to the private sector. |
| 8.9.1 | Chief Executive (as Accounting Officer) | Ensure that best value for money can be demonstrated for all services provided on an in-house basis and may also determine from time to time that in-house services should be market tested by competitive tendering. |
| 9.2.2 | Chief Financial Officer | Have authority to vary or amend funded establishments. |
| 9.4.1 | Chief Financial Officer | In respect of processing the payroll the CFO is required to: specify timetables for submission of properly authorised time records and other notifications; ensure the final determination of pay and allowances (including verification that the rates of pay and relevant conditions of service) are in accordance with current agreements; make payment on agreed dates; and agree method of payment. |
| 9.4.2 | Chief Financial Officer | Ensure there is a contract with the payroll provider which sets out in detail how payroll payments will be administered. |
| 9.4.4 | Chief Financial Officer | Ensure that the chosen method for arranging the payroll service is supported by appropriate (contracted) terms and conditions, adequate internal controls and audit review procedures and that suitable arrangements are made for the collection of payroll deductions and payment of these to appropriate bodies. |
| 10.1.1 | Chief Executive (as Accounting Officer) | Determine the level of delegation for non-pay expenditure to budget managers. |
| 10.1.2 | Chief Executive (as Accounting Officer) | Required to set out the list of managers who are authorised to place requisitions for the supply of goods and services which should be updated and reviewed on an on-going basis and annually by the Finance/Supplies Department, the maximum level of each requisition and the system for authorisation above that level. |
| 10.1.3 | Chief Executive (as Accounting Officer) | Set out procedures on the seeking of professional advice regarding the supply of goods and services. |
| 10.2.1/
10.2.2 |
Chief Financial Officer or Chief executive | Provide advice when appropriate to the requisitioner (person issuing the purchase order) in respect of an item to be supplied where the advice of the Head of Procurement is not considered to be acceptable to the requisitioner. |
| 10.2.2 | Chief Financial Officer | Responsible for the prompt payment of accounts and claims in accordance with the Better Payment Practice Code. |
| 10.2.4 | Chief Financial Officer | For prepayments outside of normal commercial arrangements the Chief Financial Officer is to be satisfied with the proposed arrangements before contractual arrangements proceed. |
| 10.2.5 | Chief Financial Officer | Approve the official orders form. |
| 10.2.6 (a) | Chief Financial Officer | Receive notice of all contracts (except as otherwise provided for in the Schedule of Decision/Duties Delegated by the Board of Directors), including leases, tenancy agreements and other commitments which may result in a liability in advance of any commitment being made. |
| 10.2.6 (e) | Chief Financial Officer | Authorise a requisition / order for an item or items for which there is no budget provision. |
| 10.2.6 (j) | Chief Financial Officer | Maintain a list of employees and officers authorise to certify invoices. |
| 10.2.6 (l) | Chief Financial Officer | Determine the format of the petty cash records |
| 10.2.7 | Chief Financial Officer | Ensure that the arrangements for financial control and financial audit of building and engineering contracts and property transactions comply with the relevant guidance, e.g. ESTATECODE. |
| 10.2.8 | Chief Financial Officer | Determine the procedures for payments to local authorities and voluntary organisations under Section 75 arrangements. |
| 11.2.2 | Chief Financial Officer | Advise the Board of Directors of any utilization of a working capital facility at the next appropriate Board meeting. |
| 11.3.3 | Chief Financial Officer | Provide advice to the Finance and Performance Committee on investments and report periodically to the Finance and Performance Committee concerning the performance of investments held. |
| 11.3.4 | Chief Financial Officer | Prepare detailed procedural instructions on investment operations on the records to be maintained. |
| 12.1 | Chief Executive (as Accounting Officer) | Is responsible for: ensuring that there is an adequate appraisal and approval process in place for determining capital expenditure priorities and the effect of each proposal upon business plans; the management of all stages of capital schemes and for ensuring that schemes are delivered on time and to cost; and that the capital investment is not undertaken without the availability of resources to finance all revenue consequences, including capital charges. |
| 12.2 (a) | Chief Executive (as Accounting Officer) | For every major capital expenditure proposal the Chief Executive will ensure (in accordance with the limits outlined in the scheme of delegation) that a business case is produced. |
