· Web viewDERBYSHIRE COMMUNITY HEALTH SERVICES NHS FOUNDATION TRUST. SCHEME. OF. RESERVATION. OF. POWERS. TO. THE. BOAR. D OF DIRECTORS. AND. DELEGATION. OF …

DERBYSHIRE COMMUNITY HEALTH SERVICES NHS FOUNDATION TRUST

SCHEME OF RESERVATION OF POWERS TO THE BOARD OF DIRECTORS AND DELEGATION OF POWERS

Introduction

The NHS Foundation Trust Code of Governance (July 2014) requires that there should be a formal schedule of matters specifically reserved for decision by the Board of Directors. This document sets out the powers reserved to the Board of Directors and those that the Board of Directors has delegated. Notwithstanding any specific delegation, the Board of Directors remains accountable for all of its functions, including those which have been delegated. Therefore the Board of Directors will also receive information about the exercise of delegated functions to enable it to perform its monitoring role.

All powers of the Foundation Trust, which have not been retained as reserved by the Board of Directors or delegated to Committees of the Board of Directors, shall be exercised on behalf of the Board of Directors by the Chief Executive or another Executive Director. The Scheme of Delegation identifies any functions which the Chief Executive shall perform personally and those delegated to other Executive Directors, Non- Executive Directors or Officers. All powers delegated by the Chief Executive can be reassumed by him/her should the need arise.

The Scheme of Delegation is presented in the following format:

1. Functions Reserved for Decision by the Board of Directors2. Scheme of Delegation of Powers from the Constitution3. Scheme of Delegation of Powers from the Board of Directors’ Standing Orders4. Scheme of Delegation of Powers to Board Sub-Committees and Specialist Board Roles5. Scheme of Delegation of Powers from the Mental Health Act 1983 (as amended)6. Scheme of Delegation of Powers from the Standing Financial Instructions

Version 5:July 2018 1

7. Scheme of Delegation of powers from the NHS Foundation Trust Accounting Officer Memorandum8. Statement on Roles and Responsibilities of the Council of Governors

Appendix 1 – Policy Delegation TableAppendix 2 – Detailed Scheme of DelegationAppendix 3 – Corporate Framework for Governance and Associated Committees



1. FUNCTIONS RESERVED FOR DECISION BY THE BOARD OF DIRECTORS:REF THE BOARD OF

DIRECTORSDECISIONS RESERVED TO THE BOARD OF DIRECTORS

General Enabling Provision

THE BOARD OF DIRECTORS

The Board of Directors in full session may determine any matter, for which it has delegated or statutory authority, subject to any restrictions contained in the Foundation Trust's Constitution and/or the Provider Licence.

4.2(Constitution)


To exercise all powers of an NHS Foundation Trust set out in the NHS Act 2006 (as amended by the Health and Social Care Act 2012), subject to any restrictions in the Foundation Trust's Authorisation, or as delegated in accordance with this Scheme of Delegation.

3.6.4(Annex 7)


Appoint (in consultation with the Council of Governors) a Non-Executive Director (other than the Chair) as the Senior Independent Director, for such a period not exceeding the remainder of their term of office.

4.1.1(Annex 7)


Call public and/or private meetings of the Board of Directors.

4.1.2 and 4.1.3(Annex 7)


Resolve to require withdrawal of the press and public from meetings of the Board of Directors.

4.2.2(Annex 7)


One third or more of the Board of Directors may call a meeting of the Board should the Chair refuse to call a meeting when he has been requisitioned.

4.11.1(Annex 7)


Any member of the Board of Directors may propose a motion.

4.11.6(Annex 7)


Notice to rescind any resolution (or the general substance of any resolution) which has been passed within the preceding six calendar months shall bear the signature of the member of the Board of Directors who gives it and the signatures of four other Board members.

4.13(Annex 7)


Approve minutes of the proceedings of meetings of the Board of Directors.


REF THE BOARD OF DIRECTORS

DECISIONS RESERVED TO THE BOARD OF DIRECTORS

4.14.1(Annex 7)


Except where this would contravene any statutory provision or any guidance or best practice advice issued by NHS Improvement (NHSI), any one or more of the SOs may be suspended at any meeting, provided that at least two-thirds of the Directors are present including one Executive Director and one Non-Executive Director and that the majority of these present vote in favour of suspension.

7.1(Annex 7)


To cooperate with the Council of Governors as far as possible in order to comply with the Regulatory Framework and Engagement Policy.

7.2(Annex 7)


To prepare the information on the Trust’s Forward Plan (having regard to the views of the Council of Governors) to forward to NHSI.

7.3(Annex 7)


To prepare and present to the Council of Governors the Annual Accounts, any report of the Auditor on them and the Annual Report including the Quality Report.

11.2(Annex 7)


To authorise the sealing of documents.

39(Constitution)


Make available for inspection by members of the public the following: register of Members; register of members of the Council of Governors; register of interests of members of the Council of Governors; register of members of the Board of Directors; register of interests of members of the Board of Directors; Constitution; Provider Licence; latest Annual Accounts and Auditor's report on them; latest Annual Report and Annual Plan, Quality Report; and any notice issued by NHSI.

46.1.2(Constitution)


More than half of the members of the Board of Directors may approve amendments to the Constitution (with the approval of more than half of the members of the Council of Governors).

47(Constitution)


Jointly apply to NHSI for permission to merge with another NHS Foundation Trust or NHS Trust (with the approval of more than half the members of the Council of Governors).

4.14 THE BOARD OF At least two-thirds of the Board (including one Executive and one Non-Executive) may




(Annex 7) DIRECTORS suspend Standing Orders

4.15(Annex 7)


Vary or amend the Standing Orders in accordance with paragraph 46 of the Constitution.

5.3(Annex 7)


Ratify any urgent decisions taken by the Chair and Chief Executive in public session.

5.4(Annex 7)


Approve the formal delegation of powers to sub-committees or joint committees and approval of their terms of reference (See Section 4).

5.6(Annex 7)


Ratify or otherwise instances of failure to comply with Standing Orders.

6.1(Annex 7)


Establish terms of reference and reporting arrangements of all committees and sub-committees that are established by the Board of Directors in line with the Corporate Framework (Appendix 2).

6.1.6(Annex 7)


To approve the appointments/dismissals to each of the sub-committees it has formally constituted and ensure these are administered in line with the Corporate Framework (Appendix 2)

8(Annex 7)


Require and receive the declaration of Directors' interests that may conflict with those of the Foundation Trust and determining the extent to which each Director may remain involved with the matter under consideration.

Require and receive the declaration of Officers’ interests that may conflict with those of the Foundation Trust.

SFI 11.1.2 THE BOARD OF DIRECTORS

Approval of the Foundation Trust's banking, working capital and investment arrangements.





Approve the Trust’s Banking Procedure to ensure that it complies with the current requirements of NHSI.


Approval of the Foundation Trust's budgets


Through the Remuneration and Terms of Service Committee, appoint, appraise, discipline and dismiss Executive Directors.

SFI 18.2 THE BOARD OF DIRECTORS

Approve final business cases for the use of private finance (including PFI) for capital schemes.


Approve arrangements relating to the discharge of the Foundation Trust’s responsibility to provide safe custody for patients’ property.

SFI 25 THE BOARD OF DIRECTORS

Approval of arrangements relating to the discharge of the Foundation Trust’s responsibilities as a corporate Foundation Trustee for funds received in Foundation Trust and Funds Held on Foundation Trust.


Approve and monitor the Foundation Trust's programme of risk management, which must identify risks and liabilities, evaluate them and ensure adequate responses are in place and are monitored.

SFI 28.2 and 28.3


Review use of NHS Resolution risk pooling schemes, commercial insurers and self-insurance


Receive the Annual Business Plan from the Chief Executive and other reports from the Finance Director on financial performance against the Budget and the Annual Business Plan

SFI 11.3.4 and 11.3.5


Report to NHSI on any proposed major investments that could affect the Trust’s financial risk rating as part of the annual planning process or in year, prior to financial close. In




determining whether any investment decision is to be reported to NHSI, the Trust will take into account the REID guidance.


Approve the waiver of Competitive Tendering for building and engineering construction works and maintenance (other than in accordance with law, regulation or guidance applicable to building or engineering works).


Formal authorisation and awarding of a contract over £1,000,000


Approve the level of non-pay expenditure on an annual basis and the Chief Executive will determine the level of delegation to budget managers.


Approve details of capital expenditure programmes as part of the Annual Plan.

N/A THE BOARD OF DIRECTORS

Regulations and Control

1. Approve Standing Orders for the Board of Directors, the Scheme of Delegation, Standing Financial Instructions (SFIs) and the Directors' and Governors' Code of Conduct for the regulation of their proceedings and business.

2. Approve arrangements for dealing with complaints, compliments, comments and concerns.

3. Prescribe the financial and reporting arrangements required by the Board of Directors.

4. Adopt the organisation structures, processes and procedures to facilitate the discharge of business by the Foundation Trust and to agree modifications thereto. For clarity this would comprise details of the structure of the Board of Directors and its committees and the directorate structure of the Foundation Trust.




