POLICY REF NO; SABP/GOVERNANCE/0003
NAME OF POLICY OR
PROCEDURE:
REASON FOR POLICY OR
PROCEDURE :
WHAT THE POLICY WILL
ACHIEVE:
Reservation of Powers to the
Board of Directors and Delegation
of Powers
n Wit Within the Terms of Authorisation
issued by the Independent
Regulator, NHS Foundation Trust’s
are required to demonstrate the
existence of comprehensive
governance arrangements which
may be delegated in accordance
with Section 15 of Schedule 7 of
the National Health Service Act.
This document is the Scheme of
Delegation for Surrey and Borders
Partnership NHS Foundation Trust,
which sets out those decisions
which are reserved for the Board of
Directors and those which may be
delegated to a committee, subcommittee, or a Director or Officer
of the Trust.
WHO NEEDS TO KNOW ABOUT IT:
All Staff
DATE APPROVED:
Board March 2017
7.0
VERSION NUMBER:
APPROVING COMMITTEE:
Board of Directors
AUTHOR/REVIEWER:
Director of Governance & Planning
DATE OF IMPLEMENTATION:
01.04.17
DATE OF FORMAL REVIEW:
01.04.19
RESPONSIBLE DIRECTORATE:
DISTRIBUTION:
Chief Executive’s Office
All Directorates
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Reservation of Powers
to The Board of Directors
and
Delegation of Powers
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CONTENTS
Page No
1
Introduction
3
2
Reservation of Powers to the Board of Directors
6
3
Scheme of Delegation Derived from:

Codes of Conduct and Accountability
15

Standing Orders
18

Standing Financial Instructions
20
4
Detailed Scheme of Delegation
34
5
Senior Officer Schedule
52
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Section 1 - INTRODUCTION
1.1
Within our Licence issued by the independent regulator to providers of NHS
services, NHS Foundation Trust’s are required to demonstrate the existence of
comprehensive governance arrangements which may be delegated in accordance
with Section 15 of Schedule 7 of the National Health Service Act 2006.
This document is the Scheme of Delegation for Surrey and Borders Partnership
NHS Foundation Trust, which sets out those decisions which are reserved for the
Board of Directors and those which may be delegated to a committee, subcommittee, or a Director or Officer of the Trust.
The arrangements are to be read in conjunction with and subject to the Standing
Orders and Standing Financial Instructions adopted by the Trust. Details of the
Delegation of Duties implied from Standing Orders and Standing Financial
Instructions are given in Section 3 of this document.
It should be noted that the Board of Directors remains accountable for all of its
functions, even those delegated to the Chair, individual Directors or Officers and
would therefore expect to receive information about the exercise of delegated
functions to enable it to maintain a monitoring role.
1.2
Role of the Chief Executive
All powers of the Trust which have not been retained as reserved by the Board of
Directors or delegated to an executive committee or sub-committee shall be
exercised on behalf of the Board of Directors by the Chief Executive. A detailed
Scheme of Delegation identifying which functions the Chief Executive shall
perform personally and which functions have been delegated to other Directors
and Officers, is shown in Section 4.
The Chief Executive will establish appropriate management arrangements to
ensure that senior Officers pursue the Trust’s policies in a corporate manner. All
powers delegated by the Chief Executive can be re-assumed by him/her should
the need arise.
The Chief Executive is the Accounting Officer of the Trust (Paragraph 16(1) of
Schedule 7 to the 2006 Act). The NHS Foundation Trust Accounting Officer
Memorandum issued by the independent regulator, the Independent Regulator(17
April 2008) sets out the additional responsibilities and duties of the Chief
Executive, in relation to discharging these functions. A copy of the Memorandum is
available from the Board Secretary, on request.
1.3
Caution over the Use of Delegated Powers
Powers are delegated to directors and officers on the understanding that they
would not exercise delegated powers in a matter which in their judgment was likely
to be a cause for public concern.
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1.4
Directors' Ability to Delegate their own Delegated Powers
As indicated in 1.2 above, a detailed Scheme of Delegation is shown in Section 4,
and includes delegated procedures for the approval of the expenditure. It should
be used in conjunction with the system of budgetary control and other established
procedures within the Trust.
1.5
Management Team
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 senior officers pursue the
Trust’s policies in a corporate manner.
1.6
Absence of Directors or Officer to Whom Powers have been Delegated
In the absence of a director or officer to whom powers have been delegated those
powers shall be exercised by that director’s or officer's superior unless alternative
arrangements have been approved by the Board of Directors. If the Chief
Executive is absent powers delegated to him/her may be exercised by the Chair or
Deputy Chief Executive after taking appropriate advice from the Chief Finance
Officer.
1.7
Financial Delegation
Managers will exercise financial delegation and virement arrangements in
accordance with the Trust’s budgetary rules.
Where more than one Officer has delegated authority to commit expenditure from
a fund, those Officers have an obligation to consult with each other to ensure that
the total committed does not exceed the approved Budget for the year, or the
balance in the fund at any time as appropriate.
1.8
Reservation of Powers to the Board of Directors
The Code of Accountability which has been adopted by the Trust requires the
Board of Directors to determine those matters on which decisions are reserved
unto itself. These reserved matters are set out in tabular form in the “Reservation
of Powers to the Board of Directors” table in Section 2.
1.9
Delegation to Committees
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The Board of Directors may determine that certain of its powers shall be exercised
by Standing Committees. The composition and terms of reference of such
committees shall be that determined by the Board of Directors from time to time
taking into account where necessary the requirements of regulators e.g. NHSI and
or the Charity Commissioners. The Board of Directors shall determine the
reporting requirements in respect of these committees. In accordance with SO
5.5.1 committees may not delegate executive powers to sub committees unless
expressly authorised by the Board of Directors.
1.10
Delegation to Officers
Standing Orders and Standing Financial Instructions set out in some detail the
financial responsibilities of the Chief Executive, the Chief Finance Officer and other
directors.
Certain matters needing to be covered in the scheme of delegation are not
covered in SFIs or SOs or they do not specify the responsible officer. These are:
Area of responsibility
1.11
Overall Responsibility