| 12.2 (b) | Chief Financial Officer | Certify professionally to the costs and revenue consequences detailed in the business case. |
| 12.3 | Chief Executive (as Accounting Officer) | Where capital scheme contracts stipulate stage payments, issue procedures for their management incorporating recommendations of ESTATECODE and other relevant guidance. |
| 12.4 | Chief Financial Officer | On an annual basis the Chief Financial Officer should assess the requirement for the operation of the construction industry tax deduction scheme in accordance with Inland Revenue guidance. |
| 12.5 | Chief Financial Officer | Issue procedures for the regular reporting of expenditure and commitment against authorised expenditure. |
| 12.6 | Chief Executive (as Accounting Officer) | For the capital programme the Chief Executive will issue to the manager responsible for any scheme: specific authority to commit expenditure; authority to proceed to tender; and approval to accept a successful tender. |
| 12.6 | Chief Executive (as Accounting Officer) | Issue a scheme of delegation for capital investment management in accordance with NHS England guidance and the Foundation Trust’s Standing Orders. |
| 12.7 | Chief Financial Officer | Issue procedures governing the financial management, including variations to contract, of capital investment projects and valuation for accounting purposes. |
| 12.8 | Chief Financial Officer | Agree any finance or operating lease entered into. |
| 12.9.1 | Chief Executive (as Accounting Officer) | Maintain the registers of assets, taking account of the advice of the Chief Financial Officer 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. |
| 12.9.5 | Chief Financial Officer | Approve procedures for reconciling balances on non-current assets accounts in ledgers against balances on non-current asset registers. |
| 12.9.7 | Chief Financial Officer | Calculate and pay capital charges as specified. |
| 12.11.1 | Chief Executive (as Accounting Officer) | Has overall control for non-current assets |
| 12.11.1 | Chief Financial Officer | Advise the Chief Executive on the overall control of non-current assets. |
| 12.11.2 | Chief Financial Officer | Approve the asset control procedures (including non-current assets, cash, cheques and negotiable instruments, and also including donated assets). |
| 12.11.3 | Chief Financial Officer | Receive notification of all significant discrepancies revealed by the verification of physical assets to non-current asset register. |
| 13.2.3 | Chief Financial Officer | Set out procedures and systems to regulate the stores including records for receipt of goods, issues from and returns to stores, and losses. |
| 13.2.4 | Chief Financial Officer | Agree the stocktaking arrangements and, if a physical checking of the stock is required, determine the extent to which this would be done. |
| 13.2.5 | Chief Financial Officer | Approve alternative arrangements where it is found that a complete system of stores control is not justified. |
| 12.2.6 | Chief Financial Officer | Approval of a system for the review of slow moving and obsolete items and those for condemnation, disposal and replacement of unserviceable items |
| 13.2.6 | Chief Financial Officer | Receive a report from the designated manager/pharmaceutical officer on any evidence of significant overstocking and of any negligence or malpractice. |
| 13.3 | Chief Executive (as Accounting Officer) | For goods supplied via the central warehouses, identify those authorised to requisition and accept goods from the store. |
| 13.3 | Chief Financial Officer | Receive copies of delivery notes once goods received have been checked against this. |
| 13.4 | Chief Financial Officer | Approve all transfers and returns recorded on a system or form. |
| 14.1.1 | Chief Financial Officer | Prepare detailed procedures for the disposal of assets, including condemnations, and ensure that these are notified to staff. |
| 14.1.1 | Chief Financial Officer | Responsible for the approval of material disposals. |
| 14.1.3 (b) | Chief Financial Officer | Approve the form to be used in respect of converting, destroying or disposing of unserviceable items. |
| 14.1.4 | Chief Financial Officer | Receive a report from the Condemning Officer of any evidence of negligence and take the appropriate action |
| 14.2.1 | Chief Financial Officer | Prepare procedural instructions on the recording of and accounting for condemnations, losses, and special payments. |
| 14.2.2 | Chief Financial Officer | Report suspected criminal acts immediately to the police such a theft or arson. In cases of fraud and corruption or of anomalies which may indicate fraud or corruption, he/she must inform the relevant LCFS. |