5. Receive reports from committees of the Board of Directors and/or the Council of Governors including those reports that the Foundation Trust is required by NHSI or other statutory or contractual obligation to establish and to take appropriate action on.

6. Confirm the recommendations of the Foundation Trust’s committees where the committees do not have executive powers.

7. Discipline members of the Board of Directors or Officers who are in breach of statutory requirements or Standing Orders.

8. Approval of the Foundation Trust’s major incident plan.

9. Review the SOs annually.


Appointments/Dismissal

1. Confirm appointment of Directors and/or Officers of the Foundation Trust as representatives on outside bodies

NA THE BOARD OF DIRECTORS

Strategy, Business Plans and Budgets

1. Define the strategic aims and objectives of the Foundation Trust and approve policies and strategies related to strategic development.

2. Approve proposals for ensuring quality and developing clinical governance, risk management in services provided by the Foundation Trust, having regard to any guidance or best practice advice issued by NHSI.

3. Approve the Annual Plan.




4. Approve the Foundation Trust’s proposed organisational development proposals.


Policy Determination

1. See table in Appendix 1 for the scheme of delegation relating to policy approval.


Audit

1. Agree Annual Plan and receive an annual report from the Internal Auditor and agree action on recommendations where appropriate of the Audit and Assurance Committee.

2. Receive the annual management letter received from the Auditor and agreement of proposed action, taking account of the advice, where appropriate, of the Audit and Assurance Committee.


Monitoring

1. Receive such reports as the Board of Directors sees fit from committees in respect of their exercise of powers delegated.

2. Continuous appraisal of the affairs of the Foundation Trust by means of the provision to the Board of Directors as the Board of Directors may require of reports from Directors, committees, and Officers of the Foundation Trust as set out in management policy statements. All monitoring returns required by the Department of Health and/or NHSI and the Charity Commission or as required by any other regulatory or contractual obligation shall be reported, at least in summary, to the Board of Directors.


2. SCHEME OF DELEGATION OF POWERS FROM THE CONSTITUTIONREF DELEGATED TO AUTHORITIES/DUTIES DELEGATED

2 and 3(Annex 8)

ASSOCIATE DIRECTOR OF CORPORATE

GOVERNANCE/TRUST SECRETARY

Responsible for resolving any disputes in respect of eligibility for Membership of the Public Constituency

4.2.5(Annex 8)



Maintain the Foundation Trust's Register of Members.

4.1(Annex 5)

CHAIR/ASSOCIATE DIRECTOR OF CORPORATE


Accept resignations by Governors from membership of the Council of Governors.

4.11.2(Annex 6)

CHAIR/VICE CHAIR Have a second or casting vote at meetings of the Council of Governors.(In the absence of the Chair/Vice Chair a nominated Non-Executive Director will Chair the meeting and have the casting vote.

36(Constitution)



Compile and maintain the Foundation Trust's registers of: members of the Council of Governors; interests of the members of the Council of Governors; members of the Board of Directors; and interests of the members of the Board of Directors; Members of the Foundation Trust

14(Annex 8)

ACCOUNTING OFFICER (CHIEF

EXECUTIVE)

Ensuring Auditor carries out his duties in accordance with Schedule 10 to the NHS Act 2006 and any directions issued by NHSI


REF DELEGATED TO AUTHORITIES/DUTIES DELEGATED

15(Annex 8)

ACCOUNTING OFFICER (CHIEF

EXECUTIVE)

Preparation of Annual Accounts.

4(Annex 5)



Accept letters of appointment for appointed Governors.

4(Annex 5)



Declare a Governor as disqualified from office.

4.2(Annex 6)

CHAIR Call meetings of the Council of Governors.

4(Annex 5)



Remove a Governor's name from the register of members of the Council of Governors where a Governor's tenure of office is terminated.

3(Annex 5)



Declare that a Governor is incapable by reason of mental disorder, illness or injury, and declare the individual either disqualified or temporarily suspended from office.



7 and 8(Annex 8)

CHAIR Receive and determine non-membership disputes and disputes between the Council of Governors and the Board of Directors. T h e C h a i r c a n c a l l a “ R e s o l u t i o n m e e t i n g ” c o m p r i s e d of Directors/Governors to resolve disputes between the Board of Directors and the Council of Governors that he is unable to determine. Refer such disputes back to the Board of Directors where the Special Committee is unable to resolve the dispute.

7 and 8(Annex 8)



Advise the Chair on the resolution of disputes between the Board of Directors and the Council of Governors.

N/A ASSOCIATE DIRECTOR OF CORPORATE


1. Ensure information flows within the Board of Directors and its committees and between senior management and the Council of Governors.

2. Ensure compliance with SOs for the Council of Governors and Board of Directors.

3. Advise Directors and Governors on Corporate governance matters.

4. Advise and support Directors with professional development initiatives.

5. Attend all meetings of the Council of Governors and meetings of the Board of Directors, and keep minutes of the same.

6. Assist the Board of Directors with the preparation and the sending to NHSI, and any other statutory body, of all returns and submissions which the Foundation Trust is required to make.


3. SCHEME OF DELEGATION OF POWERS FROM THE BOARD OF DIRECTORS STANDING ORDERS

REF(All Annex 7) DELEGATED TO AUTHORITIES/DUTIES DELEGATED

2.1 CHAIR Assume the role of final authority in interpretation of Standing Orders (SOs).

2.1 CHIEF EXECUTIVE AND ASSOCIATE DIRECTOR OF

CORPORATE GOVERNANCE/TRUST

SECRETARY

Advise the Chair on the interpretation of the SOs.

3.6.6 SENIOR INDEPENDENT DIRECTOR

Perform the role set out in NHSI’s “NHS Foundation Trust Code of Governance”.

3.7.1 ASSOCIATE DIRECTOR OF CORPORATE


Keep and maintain a Register of Directors, including their names, their capacity on the Board and an address through which they may be contacted.

3.7.2 VICE-CHAIR May act as the Chair where the Chairman has died, ceased to hold office or is unable to perform his duties as Chairman owing to illness until a new Chairman is appointed or the existing Chairman resumes his duties.

4.1.2 CHAIR Issue directions regarding arrangements for meetings of the Board of Directors and accommodation of the public and representatives of the press.

4.1.3 DIRECTORS Decide whether a member of the public or representative of the press may record proceedings (other than in writing) or make any oral report of proceedings as they take place.

4.2.2 CHAIR Call a meeting of the Board of Directors at any time.

4.2.2 DIRECTORS Call a meeting of one third or more of the Board of Directors where the Chair has refused a requisition for a meeting signed by at least one third of the Board



of Directors or has failed to call the meeting within five days of a requisition being presented to him at the Trusts Headquarters.

4.3.1 CHAIR/NOMINATED OFFICER Sign notices of meetings of the Board of Directors and deliver them to every Director.

4.3.3 DIRECTORS Where a meeting has been called by the Directors in accordance with SO 4.2.2 the Directors may sign the notice of a meeting.

4.5.2 CHAIR Give final ruling to permit late requests for items to be included on the agenda.

4.6 CHAIR Include any petition received by the Foundation Trust on the agenda for the next meeting of the Board of Directors.

4.7 CHAIR Chair all meetings of the Board of Directors.

4.7.1 VICE CHAIR/NON-EXECUTIVE DIRECTOR

The Vice-Chair may chair a meeting of the Board of Directors where the Chair is absent. If the Chair and Vice Chair are absent the acting Chairman will be any other Non-Executive Director appointed in accordance with SO 3.7.2(c).

4.7.2 VICE CHAIR/NON-EXECUTIVE DIRECTOR

The Vice-Chair may preside over an agenda item at a meeting of the Board of Directors where the Chair has declared a conflict of interest. If the Chair and Vice Chair have both declared a conflict of interest such Non-Executive Director as the members of the Board present shall choose, shall preside.

4.8 CHAIR Give final ruling in questions of order, relevancy, regularity and any other procedural matters.

4.9.2 CHAIR Include on the agenda all notices of motion received.

4.10 CHAIR Give final ruling to requests to permit emergency motions.

4.11 CHAIR Give final ruling in questions of order and procedure on handling motions and



associated matters (including proposals, contents of motions, amendments to motions, withdrawals of motions, debate of motions, rescinding of resolutions and voting) at meetings of the Board of Directors.

4.12.1 CHAIR Have a second or casting vote.

4.13.1 and 4.13.2


GOVERNANCE/TRUST SECRETARY/NOMINATED

OFFICER

Prepare minutes of the proceedings of meetings of the Board of Directors and submit such minutes for agreement at the next meeting of the Board of Directors. A copy of the minutes shall be retained in the Associate Director of Corporate Governance/Trust Secretary’s office.

4.14.5 AUDIT AND ASSURANCE COMMITTEE

Review every decision to suspend the SOs (power to suspend the SOs is reserved to the Board of Directors).