Data Protection Act
Chief Executive has overall
accountability, however day to
day responsibility is delegated
to the Chief Nursing Officer

Health & Safety
Arrangements
Chief Executive has overall
accountability, however lead
responsibility is delegated to
the Chief Medical Officer with
operational
responsibility
devolved to all Directorates.
Derived Schemes of Delegation
The Schemes of Delegation outlined in Section 3 cover those duties delegated to
Committees, Directors, or Officers from the following documents

The codes of Conduct and Accountability

Standing Orders

Standing Financial Instructions
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Section 2 – RESERVATION OF POWERS TO THE BOARD OF DIRECTORS
THE BOARD OF
DIRECTORS
BOARD OF DIRECTORS
DECISIONS RESERVED TO THE BOARD OF DIRECTORS
General Enabling Provision
The Board of Directors may determine any matter, for which it has delegated or statutory authority, it wishes
in full session within its statutory powers.
BOARD OF DIRECTORS
Regulations and Control
Approve Standing Orders (SOs) (in accordance with the Health and Social Care Act 2012 approval
requires more than 50% of the Board of Directors and more than 50% of the Council of Governors as the
SOs form part of our Constitution)
Approve a schedule of matters reserved to the Board and Standing Financial Instructions for the
regulation of its proceedings and business
Suspend Standing Orders
Vary or amend the Standing Orders (with the Council of Governors as above in accordance with the
Health and Social Care Act)
Ratify any urgent decisions taken by the Chair and Chief Executive in public/private session in accordance
with Standing Orders.
Approve a scheme of delegation of powers from the Board to committees
Require and receive the declaration of Board members’ interests that may conflict with those of the Trust
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THE BOARD OF
DIRECTORS
DECISIONS RESERVED TO THE BOARD OF DIRECTORS
and determining the extent to which that member may remain involved with the matter under
consideration.
Approve arrangements for dealing with complaints
Adopt the organisation structures, processes and procedures to facilitate the discharge of business by the
Trust and to agree modifications thereto.
Receive reports from committees including those that the Trust is required by regulation to establish and
to take appropriate action on.
Confirm the recommendations of the Trust’s committees where the committees do not have executive
powers.
Approve arrangements relating to the discharge of the Trust’s responsibilities as a corporate trustee for
funds held on trust.
Establish terms of reference and reporting arrangements of all committees and sub-committees that are
established by the Board.
Approve arrangements relating to the discharge of the Trust’s responsibilities as a bailee for patients’
property.
Authorise use of the seal
Ratify or otherwise instances of failure to comply with Standing Orders brought to the Chief Executive’s
attention
Discipline members of the Board or employees who are in breach of statutory requirements or SOs.
BOARD OF DIRECTORS
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Appointments/ Dismissal
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THE BOARD OF
DIRECTORS
DECISIONS RESERVED TO THE BOARD OF DIRECTORS
Ratify the appointment of the Deputy Chair (appointed by the Council of Governors)
Appoint the Senior Independent Director (with the support of the Council of Governors)
Appoint and dismiss committees (and individual members) that are directly accountable to the Board.
Appoint, appraise, discipline and dismiss Executive Directors (subject to SO 3.13.1.3).
Confirm appointment of members of any committee of the Trust as representatives on outside
bodies.
Approve proposals of the Remuneration Committee regarding directors and senior employees and those
of the Chief Executive for staff not covered by the Remuneration & Terms of Service Committee.
BOARD OF DIRECTORS
Strategy, Plans, Budgets and Direct Operational Decisions
Define the strategic aims and objectives of the Trust.
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.
Approve proposals for ensuring quality and developing clinical governance in services provided by the
Trust, having regard to any guidance issued by the Secretary of State or the Independent
Regulator e.g. NHSI.
Approve Outline and Final Business Cases for Capital Investment in accordance with the thresholds set
out in the Standing Financial Instructions.
Approve budgets.
Ratify proposals for acquisition, disposal or change of use of land and/or buildings through the approval
of the annual capital programme in accordance with the Standing Financial Instructions
Approve PFI proposals.
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THE BOARD OF
DIRECTORS
DECISIONS RESERVED TO THE BOARD OF DIRECTORS
Approve the appointment of bankers (including the opening of bank accounts)
Approve individual compensation payments in accordance with the thresholds set in the Standing
Financial Instructions.
Approve proposals for action on litigation against or on behalf of the Trust. (Fees over In accordance with
levels set within the Standing Financial Instructions)
Review proposals on service policies and priorities as negotiated with commissioners.
Consider advice from any such Professional Advisory Committees as the Board may establish or
recognise.
Receive reports from the Chief Finance Officer on the legally binding contracts entered into with the
purchasers
To approve business cases requiring additional revenue resources.
The introduction or discontinuance of any significant activity or operation. This decision can be made
through the acceptance of a business plan/budget for a period where the introduction or discontinuance
is clearly described.