| 14.2.2 | Chief Financial Officer | Liaise appropriately with the Local Counter Fraud Specialist, NHS Counter Fraud Authority and the External Auditor regarding all frauds. |
| 14.2.3 | Chief Financial Officer | For any losses caused by theft, arson, neglect of duty or gross carelessness, except if trivial, the Chief Financial Officer must immediately notify the Board of Directors; the External Auditor; and the NHS Counter Fraud Authority. |
| 14.2.5 | Chief Financial Officer | Take any necessary steps to safeguard the Trust’s interests in bankruptcies and company liquidations. |
| 14.2.6 | Chief Financial Officer | For any loss, he/she should consider whether any insurance claim can be made. |
| 14.2.7 | Chief Financial Officer | Maintain a Losses and Special Payments Register in which write-off action is recorded. |
| 15.1.1 | Chief Financial Officer | Responsible for the accuracy and security of the computerised financial data of the Foundation Trust and in conjunction with Information and Knowledge Services Department. |
| 15.1.2 | Chief Financial Officer | Ensure that new financial systems and amendments to current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. |
| 15.1.3 | Chief Financial Officer | Publish and maintain a FOI Publication Scheme. |
| 15.3 | Chief Financial Officer | Ensure that contracts for computer services for financial applications with another health organisation or any other agency clearly define the responsibility of all parties for the security, privacy, accuracy, completeness, and timeliness of data during processing, transmission and storage. Periodically seek assurances that adequate controls are in operation where personal data is processed on the Trust’s behalf by another organisation. |
| 16.3 | Chief Financial Officer | Provide detailed written instructions on the collection, custody, investment, recording, safekeeping and disposal of patients’ property. |
| 16.4 | Chief Financial Officer | Determine the form to be used to record patients’ property |
| 16.5 | Chief Financial Officer | The opening and operation of separate accounts for patients’ monies as may be required by Department of Health guidelines. |
| 17.1.3 | Chief Financial Officer | Ensure that each charitable fund which the Trust is responsible for is managed appropriately with regard to its purpose and to its requirements. |
| 17.4.1 | Chief Financial Officer | Ensure that regular reports are made to the Board of Trustees with regard to the receipt of funds, investments and expenditure. |
| 17.4.2 | Chief Financial Officer | Prepare and submit annual accounts for the charitable funds in the required manner and within agreed timescales. |
| 17.4.3 | Chief Financial Officer | Prepare an annual trustees’ report and the required returns to the Charity Commission for adoption by the Charitable Funds Committee. |
| 17.5.2 | Chief Financial Officer | Maintain all financial records for charitable funds to enable the production of reports and to the satisfaction of internal audit and the financial auditor. |
| 17.5.3 | Chief Financial Officer | Determine the basis on which the distribution of investment income to the charitable funds and the recovery of administration costs will be performed. |
| 17.5.4 | Chief Financial Officer | For the charitable funds ensure that the records, accounts and returns receive adequate scrutiny by internal audit during the year and liaise with the financial auditor and provide them with all necessary information, as required by the current legislation governing the administration of charities. |
| 18 | Chief Executive (as Accounting Officer) via the Chief Financial Officer | Ensure that all staff are made aware of the Trust’s policy on acceptance of gifts and other benefits in kind by staff. |
| 19.2 | Chief Executive (as Accounting Officer) | Maintain archives for all documents required to be retained under the direction contained in Department of Health guidance; Records Management Code of Practice. |
| 19.5 | Chief Executive (as Accounting Officer) | Have authority to destroy records held in accordance with latest Department of Health guidance “Records Management Code of Practice” |
| 20.1 | Chief Executive (as Accounting Officer) | Ensure that the Foundation Trust has a risk management programme, in accordance with the current assurance framework requirements. |
| 20.3 | Chief Executive (as Accounting Officer) | Draw up formal documented procedures for the management of any claims arising from third parties and payments in respect of losses which will not be reimbursed. Ensure documented procedures also cover the management of claims and payments. |
| 20.5.3 | Chief Executive (as Accounting Officer) | Manage clinical negligence clams and inform the Board of Directors of any major developments on claims related issues. |
SECTION 9 – SCHEDULE OF DECISIONS/DUTIES DELEGATED BY THE POWERS OF THE MENTAL HEALTH ACT 1983 OR ANY OF ITS SUBSEQUENT AMENDMENTS