5.1 and 5.4 DIRECTORS Delegate any of the Board of Directors functions to a committee or sub-committee.

5.3 CHAIR AND CHIEF EXECUTIVE Have power in emergencies or in cases where an urgent decision needs to be exercised by the Chair / Chief Executive after consulting at least two Non-Executive Directors.

5.5.1 and 5.5.2 CHIEF EXECUTIVE Prepare the Scheme of Delegation identifying proposals that shall be considered and approved by the Board of Directors subject to any amendment agreed during the discussion. Determine which functions she will perform personally and nominate Officers to undertake the remaining functions. Periodically propose amendment to the Scheme of Delegation.

5.6 ALL Duty to report any non-compliance with the SOs to the Associate Director of Corporate Governance/Trust Secretary as soon as possible.

5.6 ASSOCIATE DIRECTOR OF Receive notifications of any non-compliance with the SOs.



CORPORATE GOVERNANCE/TRUST

SECRETARY

6.1.4 DIRECTORS Determine the terms of reference, powers and conditions of each committee and sub-committee.

8.2 DIRECTORS Declare relevant and material interests (including direct or indirect interests and actual or potential interests) and any pecuniary interest in any contract, proposed contract or other matter under consideration by the Board of Directors.

8.1 and 8.12.2 ASSOCIATE DIRECTOR OF CORPORATE


Receive Board of Directors interests. Amend the register of interests on receipt of new or amended information.

8.9 CHAIR Where any Director has any doubt about the relevance or materiality of any interest, discuss this with them.

9.1 DIRECTORS/OFFICERS Comply with the NHS Foundation Trust Code of Governance, the Trust Code of Conduct, the Trust’s Standing Financial Instructions, the Nolan Principles of Public Life as may be amended and any applicable guidance issued by NHSI from time to time.

9.2.1, 9.2.2 and 9.2.3

DIRECTORS Have a duty not to solicit for any person any appointment under the Foundation Trust, or recommend any person for appointment, and to disclose informal discussions outside relevant panels, etc.

9.3.2 DIRECTORS AND OFFICERS Disclose to the Chief Executive any relationship between staff and candidate for staff appointment.

9.3.2 CHIEF EXECUTIVE Report any disclosure of a relationship between a member of staff and a candidate for staff appointment to the Board of Directors.



11.1 ASSOCIATE DIRECTOR OF CORPORATE


Have custody of the common seal of the Foundation Trust.

11.2.1 DIRECTORS/COMMITTEE/SUB-COMMITTEE

Authorise the use of the Foundation Trust Seal by resolution of the Board of Directors or a committee thereof which has delegated powers to pass such a resolution.

11.2.2 CHIEF EXECUTIVE Authorise a Director to attest the sealing of documents.

11.2.2 DIRECTOR/ASSOCIATE DIRECTOR OF CORPORATE


Where the use of the seal has been approved it must be fixed and attested by the Associate Director of Corporate Governance/Trust Secretary and a Director duly authorised by the Chief Executive.

11.2.3 DIRECTOR OF FINANCE, INFORMATION AND

STRATEGY

Approve and sign any building, engineering, property or capital document (providing such document has been appropriately authorised).

11.2.3 CHIEF EXECUTIVE Authorise and countersign any building, engineering, property or capital document (providing such document has been appropriately authorised).

11.2.2 CHIEF EXECUTIVE Authorise Officers to attest sealings.

11.3 ASSOCIATE DIRECTOR OF CORPORATE


Establish and maintain register of sealings and report all sealings to the Audit and Assurance Committee, quarterly.

12.1 CHIEF EXECUTIVE Sign any document required as a necessary step in legal proceedings involving the Foundation Trust (providing such document has been appropriately authorised by the Board of Directors and unless any enactment requires or



otherwise authorises it or the Board of Directors have given the necessary authority to another individual).

12.2 CHIEF EXECUTIVE/NOMINATED

OFFICER

Authority to sign any agreement or document (save for deeds) the subject matter of which has been approved by the Board of Directors or a committee thereof.

13.1 CHIEF EXECUTIVE Duty to ensure that Directors, Nominated Officers and new appointees are notified of and understand their responsibilities within the SOs.

13.1 CHIEF EXECUTIVE Duty to distribute SOs to newly appointed Directors and Nominated Officers.

13.3 DIRECTORS Review SOs annually.

13.4 CHIEF EXECUTIVE Duty to store corporate documents specific to the setting up of the Foundation Trust securely.


4.SCHEME OF DELEGATION OF POWERS TO COMMITTEES AND SPECIALIST BOARD ROLES

REF COMMITTEE AUTHORITIES/DUTIES DELEGATED

N/A Trust Board The Board will ensure that all matters that have been reserved to the Trust Board for its collective decision are dealt with accordingly.

Such matters as laid out in the Foundation Trust Scheme of Delegation and Standing Financial Instructions.

The Board will receive and consider high level reports on matters material to the Trust detailing, in particular, information and action with respect to:

human resource matters; operational performance; clinical quality and safety, including infection prevention and control; financial performance; the identification and management of risk; matters pertaining to the reputation of the Trust; any other significant issue that is deemed appropriate

SFI 7 Audit and Assurance Committee

The Audit and Assurance Committee will:

1. Review the establishment and maintenance of an effective system of integrated governance, risk management and internal control across the whole of the organisations activities that supports the achievement of the organisations objectives, being mindful of the wider system changes, and manages the key risks facing the Trust.

In particular, the committee shall review the adequacy and effectiveness of: The underlying assurance processes that indicate the degree of achievement of

corporate objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements.

The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements and related reporting and self-certification.

2. Monitor the integrity of the financial statements of the NHS foundation trust, and any formal


announcements relating to the trust’s financial performance, reviewing significant financial reporting judgements contained in them

3. Review and monitor the integrity of any statements that are risk and control related. These specifically include, but are not limited to, the Annual Governance Statement, the accompanying Head of Internal Audit Opinion, any external audit opinion and the financial statements of the Trust.

4. Review the Trusts internal financial controls and review the systems and controls in place to manage risk.

5. Review and make recommendations to the Trust Board on the Trust’s Annual Report, Quality Accounts and Financial Statements

6. Review any declarations for CQC registration and the assurances required for the Board.

7. Make recommendations to the Board of Directors, in relation to the appointment of the internal audit function, and to approve remuneration and terms of engagement.

8. Monitor and review the effectiveness of the NHS foundation trust's internal audit function, taking into consideration relevant UK professional and regulatory requirements

9. To report to the Council of Governors on the performance of the External Auditor and make a recommendation to the Council of Governors on the appointment, re-appointment or removal of the External Auditor and approve the remuneration and terms of engagement of the external auditor

10.Review and monitor the external auditor’s independence and objectivity and the effectiveness of the audit process, taking into consideration relevant UK professional and regulatory requirements

11.Review the findings of other significant assurance functions, both internal and external to the organisation, and consider the implications on governance of the Trust.

12.Review and monitor and ensure that the organisation has adequate arrangements in place for


both preventing and countering fraud and will review the outcomes of counter fraud reports.

13.Consider and review all aspects of the Assurance Framework to ensure that the principles are embedded within the organisation.

14.Review the assurances that the Trust has an effective control system in place for ensuring good quality data.

15.Review the assurances that the Trust has an effective control system in place for the delivery of clinical audit.

16.Review arrangements that allow staff of the NHS foundation trust and other individuals where relevant, to raise, in confidence, concerns about possible improprieties in matters of financial reporting and control, clinical quality, patient safety or other matters.

17.Develop and implement policy on the engagement of the external auditor to supply non-audit services, taking into account relevant ethical guidance regarding the provision of non-audit services by the external audit firm;

18.Report to the council of governors, identifying any matters in respect of which it considers that action or improvement is needed and making recommendations as to the steps to be taken.

19.Consider and approve relevant policies, Financial Instructions and processes.

In carrying out this work the Committee will primarily utilise the work of internal audit, external audit and other assurance functions, but will not be limited to these sources. It will also seek reports and assurances from directors and managers as appropriate, concentrating on the over-arching systems of integrated governance, risk management and internal control, together with indicators for their effectiveness.

N/A Council of Governors

The Council of Governors will carry out:

Statutory Dutieso Appointing/removing our Chair and Non-Executive Directorso Determining the pay and terms of office of our Chair and Non-Executive Directorso Approving the appointment of our Chief Executive by the Non-Executive Directors


Being consulted on forward planning by the Board of Directors Receiving the annual report and accounts, and the report of the external auditor Receive and comment on the annual report of the audit committee on the work, fees and

performance of the external auditor Appointing/removing our external auditor Holding the Non-Executive Directors to account for the performance of the Board Acting as a critical partner to the Board of Directors in the development of the Annual Plan,

including reviewing progress reports Decide whether the Trust’s private patient work would significantly interfere with the Trust

delivering health service or other functions Consider approval of: mergers and acquisitions significant transactions proposed increases of non-NHS income of more than 5% of total income

constitutional changes jointly with the Board Requiring one or more directors to attend a meeting to answer questions Ensuring we operate in accordance with our legal framework

Other AreasReceive and review reports:

Presented on behalf of the Board of Directors on the performance of the Trust against agreed key financial, operational, quality and regulatory compliance indicators and stated objectives

Annual report from the Non-Executive Directors regarding their role and performance in key governance committees within the organisation.