An activity or operation shall be regarded as significant if it has a gross annual
income or expenditure as set out in the Trust’s Standing Financial Instructions. Any transaction which
meets the definition of “significant transaction” as defined in our Constitution is subject also to the
approval of the Council of Governors in accordance with our Constitution.
BOARD OF DIRECTORS
Human Resources
Approve pay and terms and conditions of employment for Trust employees (except where covered by
National Agreements)
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THE BOARD OF
DIRECTORS
DECISIONS RESERVED TO THE BOARD OF DIRECTORS
Approve salaries for Trust Directors and Senior Managers
BOARD OF DIRECTORS
Audit
Review of the annual management letter received from the external auditor and agreement of proposed
action, taking account of the advice, where appropriate, of the Audit Committee
Consider external auditor’s reports on the affairs and accounts of the Trust as referred to it by the
Audit Committee.
BOARD OF DIRECTORS
Annual Report and Accounts
Receipt and approval of the Trust’s Annual Report and Annual Accounts.
BOARD OF DIRECTORS
Monitoring
Receipt of such reports as the Board sees fit from committees in respect of their exercise of powers
delegated
Board may require from directors, committees, and officers of the Trust as set out in management policy
statements. All monitoring returns required by the independent regulator e.g. NHSI shall be reported at
least in summary, to the Board
Receive reports from Chief Finance Officer (CFO) on financial performance against budget and business
plans
Receive reports from CFO on actual and forecast income from service contracts
Receive reports from the Chief Executive and Chief Finance Officer upon the implementation of and
variances from, agreed business plans, service level agreements, budgets and capital programmes, and
where appropriate take necessary action.
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THE BOARD OF
DIRECTORS
DECISIONS RESERVED TO THE BOARD OF DIRECTORS
Make such directions regarding internal financial control and control of income/expenditure as required by
the independent regulator e.g. NHSI
Authorise payments which require the prior approval of the Trust Board under Standing Orders and
Standing Financial Instructions
Receive reports of external and internal issues affecting the services within the Trust from the Chief
Executive and the other Directors and take action where necessary
Make arrangements for the investigation of serious complaints
BOARD OF DIRECTORS
Buildings, Land and Equipment
Ensure that the capital programme is within the terms of the Prudential Borrowing Code
Approve all asset disposals and transfers in accordance with the thresholds set within the Standing
Financial Instructions and the Trust’s Terms of Authorisation
Determine matters relating to land and property transactions other than those covered by any delegation
to the Chief Executive and to approve any transactions being subject to procedures set by the Secretary
of State
Approve capital programmes and determine guidelines within which the Chief Executive and/or Executive
Board may approve variations to the programme.
BOARD OF DIRECTORS
General
Establish and maintain relationships with other relevant external bodies
Consider any other matters not falling within the established policies and practice of the trust of which
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THE BOARD OF
DIRECTORS
DECISIONS RESERVED TO THE BOARD OF DIRECTORS
officers think desirable or expenditure to be considered by the Trust Board
Establish management arrangements as appropriate and to consider specific management of other
aspects of the Trust’s responsibilities
Appoint Directors and Officers to represent the Trust on other bodies
Approve the appointment of professional advisors where such approval is required in accordance with
Standing Orders
Approve any changes to the Trust’s corporate governance framework
Establish and agree terms of reference and constitution of Committees and sub committees of the Board
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Policy Ref No. SABP/GOVERNANCE/003
Section 3 - SCHEME OF DELEGATION DERIVED FROM THE CONSTITUTION, FIT & PROPER PERSONS REQUIREMENTS AND THE
THE INDEPENDENT REGULATOR CODE OF GOVERNANCE (JULY 2014) SET OUR EXPECTATIONS FOR THE CONDUCT AND
ACCOUNTABILITY OF THE BOARD AND SENIOR MANAGERS
REF
DELEGATED TO
CONSTITUTION
BOARD OF DIRECTORS
AUTHORITIES/DUTIES DELEGATED
All the powers of the Trust shall be exercised by the Board of Directors on behalf of the Trust. (The
Constitution: 3.3)
The Board must exercise these powers in accordance with the Trust’s Constitution, including its Standing
Orders.
CONSTITUTION
BOARD OF DIRECTORS
In the exercise of its powers on behalf of the Trust Board, members shall have regard to the core principles
of the NHS and the Trust as set out in Appendix A of the Annexe 9 of the Constitution.
BOARD OF DIRECTORS
The Board of Directors is a unitary Board. This means that within the Board of Directors, the NonExecutive Directors and Executive Directors make decisions as a single group and share the same
responsibility and liability.
VALUES AND
CORE
PRINCIPLES
CODE OF
GOVERNANCE
The Trust Board will govern the Trust with regard to the NHS Foundation Trust Code of Governance on a
comply or explain basis.
The general duty of the Board of Directors and of each Director individually, is to act with a view to
promoting the success of the organisation so as to maximise the benefits for the members of the Trust as
a whole and for the public.
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REF
DELEGATED TO
AUTHORITIES/DUTIES DELEGATED
ACCOUNTING
OFFICER
MEMORANCUM
CHIEF EXECUTIVE