FUNCTIONS WHICH CANNOT BE DELEGATED TO OFFICERS OF THE TRUST
FUNCTION |
STATUTORY REFERENCE |
CODE OF PRACTICE REFERENCE |
AUTHORISED PERSON/COMMITTEE |
| Review of patients’ detention or Community Treatment Order | MHA S20(3)
MHA S20A(5) |
Chapter 38 | Non-executive Directors and the committee of Mental Health Act Managers (MHAM)
|
| Exercise of hospital managers’ power to discharge unrestricted detained patients and patients subject to a Community Treatment Order | MHA S23(2)(a)
|
Chapter 38 | Non-executive Directors and the committee of Mental Health Act Managers (MHAM) |
FUNCTIONS WHICH CAN BE DELEGATED TO OFFICERS OF THE TRUST
FUNCTION |
STATUTORY REFERENCE |
CODE OF PRACTICE REFERENCE |
AUTHORISED PERSONS |
| Formal receipt of statutory admission documents for detained patients | MHA S11(2)
Regulation 4* |
Chapter 35 | Professional in charge of a ward/unit or deputy
Mental Health Legislation Officer Mental Health Law Adviser Mental Health Legislation Team Leader Head of Mental Health Legislation |
| Receipt of statutory documents in respect of section 5(2) | MHA S5(2)
Regulation 4(1)(g)* |
Chapter 18
paragraph 18.6 |
Professional in charge of a ward/unit or deputy
Mental Health Legislation Officer Mental Health Law Adviser Mental Health Legislation Team Leader Head of Mental Health Legislation |
| Receipt of record for purposes of section 5(4) | MHA S5(4)
Regulation 4(1)(h)* |
Chapter 18
Paragraph 18.26 |
Professional in charge of a ward/unit or deputy
Mental Health Legislation Officer Mental Health Law Adviser Mental Health Legislation Team Leader Head of Mental Health Legislation |
| Receipt of discharge notice/order by the patient’s nearest relative | MHA S25(1)
Regulation 25(1)* |
Chapter 32
paragraphs 32.21, 32.22 & 32.24 |
Professional in clinical team
Mental Health Legislation Officer Mental Health Law Adviser Mental Health Legislation Team Leader Head of Mental Health Legislation |
| Receipt of report barring discharge by nearest relative | MHA S25(1)
Regulation 25(1)* |
Chapter 32
paragraphs 32.21, 32.22 & 32.24 |
Mental Health Legislation Officer
Mental Health Law Adviser Mental Health Legislation Team Leader Head of Mental Health Legislation |
| Scrutiny of statutory forms | MHA S15
Regulation 4(3)* |
Chapter 35 | Administrative scrutiny:
Mental Health Legislation Officer Mental Health Law Adviser Mental Health Legislation Team Leader Head of Mental Health Legislation Medical scrutiny: Consultant Psychiatrist (section 12 approved) |
| Rectification of documentation | MHA S15
Regulation 4(3)* |
Chapter 35 | Mental Health Legislation Officer
Mental Health Law Adviser Mental Health Legislation Team Leader Head of Mental Health Legislation |
| Recording of admission | Regulations 4 and 6* | Chapter 35 | Professional in Charge of a ward/unit or deputy
Mental Health Legislation Officer Mental Health Law Adviser Mental Health Legislation Team Leader Head of Mental Health Legislation |
| Authorisation of the transfer of patients | MHA S19
Regulation 7* |
Chapter 37
paragraphs 37.16 – 37.27 |
Decision to transfer is made by the Responsible Clinician
Documentation is completed by: Professional in charge of a ward/unit or deputy Mental Health Legislation Officer Mental Health Law Adviser Mental Health Legislation Team Leader Head of Mental Health Legislation |
| Formal receipt of renewal and extension documentation on behalf of the hospital managers | MHA S20(3)(b)
MHA S20A(5) Regulation 13* |
Chapter 32 | Mental Health Legislation Officer
Mental Health Law Adviser Mental Health Legislation Team Leader Head of Mental Health Legislation |
| Provision of information to patients and their nearest relatives | MHA S130d, 132, 132A & 133
Regulation 26* |
Chapter 4
paragraphs 6.15 and 12.6 |
Multidisciplinary team
Mental Health Legislation Officer Mental Health Law Adviser Mental Health Legislation Team Leader Head of Mental Health Legislation As prescribed in Trust s.132 protocol |
| Submission of statement of authority to the Tribunal | Tribunal Rule 32** | Chapter 12
paragraph 12.11 |
Mental Health Legislation Officer
Mental Health Law Adviser Mental Health Legislation Team Leader Head of Mental Health Legislation |
| Referral of cases to the Tribunal | MHA S68
Tribunal Rule 32** |
Chapters 12 and 39
paragraphs 12.10 and 37.39 |
Mental Health Legislation Officer
Mental Health Law Adviser Mental Health Legislation Team Leader Head of Mental Health Legislation |
| Referral of cases to the Secretary of State | MHA S67 | Chapter 37
paragraphs 37.44 – 37.46 |
Mental Health Legislation Officer
Mental Health Law Adviser Mental Health Legislation Team Leader Head of Mental Health Legislation |
| Return of patients who are absent without leave (AWOL) | MHA S18 | Chapter 28
Paragraph 28.4, 28.8 |
Any member of staff of the Trust or staff contracted to the Trust from Aspire, Community Links, Touchstone and North Point.