Patient experience in areas such as accessibility, cleanliness and the environment, and overall ‘customer care’

Staff experience such as Staff Surveys including quarterly “Pulse Checks” Campaigns such as smoking, alcohol, nutrition, drug abuse and accident prevention Regular summary reports from sub-committees of the Council of Governors Working groups formed by Governors with selected Non-Executive Directors, each led by an

Executive Director and targeted at the key areas of the Trust’s activity and strategic planning. Membership strategy and the development of plans for growing and developing the

membership Other areas of activity of interest to Governors Hold Annual Members’ Meeting to present and receive feedback on the overall strategic aims of


the Trust Commission an annual review of its effectiveness and efficiency in the discharge of its

responsibilities and achievement of objectives Appoint the Lead Governor and the Deputy Lead Governor Receiving regular reports from Governor Groups Ensure appropriate processes are in place for the overall conduct of individuals and collectively.

7(Annex 5)

Nominations and Remuneration Committee

The Nominations and Remuneration Committee will: Consider and make recommendations to the Council of Governors on the appointment of the

Chairman and Non-Executive Directors. The Committee is to satisfy itself that its recommendations fulfil DCHS needs in terms of skills and experience.

Agree the process for recruitment of the Chairman and Non-Executive Directors taking into account the views of the Board of Directors on the process in general and the qualifications, skills and experience required for the position. For NED appointments the Chairman will be asked to Chair the appointments panel. For appointments to the Trust Chair position, the panel will be chaired by the Vice Chair (or in the event of the Vice Chair submitting an application, the Senior Independent Director or other suitable NED).

Ensure appointments are based on merit and objective criteria as well as meeting the ‘fit and proper’ persons test described in the Provider Licence and Care Quality Commission (CQC) Regulations.

Make recommendations to the Council of Governors on the re-appointment of the Chair and/or Non-Executive Directors where it is sought and is constitutionally permissible. The Committee will look at the existing candidate/s against the required role description.

Consider and make recommendations to the Council of Governors as to the remuneration and allowances and other terms and conditions of office of the Chairman and other Non-Executive Directors.

In conjunction with the Chairman, contribute to an annual review of the structure, size and composition of the Board of Directors and to make recommendations for changes to the NED element of the Board of Directors to the Council of Governors where appropriate. When undertaking this review, the Committee will consider the balance of skills, knowledge and experience of the Non-Executive Directors.

Consider succession planning to include the balance of appropriate skills and experience for Non-Executive Directors which will complement the full Trust Board.

To consider issues relating to the performance and attendance of the Council of Governors


(individually and collectively). Instigate any investigation required into non-compliance with the Governors Code of Conduct

and to make recommendations to the Council of Governors regarding the outcome of any investigations.

N/A Quality Service Committee

The Quality Service Committee will shape, influence and produce overall assurance in relation to the quality of our services. This will involve defining the scope, requirements and pace of the service plans to ensure these are aligned to the delivery of the five year Integrated Business Plan (IBP).

This will incorporate the three elements of quality governance i.e. – patient safety, the patient experience and the effectiveness of care in relation to patient outcomes. This will be achieved by:

1. DCHS Quality Improvement and Assurance Framework: Oversee the production of a Quality Strategy Develop an annual plan for delivery of the Quality Strategy ensuring a year on year

improvement in quality service delivery Monitor delivery of the Annual Quality Plan Provide assurance to the Board in relation to the delivery of quality services Review progress against the DCHS Quality Strategy and refresh the strategy accordingly ‘Horizon scan’ for best practice on an international, national and local basis,

incorporating relevant practice into quality service improvement at DCHS.

2. Compliance against regulatory requirements and external scrutiny: Provide assurance to the Board in relation to compliance with Care Quality Commission

(CQC) requirements. Ensure that DCHS maintains CQC registrationo Ensure compliance is maintained in relation to the Mental Capacity Act (2005) Ensure delivery of Deprivation of Liberty and Mental Capacity requirements and the

safeguarding of vulnerable adults Ensure compliance against any new regulations or statutory requirements Ensure compliance to relevant aspects of Health Acts in relation to : Infection, Prevention and Control (Health Act 2006) Safeguarding of children, young people and adults (Care Act 2014, Domestic Violence,

Crime and Victims Act 2004, Human Rights Act 1998, Children Act 1989 & 2004, Children and Families Act 2014 and Working Together to Safeguard Children 2015)

Public and patient engagement


Ensure compliance against the Equality Act 2010 and the Equality Delivery System best practice framework

Ensure compliance with the Quality aspects of NHSI’s Regulatory Framework Ensure compliance to the Data Protection Act 1998 and to the NHS Regulatory

Framework in relation to information governance Ensure Compliance with the General Data Protection Regulations Ensure compliance with the Department of Health Guidelines on Records Management

and their retention periods

3. Performance Framework: Maintain oversight and monitoring of quality performance in relation to commissioners Oversee and provide assurance to the Board in relation to the performance of DCHS in

relation to patient safety, patient experience and the effectiveness of care via a suite of key performance indicators

Ensure quality across DCHS via the Quality Assurance Framework to ensure “Front Room to Board Room” assurance throughout service delivery areas

4. Controls and Assurance: Oversee the controls and assurance that are and should be in place to ensure

compliance and the delivery of quality services Identify any significant gaps and ensure corrective action Ensure there is a risk based prioritisation and that actions are taken to mitigate identified

risk, with leads identified and that risks are addressed in a timely manner Have overarching responsibility for all risks and review a monthly report provided to each

Committee meeting Review the risk register on a quarterly basis Monitor performance against the Board Assurance Framework for Quality Service,

providing assurance to the Board Ensure there are effective arrangements in place for managing Serious Incidents Ensure there are effective arrangements in place for managing legal issues, including

claims, coroners inquests, court of protection and other legal matters Ensure thematic reviews are conducted a result of issues identified from Incidents,

complaints, and other legal or high risk matters. Have delegated authority from the Board to approve policies in line with the Scheme of


Delegation Hold to account the subgroups identified by the Quality Service Committee, and

commission/decommission any others as required Monitor the work programmes of the subgroups, receiving reports Ensure that the Board is aware of risks in relation to the strategic delivery of quality

services and provide assurance in relation to the management of clinical risk within the organisation

Monitor Research and Innovation activity within the Trust to ensure it is rigourously governed and that it results in new practice that is evaluated and adopted to maximise clinical effectiveness.

5. Effectiveness of care: Oversee the development of a Clinical Strategy which supports the effectiveness of care

delivered within the organisation Oversee, and monitor the implementation of the Clinical Effectiveness Strategy to ensure

that all Patient Outcomes are recorded and learnt from to improve effectiveness of treatment and care

Ensure on behalf of the Board that the Trust is fully engaged and compliant with national guidelines on governance related to Deaths in the NHS

Embed the emerging Frameworks for NHS Outcomes, Public Health and Social Care within a Key Performance Indicator (KPI) framework

Ensure that a system of ‘early warning’ is established to identify any negative impact upon the care delivered, taking corrective actions as necessary and ensuring that the Board is aware of associated risk

Oversee the Clinical Audit Programme.

6. Safety: The Quality Service Committee provides the Board with overall assurance on the safety

management systems and processes in place, to meet statutory, mandatory, legislative and best practice requirements for patient safety, and environmental and specialist prevention and protection

The Committee has delegated responsibility from the Board to set and discharge standards of safety and behaviour (in accordance with the Health Act 2006) regarding the Trust business in delivering patient care across all directorates. This includes monitoring delivery of the ‘Safe Care’ agenda (Falls, Venous Thrombo Embolism, Pressure Ulcers


and Catheter acquired infections)

7. Patient Experience: Provide the Board with assurance that patients have the opportunity to provide feedback,

and that their feedback is used for learning and on which to base improvements

Provide the Board with assurance that people using DCHS services have a positive experience and that exceptions to this are managed appropriately. For example that there is a well led complaints process.

Provide the Board with assurance that DCHS is actively promoting the engagement and involvement of patients and service users in the work of the Trust, and that the Trust is proactive in involving service users in evaluating, reviewing, monitoring and planning services that we deliver.

8. Vulnerable patients: Vulnerable patients will be protected through the development of robust governance

arrangements which will meet national best practice and statutory responsibilities. Routine reporting will be delivered through the Safeguarding Governance Group to QSC and the Board.

9. Information Governance: The committee also has a remit to provide assurance to the Board regarding information

governance This Committee will receive reports upon on development and use of the Information

Governance Toolkit through the year.

10. Assurance:The Quality Service Committee is responsible for reviewing the effectiveness of the controls in place relevant to the risks identified within the Quality Service section of the BAF. The number of risks may vary during the course of the year. The Committee will review and challenge the strength of the assurances that have been provided, identify any gaps in control or assurance and will confirm if the appropriate level of risk has been identified based on the information presented to the Committee.