The Chief Executive is accountable to the Chair and Non-Executive Directors of the Board for ensuring
that its decisions are implemented, that the organisation works effectively, in accordance with
Government policy, the Trust’s Constitution, and public service values and for the maintenance of proper
financial stewardship.
The Chief Executive should be allowed full scope, within clearly defined delegated powers, for action in
fulfilling the decisions of the Board of Directors.
The Chief Executive Officer is designated as the Accounting Officer. It is incumbent on the Accounting
Officer to combine these duties with their duties to the Board of Directors. It is an important principle that
the Accounting Officer is responsible to Parliament for the resources under their control.
FIT & PROPER
PERSONS
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The Trust’s most Senior Managers (as defined by the board) are required to meet the Fit & Proper Person
requirements including completion of a Fit & Proper Persons Declaration.
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Section 3 - SCHEME OF DELEGATION IMPLIED BY STANDING ORDERS
SO REF
DELEGATED TO
1.1
CHAIR
DUTIES DELEGATED
Final authority in interpretation of SOs.
(ADVISED BY THE CHIEF
EXECUTIVE AND
SECRETARY)
3.2
CHAIR
Calling meetings.
3.7
CHAIR
Chair all Board of Directors meetings and associated responsibilities.
3.13
CHAIR
Give final ruling in questions of order, relevancy and regularity of meetings
3.14
CHAIR
Having a second or casting vote
3.16
BOARD OF DIRECTORS
Suspension of Standing Orders
3.16
AUDIT COMMITTEE
4.2
CHAIR & CHIEF
EXECUTIVE
4.4
CHIEF EXECUTIVE (CE)
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Audit Committee to review every decision to suspend Standing Orders (power to suspend Standing Orders
is reserved to the Board of Directors)
The powers which the Board of Directors has retained to itself within these Standing Orders may in
emergency be exercised by the Chair and Chief Executive after having consulted at least two nonExecutive Directors
The Chief Executive shall prepare a Scheme of Delegation (within the Reservation of Powers document)
identifying his/her proposals which shall be considered and approved by the Board of Directors , subject to
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Section 3 - SCHEME OF DELEGATION IMPLIED BY STANDING ORDERS
SO REF
DELEGATED TO
DUTIES DELEGATED
any amendments agreed during the discussion.
4.5
ALL
7.1
BOARD OF DIRECTORS
7.17
BOARD SECRETARY
8.1
ALL STAFF
Comply with national guidance contained in HSG 1993/5 “Standards of Business Conduct for NHS Staff”
and the NHS Foundation Trust Code of Governance.
8.4
ALL STAFF
Disclose relationship between self and candidate for staff appointment (CE to report the disclosure to the
Board of Directors )
-
CHIEF EXECUTIVE
9.1
CHIEF EXECUTIVE (OR
NOMINATED OFFICER) &
BOARD DIRECTOR
9.2
CFO (DOF)
9.3
AUDIT COMMITTEE
13.1
CE
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Disclosure of non compliance with Standing Orders to the Chief Executive as soon as possible
Declare relevant and material interests
Register of interests.
Approval of Consultant Job Planning Appeal recommendations
Authorise use of the Seal
Keep seal in safe place and maintain a register of sealing.
Review the register of sealing
Existing Directors and employees and all new appointees are notified of and understand their
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Section 3 - SCHEME OF DELEGATION IMPLIED BY STANDING ORDERS
SO REF
DELEGATED TO
DUTIES DELEGATED
responsibilities within Standing Orders SFIs.
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Section 3 - SCHEME OF DELEGATION IMPLIED BY STANDING FINANCIAL INSTRUCTIONS
SFI REF
DELEGATED TO
1.1.3
CFO
Approval of all financial procedures
1.1.5
CFO
Advice on interpretation or application of SFIs
1.1.7
ALL MEMBERS OF THE BOARD
OF DIRECTORS AND ALL STAFF
1.3.4
CHIEF EXECUTIVE (CE)
1.3.6
CE
To ensure all Board of Directors, members, officers and employees, present and future, are notified of and
understand Standing Financial Instructions.
1.3.7
CFO
Responsible for
a) Implementing the Trust's financial policies and coordinating corrective action
b) Maintaining an effective system of financial control including ensuring detailed financial procedures
and systems are prepared and documented.
c) Ensuring that sufficient records are maintained to explain Trust’s transactions and financial position
d) Providing financial advice to the Board of Directors and Staff
e) Maintaining such accounts, certificates etc as are required for the Trust to carry out its statutory
duties
1.3.8
ALL BOARD DIRECTORS AND
EMPLOYEES
Responsible for security of the Trust's property, avoiding loss, exercising economy and efficiency in using
resources and conforming to Standing Orders, Financial Instructions and financial procedures.
1.3.9
CE
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DUTIES DELEGATED
Have a duty to disclose non compliance with SFIs as soon as possible to the CFO. CFO to report to the
Audit Committee
Responsible as the Accounting Officer to ensure financial targets and obligations are met and has overall
responsibility for the system of internal control
Ensure that any contractor or employee who is empowered by the Trust to commit the Trust to expenditure
or who is authorised to obtain income are made aware of these instructions and their requirement to
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comply
1.3.10
CFO
2.1.1
AUDIT COMMITTEE
2.1.2
CHAIR
Raise the matter at the Board of Directors meeting where the Audit Committee considers there is evidence
of ultra vires transactions or improper acts.
2.1.3 &
2.3.1
CFO
Ensure an adequate internal audit service, for which he/she is accountable, is provided (and involve the
Audit Committee in the selection process when/if an internal audit service provided is changed)