Any other person authorised by the Hospital Managers (for written authorisation purposes, the Schedule of Decisions directs that this function can be exercised by a service manager, the patient’s responsible clinician or anyone delegated by the service manager or responsible clinician). |
*The Mental Health (Hospital, Guardianship and Treatment) (England) Regulations 2008 (SI2008/1184)
**Health, Education and Social Care Chamber of the First-tier Tribunal
References
Mental Health Act 1983 Mental Health Act 1983 Code of Practice 2015
The Mental Health (Hospital, Guardianship and Treatment) (England) Regulations 2008 (SI 2008/1184)
Tribunal Procedure (First Tier Tribunal) (Health, Education and Social Care Chamber) Rules 2008 (SI 2008/2699)
Reference Guide to the Mental Health Act 1983, Department of Health 2015
SECTION 10 – SCHEDULE OF RESPONSIBILITIES DELEGATED TO THE SUB-COMMITTEES OF THE BOARD OF DIRECTORS
The table below sets out the responsibilities that have been delegated to the sub-committees of the Board of Directors (including Committee in Common). Further details of the individual duties can be found in their respective Terms of Reference.
| NAME OF COMMITTEE |
DELEGATED RESPONSIBILITY OF THE COMMITTEE |
| Audit Committee | The purpose of the Audit Committee is to provide the Board of Directors with assurance that:
· Clinical, financial reporting, compliance, risk management, health and safety and internal control principles and standards are being appropriately applied and are effective, reliable and robust · An effective governance framework is in place for monitoring and continually improving the quality of health care provided to service users to enable the Trust’s strategic objectives to be achieved. |
| Quality Committee | The Quality Committee has responsibility for providing assurance to the Board of Directors on the effectiveness of the:
· Trust’s quality and safety systems and processes · Quality and safety of the services provided by the Trust · Control and management of quality and safety related risk within the Trust. |
| Finance and Performance Committee | The principle purpose of Finance and Performance Committee is to provide the Board with Assurance on:
· Financial governance and performance; · Contractual performance · Strategic matters in relation to procurement, estates, information technology and information management; · Financial and clinical service performance including clinical actively and key performance indicators. |
| Mental Health Legislation Committee | The MHL Committee provides assurance to the Board regarding compliance with all aspects of the Mental Health Act 1983 and subsequent amendments and on compliance with all aspects of mental health legislation including, but not limited to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. |
| Workforce Committee | The purpose of the committee is to provide the Board with assurance in relation to:
· All aspects of strategic workforce matters relating to the provision of care and services in support of getting the best clinical outcomes and experience for patients and staff. · A positive working environment for staff which promotes an open culture that helps staff do their job to the best of their ability. |
| Nominations Committee | The purpose of the Nominations Committee is to regularly review the structure, size and composition of the Board of Directors and make recommendations for changes where appropriate. In particular, the committee should evaluate the balance of skills, knowledge and experience on the Board of Directors. It shall also have a role in ensuring appropriate succession plans are in place for members of the executive team. In relation to the appointment of executive and non-executive directors the committee shall prepare a description of the role and capabilities required for appointment of both executive and non-executive directors, including the Chair of the Trust. |
| Remuneration Committee | The purpose of the Remuneration Committee is to provide the Board of Directors with assurance that executive directors are rewarded appropriately for their contribution; that appropriate contractual arrangements are in place; and to be assured of the performance of individual executive directors against their agreed objectives, and that plans are in place to address any areas of development. |
| West Yorkshire Mental Health Services Collaborative Committees in Common | With our mental health partners in West Yorkshire (Bradford District Care Foundation Trust, Leeds Community Healthcare NHS Trust, and South West Yorkshire Partnership Foundation Trust) the Committees in Common will progress working together to improve acute and specialist mental health services for local communities, as part of the wider West Yorkshire & Harrogate Health and Care Partnership. It will work together as the lead organisations to deliver the Mental Health Five Year Forward View for local people in West Yorkshire, build on what’s good and working well already across the region, sharing best practice and designing new service models together. |
It should be noted that strategies that sit beneath the five supporting strategies are presented to Board sub-committees (Workforce Committee, Quality Committee, Finance and Performance Committee and Mental Health Legislation Committee) so they are sighted on the detail, but are not presented for approval.