N/A Quality People 1. The Quality People Committee will oversee the development of the People and Organisational


Committee Effectiveness Strategy providing assurance to the Board that DCHS has the right staff, in the right place, doing the right things:

Ensuring staff are recruited, trained, qualified and retained to do the roles required Define the scope, requirements and pace of the developing workforce plans and staffing for

quality and ensure these are aligned to the delivery of the Operational and Financial plans and the Sustainability and Transformation Plan. Monitor the national workforce requirements related to staffing levels and the use of agency workforce and ensure compliance to NHSI Requirements.

Oversee the delivery of the People and Organisational Effectiveness Strategy

2.The Quality People Committee will:

Monitor and track employee relations across DCHS with the aim of positive engagement with Staff Partnership Representatives

Provide direction to achieve a positive employee relations climate across DCHS Consider DCHS’ Quality People performance targets (KPI’s) and monitor perfomance against

these before submission to the Trust Board Ensure DCHS has People policies that meet the needs of the organisations vision and

objectives and have delegated authority from Board to approve such policies Maintain an oversight of DCHS’ Quality People proposals ensuring they are in compliance with

the DCHS requirements

3. The Quality People Committee will ensure:

Effective workforce plans and development are in place Understand and seek assurance of impact of Sustainable Quality Improvement Plans plans on

the workforce Develop effective strategies to achieve the essential learning and CPD requirements and

evaluate effectiveness Monitor the ongoing development and implementation of the DCHS appraisal process

4. The Quality People Committee will be responsible for ensuring DCHS has effective staff involvement and engagement :


Review business cases for major investments into staff development and organisational change Seek assurance of the people impact arising from business changes and ensure the change

management is effectively handled Ensure a culture of continuous improvement in staff survey participation and positive trends Consider post project evaluation reports on significant change and people investment project to

capture lessons learnt Ensure that staff transfers in and out of DCHS are managed in an appropriate way and fulfill

legal requirements Monitor DCHS’ staff engagement acitivity and develop proposals to increase involvement Oversee the development and implementation of the DCHS Employee Well Being strategy and

climate Oversee the development of DCHS staff membership and staff governors

5. The Quality People Committee will have joint responsibility with the Quality Service Comittee for developing and assuring our equality, diversity and inclusion activity:

Oversee the delivery and achievement in the Equality Delivery System Oversee the development and delivery of the DCHS Equality, Diversity, Inclusion and Human

Rights strategy and implementation Oversee that DCHS meets and exceeds all legal requirments

6. The Quality People will set the aspiration of the organisation to become a great partner and teaching organisation in the wider health and social care community by: Considering proposals for people partnering arrangements Considering forms of delivering these partnering arrangements Providing assurance that DCHS interests will be safeguarded from proposed partnering

arrangements Review the legal, financial and risk implications of any proposed partnering arrangements. Oversee the delivery of the Centre of Excellence for Teaching programme

7. The Quality People Committee will: Demonstrate compliance with relevant CQC Regulations and Outcomes, and Employment Law

requirements. Ensure compliance is maintained in relation to the Health and Safety at Work Act. It will

provide the Board with overall assurance on the safety management systems to meet


requirements for health and safety

Assurance:The Quality People Committee is responsible for reviewing the effectiveness of the controls in place relevant to the risks identified within the Quality People section of the Board Assurance Framework The number of risks may vary during the course of the year. The Committee will review and challenge the strength of the assurances that have been provided, identify any gaps in control or assurance and will confirm if the appropriate level of risk has been identified based on the information presented to the Committee.

N/A Quality Business Committee

The Quality Business Committee will shape, influence and provide overall assurance regarding the delivery of:1. Compliance against regulatory requirements

Compliance with NHS Improvement’s planning and performance requirements

2. Performance Framework

3. Financial Strategy: Consider DCHS’ financial strategy in relation to income and expenditure, balance sheet,

cashflow and NHS I Improvements financial rating. Consider DCHS’ annual financial targets and performance against them before submission to

the Board of Directors Monitor DCHS’ working capital position Consider the ‘in year’ financial performance of the Trust and make any subsequent comments

or reports to Board Monitor delivery against the Trusts Sustainable Quality Improvement Programme. Seek assurance on future plans to deliver efficiencies.

4. Contractual Performance

To oversee the material contractual negotiations / discussions with health and local authority commissioners

To understand the impact of decommissioning decisions on the financial position of the Trust


To assure the DCHS Board on the risk / opportunities of new contractual frameworks and models

5. Informatics Strategy: To ensure appropriate investment and capacity across DCHS to deliver the InformaticsStrategy To define the scope, requirements and pace of the information management and information

technology agenda of DCHS in building the Informaticscapacity of the organisation To assure the DCHS Board of delivery of the Informatics agenda

6. Estates Strategy: Oversee the development of the Trust’s Estates Strategy and Capital Programme and ensure it

is appropriately updated for approval by the Trust Board Consider & review the annual capital programme prior to Board decision Monitor progress against delivery. To review on a quarterly basis action plans produced by the Head of Estates for improving

performance against estate related targets To establish reporting mechanisms that provide the Trust Board with regular updates on all

relevant issues associated with the Trust’s estates management activities

7. Procurement Strategy To review the procurement strategy and the associated metrics for the delivery of the strategy

and annual work programme.

8. Transformation To review progress against health and social care economy transformation priorities To review progress against Trust transformational priorities To understand the benefits realisation from transformation initiatives, and to ensurethat an

approriate return on investment is delivered.

9. Business Development Framework: Develop DCHS’ Investment Policy and ensuring this is maintained to fit with best practice To maintain an oversight of DCHS’ investments, ensuring compliance with the Trust’s policy Review business cases for major investments, defined as greater than £500,000 against the


Trust’s strategy and test compliance with the Investment Policy in advance of a Board decision To ensure appropriate independent advice is sought in relation to major investments Review and consider the Trust’s financing strategy Consider post project evaluation reports on significant capital investments Consider and review the decision making criteria for investment/disinvestment and tender

opportunities

10. Business partnering arrangements: Oversee the development of the Trust’s Business Partnering arrangments Consider forms of delivering business partnering arrangements Provide assurance that DCHS interests will be safeguarded from proposed partnering

arrangements Review the legal, financial and risk implications of any proposed partnering arrangements

11. Policy Approval: Will have delegated authority from the Board to approve business, finance and corporate

policies

12. Emergency Planning & Business Continuity (EPRR) and Security Management To ensure there is an appropriate Emergency Plan in place for the organisation that fulfils

national and local requirements for EPRR To ensure there is an appropriate Security Policy in place for the organisation that fulfils

national requirements from NHS Protect

Assurance:The Quality Business Committee is responsible for reviewing the effectiveness of the controls in place relevant to the risks identified within the Quality Business section of the Board Assurance Framework. The number of risks may vary during the course of the year. The Committee will review and challenge the strength of the assurances that have been provided, identify any gaps in control or assurance and will confirm if the appropriate level of risk has been identified based on the information presented to the Committee.

SFI 25 Charitable Funds

The Charitable Funds Committee acting on the Trustee’s behalf will:


Committee Be responsible for ensuring appropriate governance arrangements are in place regarding the management of the Charitable Funds

Conduct its business in accordance with the Trustee’s wishes Adhere fully to the requirements of the Charity Commission Approve the Annual spending plans as submitted by the delegated fund managers Receive reports from both Internal and External auditors and ensure implementation of any

recommendations Develop and implement an Investment Strategy with regard to Charitable Funds. Ensure that appropriate communications strategies are developed so that best use is made of

charitable funds Conduct an annual review on the performance of the investment managers appointed to invest

funds on behalf of the Trustee Conduct a periodic review of the structure of the funds and approve any proposed changes in

line with Charity Commission guidance Monitor and understand the risks associated with investments and form mitigation plans to

provide assurance Approve any changes to delegated fund managers Approve expenditure within the delegated limits set by the Trustee (any expenditure over

£20,000 to be referred to the Board for approval) Review and approve the annual administration fee levied on the Charity Submit quarterly summary reports to the Trust Board Ensure the Annual Report and Accounts are prepared in a timely manner Ensure that the Annual Report and Accounts are examined or audited by the appointed

external auditors Recommend approval of the Annual Report and Accounts to the Trustee and ensure timely

submission to the Charity Commission following approval by the Trustees. Receive periodic evaluations on significant schemes funded by the charity Nominate Charitable Funds Committee Members to follow up on major projects/investments to

ensure outcomes are being achieved

4.3(Constitution)

Mental Health Act Committee

The Mental Health Act Committee will:Mental Health Act

Oversee the administration of the MHA by the Trust and its officers (with delegated responsibilities under the 1983 ‘Act’) in accordance with the ‘Act’ and the MHA Code of Practice.