2.2.1
CFO
Monitor and ensure arrangements in place to counter fraud and corruption including the appointment of the
Local Counter Fraud Specialist
2.3.1
CFO
Decide at what stage to involve police in cases of misappropriation and other irregularities not involving
fraud or corruption
3.1.2
CE/ DIRECTOR OF
GOVERNANCE & PLANNING
3.1.5
CFO
3.2.2
CE
3.3.5
CE/DIRECTORS
3.3.7
CFO
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Form and adequacy of financial records of all departments.
Provide independent and objective view on internal control and probity.
Compile and submit to the Board of Directors an annual business plan
Submit budgets to the Board of Directors for approval
Delegate budgets to budget holders
Identify and implement cost improvements and income generation activities in line with the Business Plan
Ensure adequate training is delivered on an on going basis to budget holders.
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4.1
CFO
Preparation of Annual Accounts and Reports ensuring that a copy of the annual accounts and any reports
of the external auditor are laid before Parliament and then sent to the Independent Regulator i.e. NHSI and
that the Annual Report is presented to the Board of Directors and Council of Governors
5.1
CFO
Submit monitoring returns to requisite organisations
5.1
CFO
Managing Banking arrangements, including the appropriate investment of the Trust’s cash
5.4
CFO
Prepare detailed procedural instructions on the operation of investments held
5.3
CFO
Will advise the Board of Directors on investments and report, periodically, on performance of same
5.4
CFO
Preparing instructions on the operation of accounts and a list of cheque signatories
6.1 & 6.4
CFO
Income systems, including system design, prompt banking, review and approval of fees and charges, debt
recovery arrangements, design and control of receipts, provision of adequate facilities and systems for
employees whose duties include collecting or holding cash.
6.2.2
ALL EMPLOYEES
Duty to inform CFO of money due from transactions which they initiate/deal with
7.1
CHIEF EXECUTIVE
Must ensure the Trust enters into suitable contacts with service commissioners for the provision of NHS
services
7.2
CFO
The Chief Executive shall nominate an officer to oversee and manage the contract on behalf of the Trust
7.5
CFO
Ensure that regular reports are provided to the Board of Directors detailing actual and forecast income form
the contracts
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7.6
CFO
8.1.1
BOARD OF DIRECTORS
Establish a Remuneration & Terms of Service Committee
8.1.5
BOARD OF DIRECTORS
Approve proposals presented by the Chief Executive for setting of remuneration and conditions of service
for those employees and officers not covered by the Remuneration Committee.
8.2.2
CFO
8.3
DIRECTOR OF WORKFORCE
Staff, including agency staff, appointments and re-grading.
8.4.1 and
8.4.2
DIRECTOR OF WORKFORCE
Payroll
a) specifying timetables for submission of properly authorised time records and other notifications
b) final determination of pay and allowances
c) making payments on agreed dates
d) agreeing method of payment
e) issuing instructions (as listed in SFI 8.4.2).
8.4.3
NOMINATED MANAGERS
8.4.4
DIRECTOR OF WORKFORCE
8.5
DIRECTOR OF WORKFORCE/HR
BUSINESS PARTNERS
9.1
CFO
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Responsible for setting the trust’s pricing methodology
Approval of variation to funded establishment of any department.
Submit time records in line with timetable
Complete time records and other notifications in required form
Submitting termination forms in prescribed form and on time.
Ensure that the chosen method for payroll processing 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.
Ensure that all employees are issued with a Contract of Employment in a form approved by the Board of
Directors and which complies with employment legislation; and deal with variations to, or termination of,
contracts of employment.
Determine, and set out, level of delegation of non-pay expenditure to budget managers, including a list of
managers authorised to place requisitions, the maximum level of each requisition and the system for
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authorisation above that level.
9.1.3
CE
9.2.1
REQUISITIONER
9.2.2
CFO
Be responsible for the prompt payment of accounts and claims
9.2.3
CFO
a) Advise the Board of Directors regarding the setting of thresholds above which quotations (competitive
or otherwise) or formal tenders must be obtained; and, once approved, the thresholds should be
incorporated in standing orders and regularly reviewed;
b) Prepare procedural instructions [where not already provided in the Scheme of Delegation or procedure
notes for budget holders] on the obtaining of goods, works and services incorporating the thresholds;
c) Be responsible for designing and maintaining a system of verification, recording and payment of all
amounts payable.
d) A timetable and system for submission to the Chief Finance Officer of accounts for payment; provision
shall be made for the early submission of accounts subject to cash discounts or otherwise requiring
early payment.
e) Instructions to employees regarding the handling and payment of accounts within the Finance
Department.
f) Be responsible for ensuring that payment for goods and services is only made once the goods and
services are received
9.2.4
APPROPRIATE EXECUTIVE
DIRECTOR
9.2.4
BUDGET HOLDER
9.2.7
CE
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Set out procedures on the seeking of professional advice regarding the supply of goods and services.
In choosing the item to be supplied (or the service to be performed) shall always obtain the best value for
money for the Trust. In so doing, the advice of the Trust's adviser on supply shall be sought.