It has also been agreed by the Board that the following NED Champion roles will be carried out through the Board sub-committee structure:
NED champion role |
NED / Sub-committee to oversee the NED Champion role |
| Maternity board safety champion | · Named champion to be the chair of the Quality Committee.
· Requirements of the role to be discharged through the Quality Committee. Note – while LYPFT does not provide maternity services, it was agreed by the Board in January 2021 that the Quality Committee would carry out the NED Champion role for the Perinatal Service. |
| Wellbeing guardian | · Named champion to be the chair of the Workforce Committee.
· Requirements of the role to be discharged through the Workforce Committee. |
| Freedom to speak up | · Named champion to be the Senior Independent Director.
· Requirements of the role to be discharged through the Board of Directors. |
| Doctors disciplinary | · Named champion to be the chair of the Workforce Committee.
· Requirements of the role to be discharged through the Workforce Committee. |
| Hip fracture, falls and dementia | · Requirements of the role to be discharged through the Quality Committee. |
| Learning from deaths | · Requirements of the role to be discharged through the Quality Committee. |
| Safety and risk | · Requirements of the role to be discharged through the Audit Committee. |
| Health and safety | · Requirements of the role to be discharged through the Audit Committee. |
| Children and young people | · Requirements of the role to be discharged through the Quality Committee. |
| Resuscitation | · Requirements of the role to be discharged through the Quality Committee. |
| Cybersecurity | · Requirements of the role to be discharged through the Finance and Performance Committee. |
| Emergency preparedness | · Requirements of the role to be discharged through the Finance and Performance Committee. |
| Safeguarding | · Requirements of the role to be discharged through the Quality Committee. |
| Procurement | · Requirements of the role to be discharged through the Finance and Performance Committee. |
| Security management – violence and aggression | · Requirements of the role to be discharged through the Workforce Committee. |
| Palliative and of Life Care Champion | · Requirements of the role to be discharged through the Quality Committee. |
| Patient Experience | · Named champion to be Kaneez Khan. |
| Sustainability | · Named champion to be Katy Wilburn. |
SECTION 11 – SCHEDULE OF RESPONSIBILITIES DELEGATED TO THE ACCOUNTABLE EMERGENCY OFFICER (AEO) (as set out in the NHS Commissioning Board’s (NHS England’s) The role of ‘Accountable Emergency Officers’ for Emergency Preparedness, Resilience and Response (EPRR))
Following the Health and Social Care Act 2012, organisations must have an appointed Accountable Emergency Officer (AEO) who is a Board-level director who is responsible for EPRR in their organisation; this person should be supported by a non-executive director (the Chair of the Finance and Performance Committee). The Accountable Emergency Officer has the appropriate authority, resources and budget to direct the EPRR portfolio and is responsible for:
- Ensuring that the organisation is compliant with the EPRR requirements as set out in the civil contingencies act (2004); the NHS planning framework and the NHS standard contract as applicable;
- Ensuring that the organisation is properly prepared and resourced for dealing with a major incident or civil contingency event;
- Ensuring their organisation, and any providers they commission, have robust business continuity planning arrangements in place which reflect standards set out in the Framework for Health Services Resilience (PAs 2015) and ISO 22301;
- Ensuring the organisation has a robust surge capacity plan that provides an integrated organisational response and that it has been tested with other providers and parties in the local community(ies) served.
- Ensuring that the organisation complies with any requirements of NHS England, or agents thereof, in respect of the monitoring of compliance.
- Providing NHS England, or agents thereof, with such information as it may require for the purpose of discharging its functions; and
- Ensuring that the organisation is appropriately represented at any governance meetings, sub-groups or working groups of the local health resilience partnership (LHRP) or local resilience forum (LRF).
In this Trust the role of Accountable Emergency Officer has been delegated to the Chief Operating Officer by the Chief Executive. The day-to-day management of an incident will be carried out through the EPRR Lead under the management of the Accountable Emergency Officer.