Exercise the power of review of detention of patients granted under the terms of the MHA to the


‘Managers’ of the Trust. Exercise the powers of discharge of detained patients granted under the terms of the MHA to

the ‘Managers’ of the Trust. Ensure the organisation complies with the MHA and oversees the implementation of and

subsequent amendments to MHA legislation, guidance and best practice, in its duties as the ‘Statutory Responsible Authority’.

Be informed of all relevant visits by external bodies with regard to compliance with the MHA. Receive an assurance that external reports and their recommendations with regard to

compliance against the Mental Health Act are being implemented and performance managed. Be responsible for the development, review, implementation and monitoring of MHA polices

and procedures to support and ensure compliance with MHA legislation. Ensure visits to the in-patient areas, provided by DCHS are carried out twice a year with the

purpose of ensuring that there are systems and processes in place in support of the correct administration of the MHA in accordance with the ‘Act and the Code of Practice’ as well as challenging the appropriateness of the care environments and the quality of the care delivered in those environments.

To ensure visits to the MHA Administration Office are carried out twice a year with the purpose of ensuring that there are robust systems and processes in place in support of the correct administration of the MHA in accordance with the ‘Act and the Code of Practice’.

Receive the reports of the visits of the Care Quality Commission (CQC) to the LD and OPMH in-patient areas and in addition, consider critically, the responses to these individual reports required to be made to the CQC by the responsible service managers and including the formal plans showing the actions that have been taken.

Ensure there are systems in place to develop and deliver high quality care for the patients and clients of DCHS covered by the aforementioned Acts, including compliance with the CQC Registration against the Essential Standards of Quality & Safety.

Review Serious Incidents (SIs) pertaining to Mental Health Act compliance OPMH and LD in-patient areas, highlight any areas of concern or of notable practice and review and act on summary reports of Incidents, Patient Experience, Coroner’s Inquests, Court of Protection and Claims in relation to compliance with the MHA.

Ensure that information regarding the MHA, their detention under the Act and rights of appeal is accessible for users in accordance with Section 132 of the Act.

Ensure appropriate training and support of relevant officers of the Trust (as outined in the Trust Scheme of Delegation) to enable them to carry out the duties and responsibilities delegated to them by the ‘Hospital Managers’ in accordance with the MHA Code of Practice, in order to


ensure patients legal rights and safety. Review and monitor the use of the MHA within the Trust, noting and where relevant

investigating, any emerging trends in relation to service, age, gender, ethnicity and cultural background.

Receive an assurance that all restrictive interventions used within the Trust are carried out in compliance with the MHA Code of Practice and associated guidelines

SFI 14.1 Remuneration and Terms of Service Committee

Appointments RoleThe Committee will:

Regularly review the structure, size and composition (including skills, knowledge, experience and diversity of the Board, making use of the output of the Board evaluation process as appropriate and make recommendations to the Board and Nominations and Remuneration Committee as appropriate with regard to any changes

Consider and make plans for succession planning for the Chief Executive and other Executive Directors taking into account the challenges and opportunities facing the Trust and the skills and expertise needed on the Board in the future

Keep the leadership needs of the Trust under review at Executive level to ensure continued ability of the Trust to operate effectively in the health economy

Be responsible for identifying candidates and appointing candidates to fill posts within its remit as and when they arise

When a vacancy is identified, evaluate the balance of skills, knowledge and experience on the Board and its diversity. Following the evaluation, prepare a description of the role and capabilities required for the particular appointment. In identifying suitable candidates the Committee shall use open advertising or the services of external advisers to facilitate the search, will consider candidates from a wide range of backgrounds and consider candidates on merit against objective criteria

Ensure the Trust seeks the views of ministers via NHS Improvement and NHS England before making any appointments with a salary higher than the Prime Minister

The Chair will personally scrutinise and approve new Very Senior Manager appointments Ensure the proposed Executive Director’s other significant commitments (if applicable) are

disclosed before appointment and that any changes to their commitments are reported to Board as they arise

Ensure that proposed appointees disclose any business interests that may result in a conflict of interest prior to appointment and that any future business interest that could result in a conflict of interest are reported


Consider any matter relating to the continuation in office of any Board Executive Director including the suspension or termination of service of an individual as an employee of the Trust, subject to the provisions of the law and their service contract

Remuneration RoleThe Committee will:

Establish and keep under review a remuneration policy in respect of Executive Board Directors and senior managers on locally-determined pay

Consult the Chief Executive about proposals relating to the remuneration of the other Executive Directors

In accordance with all relevant laws, regulations and Trust policies, decide and keep under review the terms and conditions of office of the Trust’s Executive Directors and senior managers on locally-determined pay, including:

o salary (including any performance-related elements/bonuses);o Provisions for other benefits, including pensions and leased vehicles;o Allowanceso Payable expenseso Compensation payments

In adhering to all relevant laws, regulations and Trust policies:o Establish levels of remuneration which are sufficient to attract, retain and motivate

Executive Directors of the quality and with the skills and experience required to lead the Trust successfully, without paying more than is necessary and at a level that is affordable to the Trust

o Use national guidance and market benchmarking analysis in the annual determination of remuneration of Executive Directors and senior managers on locally determined pay, while ensuring increases are not made where the Trust or individual performance do not justify them

o Be sensitive to pay and employment conditions elsewhere in the Trusto Monitor and assess the output of the evaluation of performance of individual Executive

Directors and consider this output when reviewing changes to remuneration levelso Advise upon and oversee contractual arrangements for Executive Directors including but

not limited to termination payments to avoid rewarding poor performanceo Advise on, and oversee, the proper calculation and scrutiny of all other termination


payments, greater than £10,000, for all other staff, taking account of such national guidance as is appropriate

General The Committee shall receive and agree a description of the work of the Committee, its policies

and all Executive Director emoluments in order that these are accurately reported in the required format in the Trust’s Annual Report


SPECIALIST BOARD ROLES

REF BOARD MEMBER AUTHORITIES/DUTIES DELEGATEDN/A Chief Nurse Safeguarding and Infection Control LeadN/A Associate Director of Transformation Senior Information Risk OfficerN/A Medical Director Caldicott Guardian and Responsible Officer for the Trust as a body

designated by the General Medical CouncilN/A Chief Operating Officer Security Management LeadN/A Director of People Services and

Organisational EffectivenessHealth and Safety Lead

N/A Associate Director of Corporate Governance/Trust Secretary

Freedom to Speak up Guardian

N/A Associate Director of Transformation Cyber Security LeadN/A Non-Executive Director Learning from Deaths LeadN/A Medical Director Learning from Deaths LeadSO 3.6.5 Non-Executive Director A Non-Executive Director will perform the role of Senior Independent Director

as per NHSI’s Code of Governance


5. SCHEME OF DELEGATION OF POWERS FROM THE MENTAL HEALTH ACT


4.3(Constitution)

MENTAL HEALTH ACT MANAGERS

Functions pursuant to Section 23 of the Mental Health Act 1983 (as amended). All Mental Health Act functions delegated to Officers by the Board of Directors are detailed in the Mental Health Act Policy. The Mental Health Act Policy provides assurance that the Foundation Trust has appropriate governance arrangements in place in order to lawfully exercise its powers under the Mental Health Act 1983 (as amended).


FUNCTIONS IMPOSED ON HOSPITAL MANAGERS BY THE MENTAL HEALTH ACT 1983, THE CODE OF PRACTICE & OTHER STATUTES

SCHEME OF DELEGATION TO OFFICERS OF THE TRUST

FUNCTIONS WHICH CANNOT BE DELEGATED TO OFFICERS OF THE TRUST

FUNCTION STATUTORY REFERENCE (1) CODE OF PRACTICE REFERENCE (2)

AUTHORISED PERSON/COMMITTEE

Review of patients’ detention Section 20(3) Chapter 37 & 38Non-executive Directors and Associate Mental Health Act Managers

Exercise of hospital managers’ power to discharge unrestricted detained and Supervised Community Treatment (SCT) patients

Section 23(2)(a) Chapter 38Non-executive Directors and Associate Mental Health Act Managers

(1) Mental Health Act 1983 [as amended by the MHA 2007].The Mental Health (Hospital, Guardianship and Consent to Treatment) (England) Regulations 2008 (S.I. 1184)

[as amended by the Mental Health (Hospital, Guardianship and Treatment) (England) (Amendment) Regulations 2008 (S.I.2560)]

(2) The Mental Health Act 1983 Code of Practice (published in 2008 - amended April 2015)


FUNCTIONS WHICH CAN BE DELEGATED TO OFFICERS OF THE TRUST

FUNCTION STATUTORY REFERENCE (1) CODE OF PRACTICE REFERENCE (2) AUTHORISED PERSON/COMMITTEE

Receipt, scrutiny and rectification of statutory admission documents for detained patients

MHA Section 11(2)

MHA Section 15Regulation 4(3)

Chapter 35

Chapter 35

Receipt of documents:Ward Managers/Nurse in Charge/Matrons

Scrutiny of documents:Associate Director Corporate Governance - Trust Secretary/Deputy Trust Secretary/Legal Services Manager/ Mental Health and Legal Officer/Ward Managers/Nurse in Charge/Matrons