Make a written case to support the need for a prepayment.
Ensure that all items due under a prepayment contract are received (and immediately inform CFO if
problems are encountered).
Authorise who may use and be issued with official orders.
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9.2.8
MANAGERS AND OFFICERS
9.2.7
CFO
Ensure that the arrangements for financial control and financial audit of building and engineering contracts
and property transactions comply with the guidance contained within CONCODE and ESTATECODE. The
technical audit of these contracts shall be the responsibility of the relevant Director.
10.4
CFO
Authorising Director for short term borrowing approval
10.7
CFO
The CFO will advise the Board of Directors on the Trust’s ability to pay dividend on PBC and report
periodically, concerning the PDC debt and all loans and overdrafts
11.1.1 &
2
CHIEF FINANCE OFFICER
11.1.3
CFO
Certify professionally the costs and revenue consequences detailed in the business case for capital
investment.
11.1.4
CFO
Issue procedures for management of contracts involving stage payments.
11.1.4
CFO
Issue procedures for the regular reporting of expenditure and commitment against authorised capital
expenditure.
11.1.5
CE
Issue manager responsible for any capital scheme with authority to commit expenditure, authority to
proceed to tender and approval to accept a successful tender.
Issue a scheme of delegation for capital investment management.
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Ensure that they comply fully with the guidance and limits specified by the Chief Finance Officer
Capital investment programme
a) ensure that there is adequate appraisal and approval process for determining capital expenditure
priorities and the effect that each has on business plans
b) responsible for the management of capital schemes and for ensuring that they are delivered on time
and within cost
c) ensure that capital investment is not undertaken without availability of resources to finance all revenue
consequences
d) ensure that a business case is produced for each proposal
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11.1.6
CFO
Issue procedures governing financial management, including variation to contract, of capital investment
projects and valuation for accounting purposes.
11.2.1
CFO
Demonstrate that the use of private finance represents value for money and genuinely transfers significant
risk to the private sector.
11.2.3
BOARD OF DIRECTORS
11.3.3
CE
11.3.6
CFO
Approve procedures for reconciling balances on fixed assets accounts in ledgers against balances on fixed
asset registers.
11.3.9
CFO
Calculate and pay capital charges in accordance with Department of Health requirements.
11.4.1
CE
11.4.2
CFO
11.4.4
DIRECTORS AND ALL SENIOR
STAFF
12.2
RELEVANT DIRECTOR
12.2
CFO
12.2
DESIGNATED PHARMACEUTICAL
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Proposal to use PFI must be specifically agreed by the Board of Directors.
Maintenance of asset registers (on advice from CFO).
Overall responsibility for fixed assets.
Approval of fixed asset control procedures.
Responsibility for security of Trust assets including notifying discrepancies to CFO, and reporting losses in
accordance with Trust procedure.
Delegate overall responsibility for control of stores (subject to CFO responsibility for systems of control).
Further delegation for day to day responsibility subject to such delegation being recorded.
Responsible for systems of control over stores and receipt of goods.
Responsible for controls of pharmaceutical stocks
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OFFICER
12.2
DESIGNATED ESTATES OFFICER
12.3
NOMINATED OFFICERS
12.4
CFO
Set out procedures and systems to regulate the stores.
12.5
CFO
Agree stocktaking arrangements.
12.6
CFO
Approve alternative arrangements where a complete system of stores control is not justified.
12.7
CFO
Approve system for review of slow moving and obsolete items and for condemnation, disposal and
replacement of all unserviceable items.
12.7
NOMINATED OFFICERS
12.8
CE
13.1
CFO
Prepare detailed procedures for disposal of assets including condemnations and ensure that these are
notified to managers.
13.2.1
CFO
Prepare procedures for recording and accounting for losses and special payments and informing police in
cases of suspected arson or theft.
13.2.2
ALL STAFF
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Responsible for control of stocks of fuel oil and coal.
Security arrangements and custody of keys
Operate system for slow moving and obsolete stock, and report to CFO evidence of significant
overstocking.
Identify persons authorised to requisition and accept goods from NHS Supplies stores.
Discovery or suspicion of loss of any kind must be reported immediately to either head of department or
nominated officer. The head of department / nominated officer should then inform the CE and CFO.
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13.2.2
CFO
Where a criminal offence is suspected CFO must inform the police if theft or arson is involved. In cases of
fraud and corruption CFO must inform the relevant CFOS team in line with SoS directions.
13.2.2
CFO
Notify DCFS CFMS.
13.2.3
CFO
Notify Board of Directors and External Auditor of losses caused theft, arson, neglect of duty or gross
carelessness (unless trivial).
13.2.4
BOARD OF DIRECTORS OR
DELEGATED COMMITTEE
13.2.5
CFO
Consider whether any insurance claim can be made.
13.2.6
CFO
Maintain losses and special payments register.
14.1
CFO
Responsible for accuracy and security of computerised financial data.
14.2
CFO
Satisfy himself that new financial systems and amendments to current financial systems are developed in a
controlled manner and thoroughly tested prior to implementation. Where this is undertaken by another
organisation assurances of adequacy must be obtained from them prior to implementation.
14.3 &
14.4
CFO
Ensure that contracts with other bodies for the provision of computer services for financial applications
clearly define responsibility of all parties for security, privacy, accuracy, completeness and timeliness of
data during processing, transmission and storage, and allow for audit review.
Approve write off of losses In line with limits set out in the Standing Financial Instructions
Seek periodic assurances from the provider that adequate controls are in operation.
14.5
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Where computer systems have in impact on corporate financial systems satisfy himself that:
a) systems acquisition, development and maintenance are in line with corporate policies
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Policy Ref No. SABP/GOVERNANCE/003
b) data assembled for processing by financial systems is adequate, accurate, complete and timely, and
that a management rail exists
c) CFO and staff have access to such data
d) Such computer audit reviews are being carried out as are considered necessary.
15.2
SERVICE DIRECTOR
15.3
CFO
15.6
DEPARTMENTAL MANAGERS
17.2
CALDICOTT GUARDIAN
18.1
CHIEF MEDICAL OFFICER
18.1
BOARD OF DIRECTORS
Approve and monitor risk management programme
18.4
BOARD OF DIRECTORS
18.5
CHIEF MEDICAL OFFICER
Decide whether the Trust will use the risk pooling schemes administered by the NHS Litigation Authority or
self insure for some or all of the risks. Decisions to self insure should be reviewed annually.
Where the Board of Directors decides to use the risk pooling schemes administered by the NHSLA the
Chief Medical Officer shall ensure that the arrangements entered into are appropriate and complementary
to the risk management programme. The Director of Quality / Deputy Chief Executive shall ensure that
documented procedures cover these arrangements.
CFO
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Responsible for ensuring patients and guardians are informed about patients' money and property
procedures on admission.
Provide detailed written instructions on the collection, custody, investment, recording, safekeeping, and
disposal of patients' property (including instructions on the disposal of the property of deceased patients
and of patients transferred to other premises) for all staff whose duty is to administer, in any way, the
property of
Inform staff of their responsibilities and duties for the administration of the property of patients.
Retention of document procedures in accordance with Records Management - NHS Code of Practice
Guidance
Risk management programme
Where the Board of Directors decides not to use the risk pooling schemes administered by the NHS
Litigation Authority for any one or other of the risks covered by the schemes, the Chief Finance Officer
(shall ensure that the Board of Directors is informed of the nature and extent of the risks that are self
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insured as a result of this decision. The Chief Medical Officer will 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.
18.6
CFO
19.1
Director of Governance &
Planning
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CHIEF EXECUTIVE (CE)
20.11
CHIEF EXECUTIVE OR NOMINATED
OFFICER
20.12
CFO
20.17
CE
Nominate an officer to oversee and manage the contract on behalf of the Trust.
20.18
CE
Nominate officers to enter into contracts of employment, regrading staff, agency staff or consultancy service
contracts.
20.20
CE
Nominate officers with power to negotiate for the provision of healthcare services with purchasers of health
20.14
CHIEF EXECUTIVE (CE)/CFO
20.15
CFO
Annex 1
Section
2.3
CE
Annex 1
Section
CE OR NOMINATED OFFICERS
Version 7.0
Ensure documented procedures cover management of claims and payments below the deductible.
Ensure all staff are made aware of the Trust policy on acceptance of gifts and other benefits in kind, by
staff.
Tendering and contract procedure
Evaluate the quotations and select the one which gives best value for money
Best value for money is demonstrated for all services provided under contract or in-house
Waive formal tendering procedures
Report waivers of tendering procedures to the Audit Committee
Designate an officer responsible for receipt and custody of tenders before opening.
Open tenders.
(See Section 5)
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Policy Ref No. SABP/GOVERNANCE/003
3
Annex 1
Section
4
Annex 1
Section
5
CE /CFO
DIRECTOR OF PROPERTY AND
ASSOCIATE DIRECTOR ESTATES
& FACILITIES
Decide whether any late tenders should be considered.
Keep lists of approved firms of building & engineering firms for competitive tenders/quotations.
Keep list of providers of healthcare services to the Trust by a private sector provider.
CFO
Annex 1
Section
4
Annex 1
Section
5
Version 7.0
Acceptance of a compliant tender other than the lowest
CFO
Up to £50,000 – CFO
Above £50,000 – Chief Executive
CE OR CFO
Approved Board March 2017
Use of a firm/individual not on an Approved List
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Section 4 – DETAILED SCHEME OF DELEGATION
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. Delegation to lower levels is only permitted with written approval of the Chief Executive
who will, before authorising such delegation, consult with other Senior Officers as appropriate.
Any changes to approval levels within the
procurement system (currently SBS) require written approval of the Chief Finance Officer. All items concerning Finance must be carried out in
accordance with Standing Financial Instructions and Standing Orders.
DELEGATED MATTER
1.
Expenditure
a)
Approving a Requisition / Letter of Intent or
any other commitment to spend
AUTHORITY DELEGATED TO
Revenue, Stock, Non-Stock