Medical Scrutiny:A Consultant Psychiatrist with appropriate clinical expertise will scrutinise medical recommendations of new applications under Part 2 of MHA

Recording admission(for section 2, 3 & 4 – Form H3)

MHA sections 2, 3 & 4

Regulation 4(4) and 4(5)

Chapter 35 Ward Managers/Nurse in Charge/Matrons

Recording admission(For section 5(2) – Form H1)(For section 5(4) – Form H2)

MHA section 5(2) & 5(4)

Regulation 4(1)(g)Regulation 4(1)(h)

Ward Managers/Nurse in Charge/Matrons

Receipt of Renewal documentation on behalf of Hospital Managers (Form H5)

MHA Section 20(3)(b)

Regulation 13(3)

Chapter 32 & 35 Associate Director Corporate Governance - Trust Secretary/Deputy Trust Secretary/Legal Services Manager/ Mental Health and Legal Officer




Receipt of order for the discharge of a patient, or notice of intention to make such an order, from detention or CTO by RC or nearest relative

MHA Sections 23 and 25 Chapter 29 and 32 Associate Director Corporate Governance - Trust Secretary/Deputy Trust Secretary/Legal Services Manager/ Mental Health and Legal Officer

Receipt of Community Treatment Order (Form CTO1)

MHA Section 17ARegulation 6(1)(c)

Chapter 25 and 35 Associate Director Corporate Governance -Trust Secretary/Deputy Trust Secretary/ Legal Services Manager/ Mental Health and Legal Officer

Receipt of order varying CTO conditions(Form CTO2)

MHA Section 17B(4)

Regulation 6(2)(b)


Receipt of extension report of CTO(Form CTO7)

MHA Section 20A(4)(b)

Regulation 13(6)(a) and (b), and 13(7)

Chapter 29 35 and 35 Associate Director Corporate Governance -Trust Secretary/Deputy Trust Secretary/ Legal Services Manager/ Mental Health and Legal Officer

Receipt of notice recalling patient from CTO (Form CTO3)

MHA Section 17E(6)

Regulation 6(3)(a)





Record of detention in hospital after recall from CTO (Form CTO4)

MHA Section 17E

Regulation 6(3)(d)


Ward Managers/Nurse in Charge/MatronsReceipt of CTO revocation order (Form CTO5)

MHA Section 17F(4)

Regulation 6(8)(a) and (b)

Chapter 29, 32 and 35 Associate Director Corporate Governance -Trust Secretary/Deputy Trust Secretary/ Legal Services Manager/ Mental Health and Legal Officer

Ward Managers/Nurse in Charge/MatronsTransfer of CTO patient to a hospital under different managers(Form CTO6)

MHA Section 17F(2)Regulation 9(3)(a) and (5)

Chapter 37 Associate Director Corporate Governance -Trust Secretary/Deputy Trust Secretary/ Legal Services Manager/ Mental Health and Legal Officer

Assignment of transfer of responsibility to another hospital for CTO patient (Form CTO10)

MHA Section 19ARegulation 17(3)(a) and (d)(i) and (d)(ii)


Transfer of detained patients(Form H4)

(For restricted patients, consent of MoJ required).

MHA Section19Regulation 7(2)(a) and 7(3)

Chapter 12 and 37 Transfer decision is made by the Responsible Clinician

Submission of Statements and reports to MHRT

Tribunal Rules and New Practice Directions 2008

Chapter 12 and 37 Sections B and C (information and documents):Associate Director Corporate Governance -Trust Secretary/Deputy Trust Secretary// Legal Services Manager/ Mental Health



and Legal OfficerReferral of cases to MHRT

Or request Sec of State for Health to refer

MHA Section 68 Chapter 12 and 37 Associate Director Corporate Governance -Trust Secretary/Deputy Trust Secretary/ Legal Services Manager/ Mental Health and Legal Officer

Assisting detained and CTO patients with MHRT applications



Any member of the MDTDuties to give information to detained and CTO patients, and nearest relatives

MHA Section 20(3), 25(2)132, 132A and 133


Ward Managers/Nurse in Charge/MatronsPatients Correspondence; Inspection and withholding of Postal Packets

MHA Section 134

Safety and Security in Ashworth, Broadmoor and Rampton Hospital Directions 2000 para 23(1)

Chapter 4 Outgoing mail only (only if requested by the addressee) – any member of the MDT



Conveyance of detained and CTO patients under the Act and retaking of patients absent without consent

MHA Section 18 Chapters 17 and 28 Any officer on the staff of the hospital/registered establishment, any police officer (or other constable), any person authorised in writing by the managers of the hospital or the managers of the hospital/registered establishment or an AMHP

Information for Victims (in regard to certain Part 3 patients)

Domestic Violence, Crime and Victims Act 2004

Chapter 40 Responsible Clinicians


6. SCHEME OF DELEGATION OF POWERS FROM THE STANDING FINANCIAL INSTRUCTIONSSTANDING FINANCIAL INSTRUCTIONS

INTRODUCTION

6.1 General

6.1.1 These Standing Financial Instructions (SFIs) are for the regulation of the conduct of Trust’s Officers (as defined in the SOs) in relation to all financial matters with which they are concerned. They shall have effect as if incorporated into the SOs.

6.1.2 These Standing Financial Instructions detail the financial responsibilities, policies and procedures adopted by the Trust. They are designed to ensure that the Trust's financial transactions are carried out in accordance with the law and relevant policy in order to achieve probity, accuracy, economy, efficiency and effectiveness. They should be used in conjunction with the Schedule of Decisions Reserved to the Board of Directors and the Scheme of Delegation adopted by the Trust. All Directors and Officers should be aware of the existence of these documents and, to the extent necessary, be familiar with their provisions.

6.1.3 These Standing Financial Instructions identify the financial responsibilities which apply to everyone working for the Trust and its constituent trading units. They do not provide detailed procedural advice and should be read in conjunction with the detailed departmental and financial procedure notes. All financial procedures must be approved by the Director of Finance, Information and Strategy.

6.1.4 Should any difficulties arise regarding the interpretation or application of any of the Standing Financial Instructions then the advice of the Director of Finance, Information and Strategy must be sought before acting. The user of these Standing Financial Instructions should also be familiar with, and comply with, the provisions of the Trust’s SOs and its Constitution.

6.1.5 Failure to comply with Standing Financial Instructions and Standing Orders can in certain circumstances be regarded as a disciplinary matter that could result in dismissal.

6.1.6 Overriding Standing Financial Instructions – If for any reason these Standing Financial Instructions are not complied with, full details of the non-compliance and any justification for non-compliance and the circumstances around the non-compliance shall be reported to the next formal meeting of the Audit and Assurance Committee for referring action or ratification. All


Officers have a duty to disclose any non-compliance with these Standing Financial Instructions to the Director of Finance, Information and Strategy as soon as possible.

6.2 Responsibilities and delegation

6.2.1 The Trust’s Board of Directors

The Board of Directors exercises financial supervision and control by:

(a) Formulating the financial strategy;

(b) Requiring the submission and approval of budgets within overall income;

(c) Defining and approving essential features in respect of important procedures and financial systems (including the need to obtain value for money); and

(d) Defining specific responsibilities placed on members of the Board of Directors and employees as indicated in the Scheme of Delegation document.

6.2.2 The Board of Directors has resolved that certain powers and decisions may only be exercised by the Board of Directors in formal session. These are set out in the ‘Schedule of Matters Reserved to the Board’ document. Powers of the Trust have also been delegated to committees and sub-committees of the Trust (to the extent allowable under the Constitution) as specified in the Scheme of Delegation.

Any variation of these SFIs shall only be made by resolution of the Board of Directors.

6.2.3 The Chief Executive and Director of Finance, Information and Strategy

The Chief Executive and Director of Finance, Information and Strategy will, as far as possible, delegate their detailed responsibilities, but they remain accountable for financial control.


Within the Standing Financial Instructions, it is acknowledged that the Chief Executive is ultimately accountable to the Board of Directors (and as Accounting Officer to the Secretary of State in accordance with the Accounting Officer Memorandum). The Chief Executive has overall executive responsibility for the Trust's activities; is responsible to the Chair and the Board of Directors for ensuring that its financial obligations and targets are met and has overall responsibility for the Trust’s system of internal control.

6.2.4 It is a duty of the Chief Executive to ensure that Directors, Officers and all new appointees are notified of, and put in a position to understand their responsibilities within these Instructions.