Up to £2,500
Any employee duly authorized by their Line Manager

Up to £5,000
Budget Manager

Up to £10,000
Budget holder - Level 4 Leader (Team Manager)

Up to £20,000
Budget holder - Level 3 Leader (Senior Manager)

Up to £100,000
Level 1 & Level 2 Leaders (Directors)

Up to £200,000
Director of Finance


Up to £500,000
500,001 and above
Chief Finance Officer
Chief Finance Officer and Chief Executive
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REFERENCE
DOCUMENTS
SFIs Section
Policy Ref No. SABP/GOVERNANCE/003
With the exception of the Chief Finance Officer and the Chief Executive no one individual can approve a requisition and approve the same purchase
order
b)
c)
2.
Purchasing Cards (authorization limits): maximum single or total transactions £500
 maximum single or total transactions £1,000
 maximum single or total transactions £5,000
 maximum single or total transactions £10,000
Cardholder
Line Manager
Line Manager & Deputy Director of Finance
Line Manager & Chief Finance Officer
Authorisation of Expenditure from Clients Monies
Up to £2500
Service Manager (Level 4 Leader)
Up to £20,000
Director of Finance
Over £20,001
Chief Finance Officer
All Capital Expenditure
Approval of capital expenditure (acquisition or
disposal of assets permanent or temporary) and
disposal of assets
Up to £100,000
Director of Property
Up to £200,000
Director of Finance
Up to £500,000
Chief Finance Officer
Up to £5,000,000
Chief Executive on behalf of the Executive Board
Above £5,000,000
Chief Executive on behalf of the Trust Board
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Policy Ref No. SABP/GOVERNANCE/003
b)
3.
Granting and termination of leases
Up to £50,000
Finance Business Partner and / or Head of Financial Accounting
Up to £100,000
Director of Finance
Up to £200,000
Chief Finance Officer
Above £200,000
Chief Executive
Procurement
Nominated Manager (Procurement, Estates, Maintenance and
Pharmacy)



£5,000 1 verbal quote
£5,001 to £10,000 1 written quote
£10,001 - £20,000 minimum 2 competitive
quotes

£20,001 - £100,000 minimum 3 competitive
tenders (minimum 2 received)

£100,001 and above minimum 5 tender
invitations (minimum 2 received)

OJEU threshold and above – full procurement
process
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Policy Ref No. SABP/GOVERNANCE/003
DELEGATED MATTER
4.
Expenditure on Charitable and Endowment
Funds
 Up to £1,000
Fund Manager

Up to £10,000 per request
Director of Finance

Up to £20,000 per request
2 Signatories from: Chief Executive, Chief Finance Officer or Chair
 Over £20,001 per request
5.
AUTHORITY DELEGATED TO
REFERENCE
DOCUMENTS
SFIs Section 16
Chief Executive on behalf of the Trustees
Income
Contracts/Agreements/Licenses
Any changes to income associated with health
and social care services.
a) Authorisation
6.
Up to £100,000
Level 1 and Level 2 Leaders
Up to £200,000
Director of Finance
Up to £500,000
Chief Finance Officer
Over £500,000
Chief Executive
Losses, Write-off & Compensation
SFIs Section 13
All losses and payments need to be reported.
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Policy Ref No. SABP/GOVERNANCE/003
All payments above the limits specifiedbelow
require Board approval
a) Losses and Cash due to theft, fraud,
overpayment and others
 Up to £5,000
Director of Finance

Up to £20,000
Chief Finance Officer

Over £20,000
Chief Executive
b) Fruitless Payments (including abandoned
Capital Schemes)
Up to £250,000
Chief Executive or Chief Finance Officer
c) NHS Bad Debts and Claims Abandoned.
Up to £20,000
Director of Finance
Up to £100,000
Chief Executive or Chief Finance Officer
Over £100,000
Audit Committee

Damage to buildings, fittings, furniture and
equipment and loss of equipment and
property in stores and in use due to:
Culpable cause (eg fraud, theft, arson) or other
up to £50,000
Chief Executive or Chief Finance Officer

Compensation payments made under legal
obligation
Chief Executive or Chief Finance Officer
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Policy Ref No. SABP/GOVERNANCE/003

Extra contractual payments to contractors
Chief Executive or Chief Finance Officer
Up to £50,000

a)
b)
Severance Payments to staff beyond
contractual or statutory entitlements
(NHSI & DOH approval required)
Chief Executive, Chief Finance Officer, NHSI & DoH
Ex Gratia Payments
Up to £5,000
Director of Finance, Director of Workforce
Up to £100,000
Chief Finance Officer
Over £100,000
Chief Finance Officer Report to Audit Committee (via Losses and
Compensations Procedure)
Compensation arrangements

For personal injury claims involving
negligence where legal advice has been
obtained and guidance applied. Up to
£1,000,000 (including plaintiff’s costs)
Chief Executive and Chief Finance Officer

Other, except cases of mal-administration
where there was no financial loss by claimant
£50,000
Reported to Audit Committee for information

All clinical negligence claims
NHS Litigation Authority
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Policy Ref No. SABP/GOVERNANCE/003

7.
Write off of Non-NHS debtors
 Up to £10,000
 Over £10,000
Chief Finance Officer
Audit Committee
New Business Development Opportunities
Annual Tender Value
Up to £100,000 p.a.
Director of Innovation, Development & Therapies and Director of
Finance
Up to £1,500,000p.a.
Chief Finance Officer & Director of Innovation, Development &
Therapies
Up to £5,000,000p.a.
Chief Executive and Chief Finance Officer and Director of
Innovation, Development and Therapies
Over £5,000,000 p.a.
Board of Directors
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Policy Ref No. SABP/GOVERNANCE/003
Section 5 – SCHEME OF DELEGATION IMPLIED BY Standing Financial Instructions - TENDERING & QUOTATIONS
Senior Officer Schedule
SO REF
DELEGATED TO
Annex s3
Senior Officer List
PURCHASING MANAGER
& BUYER
PURCHASING MANAGER
AND A SENIOR OFFICER
1 BOARD MEMBER AND
A SENIOR OFFICER
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DUTIES DELEGATED
Approved Board March 2017
Open Tenders by: All Directors
All Associate Directors
Head of Financial Management
Head of Financial Services
Purchasing Manager
Open tenders in accordance with the Trust’s SFIs.
Open tenders in accordance with the Trust’s SFIs.
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