6.2.5 The Director of Finance, Information and Strategy

The Director of Finance, Information and Strategy is responsible for:

(a) Implementing the Trust's financial policies and for co-ordinating any corrective action necessary to further these policies;

(b) Maintaining an effective system of internal financial control including ensuring that detailed financial procedures and systems incorporating the principles of separation of duties and internal checks are prepared, documented and maintained to supplement these instructions;

(c) Ensuring that sufficient records are maintained to show and explain the Trust's transactions, in order to disclose, with reasonable accuracy, the financial position of the Trust at any time; and

(d) Ensuring that a systematic internal audit is carried out and appropriate audit records are maintained;

and, without prejudice to any other functions of the Trust and Officers of the Trust, the duties of the Director of Finance, Information and Strategy include:

(e) The provision of financial advice to Directors and employees;

(f) The design, implementation and supervision of systems of internal financial control and the documentation of such systems in detailed financial procedure notes;


(g) The preparation and maintenance of such accounts, certificates, estimates, records and reports as the Trust may require for the purpose of carrying out its statutory duties.

6.2.6 Board Members and Officers

All Directors and Officers, severally and collectively, are responsible for:

(a) The security of the property of the Trust;

(b) Avoiding loss;

(c) Exercising economy and efficiency in the use of resources; and

(d) Conforming with the requirements of SOs, Standing Financial Instructions, Trust’s financial procedures from time to time and the Scheme of Delegation.

Contractors and their employees

6.2.7 Any contractor or employee of a contractor who is empowered by the Trust to commit the Trust to expenditure or who is authorised to obtain income shall be covered by these instructions. It is the responsibility of the Chief Executive to ensure that such persons are made aware of this.

6.2.8 For all Directors and any employees who carry out a financial function, the form in which financial records are kept and the manner in which Directors and Officers discharge their duties must be to the satisfaction of the Director of Finance, Information and Strategy.

6.2.9 Any request for interpretation of SFIs shall be submitted in writing to the Director of Finance, Information and Strategy who shall, where necessary, provide an interpretation of these SFIs.

6.2.10 Any variation of these SFIs shall only be made by resolution of the Board of Directors.


7. AUDIT

7.1 Audit and Assurance Committee

7.1.1 An independent Audit and Assurance Committee is a central means by which a Board of Directors ensures effective internal control arrangements are in place. In addition, the Audit and Assurance Committee provides a form of independent check upon the executive arm of the Board of Directors. In accordance with SOs the Board of Directors shall formally establish an Audit and Assurance Committee, with clearly defined terms of reference (and in compliance with guidance from the NHS Audit and Assurance Committee Handbook (as amended from time to time) to perform various tasks (including but not limited to) the following:

Review the establishment and maintenance of an effective system of integrated governance, risk management and internal control across the whole of the Trust’s activities that supports the achievement of the Trust’s objectives and manages key risks facing the Trust.

Review the adequacy and effectiveness of the underlying assurance processes that indicate the degree of achievement of corporate objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements.

Review the adequacy and effectiveness of the policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements and related reporting and self-certification.

Review and monitor the integrity of any statements, including financial statements that are risk and control related. These specifically include, but are not limited to, the Annual Governance Statement, the accompanying Head of Internal Audit Statement, any external audit opinion and the financial statements of the Trust.

Review the Trust’s internal financial controls and review the systems and controls in place to manage risk.

Review and approve the Trust’s Annual Report, Quality Report and financial statements before their submission to the Board of Directors.

Review any declarations for CQC registration and any accompanying assurances required for the Board of Directors.Version 5:July 2018 51

Ensure that there is an effective internal audit service that meets the requirements of the NHS Internal Audit Standards and provides appropriate and relevant assurance to the Audit and Assurance Committee, Chief Executive and Board of Directors. This will include the consideration and agreement of an annual internal audit plan and subsequent findings.

Review and monitor the effectiveness and objectivity of the external audit service. This will include the consideration and agreement of an annual external audit plan and subsequent findings.

Make recommendations to the Council of Governors, in relation to the appointment of the external auditor

Review the findings of other significant assurance functions, both internal and external to the organisation, and consider the implications on the governance arrangements of the Trust.

Review and monitor and ensure assurance that the organisation has adequate arrangements in place for both preventing and countering fraud

Review the outcomes of counter fraud reports.

Consider and review all aspects of the Assurance Framework to ensure that the principles are embedded within the organisation and that risks are being appropriately managed.

7.1.2 The minutes of each Audit and Assurance Committee meetings shall be formally recorded by the Audit and Assurance Committee and a summary report submitted to the Board of Directors. The Chair of the Audit and Assurance Committee shall draw to the attention of the Board of Directors any issues that require disclosure to the full Board of Directors, or require executive action. The Audit and Assurance Committee will report to the Board of Directors annually on its work in support of the Annual Governance Statement, specifically commenting on the fitness for purpose of the Assurance Framework, the completeness and embededness of risk management in the organisation, and the integration of governance arrangements.

7.1.3 Where the Audit and Assurance Committee considers there is evidence of ultra vires transactions, evidence of improper acts, or if there are other important matters that the Audit and Assurance Committee wishes to raise, the Chair of the Audit and Assurance Committee should raise the matter at a full meeting of the Board of Directors. Exceptionally, the matter may need to be referred to NHS Improvement.


7.2 Director of Finance, Information and Strategy

7.2.1 The Director of Finance, Information and Strategy is responsible for:

(a) Ensuring there are arrangements to review, evaluate and report on the effectiveness of internal financial control including the establishment of an effective internal audit function;

(b) Ensuring that the internal audit function meets the NHS mandatory audit standards and provides sufficient independent and objective assurance to the Audit and Assurance Committee and the Accounting Officer;

(c) Deciding at what stage to involve the police in cases of fraud, misappropriation and other irregularities, in accordance with the prevailing NHS requirements;

(d) Ensuring that an annual internal audit report is prepared for the consideration of the Audit and Assurance Committee and the Board of Directors. The report must cover:

(i) A clear opinion on the effectiveness of internal control in accordance with current assurance framework guidance issued by the Department of Health including for example compliance with control criteria and standards;

(ii) Major internal financial control weaknesses discovered;

(iii) Progress on the implementation of internal audit recommendations;

(iv) Progress against plan over the previous year;

(v) A strategic audit plan covering the coming three years;

(vi) A detailed plan for the coming year.

7.2.2 The Director of Finance, Information and Strategy or designated internal or external auditor is entitled without necessarily giving prior notice to require and receive:


(a) Access to all records, documents and correspondence relating to any financial or other relevant transactions, including documents of a confidential nature;

(b) Access at all reasonable times to any land, premises or members of the Board of Directors or Officer of the Trust;

(c) The production of any cash, stores or other property of the Trust under a member of the Board of Directors or an Officer's control; and

(d) Explanations concerning any matter under investigation.

7.3 Role of Internal Audit

7.3.1 “Internal Audit” is an independent and objective appraisal service within the Trust which provides:

(a) An independent and objective opinion to the Accounting Officer, the Board of Directors, and the Audit and Assurance Committee on the degree to which risk management, control and governance, support the achievement of the Trust’s agreed objectives;

(b) An independent and objective consultancy service specifically to help line management improve the Trust’s risk management, control and governance arrangements.

7.3.2 Internal Audit will review, appraise and report upon policies, procedures and operations in place to:

(a) Establish and monitor the achievement of the Trust’s objectives;

(b) Identify, assess and manage the risks to achieving the Trust’s objectives;

(c) Ensure the economical, effective and efficient use of resources;

(d) Ensure the adequacy and application of financial and other related management controls;


(e) Ensure the suitability of financial and other related management data;

(f) ensure the economical, effective and efficient use of resources, including the extent to which the Trust’s assets and interests are accounted for and safeguarded from losses of any kind, arising from:

fraud and other offences;

waste, extravagance, inefficient administration;

poor value for money or other causes;

(g) Ensure compliance with established policies (including behavioural and ethical expectations), procedures, laws and regulations

(h) Ensure the integrity and reliability of information, accounts and data, including internal and external reporting and accountability processes.

7.3.3 The Head of Internal Audit will provide to the Audit and Assurance Committee;

(a) A risk-based plan of internal audit work, agreed with management and approved by the Audit and Assurance Committee, based upon the Trust’s Assurance Framework that will enable the auditors to collect sufficient evidence to give an opinion on the adequacy and effective operation of the Trust;

(b) Regular updates on the progress against plan;

(c) Reports of management’s progress on the implementation of action agreed as a result of internal audit findings;

(d) An annual opinion, based upon and limited to the work performed, on the overall adequacy and effectiveness of the Trust’s risk management, control and governance processes (i.e. the Trust’s system of internal control). This opinion is used by the Board of Directors to inform the Annual Governance Statement.


(e) Additional reports as requested by the Audit and Assurance Committee.

7.3.4 Whenever any matter arises which involves, or is thought to involve, irregularities concerning cash, stores, or other property or any suspected irregularity in the exercise of any function of a pecuniary nature, the Director of Finance, Information and Strategy must be notified immediately.

7.3.5 The Head of Internal Audit will normally attend Audit and Assurance Committee meetings and has a right of access to all Audit and Assurance Committee members, the Chair and Chief Executive of the Trust.

7.3.6 The Head of Internal Audit reports to the Audit and Assurance Committee and is managed by the Director of Finance, Information and Strategy. The reporting system for Internal Audit shall be agreed between the Director of Finance, Information and Strategy, the Audit and Assurance Committee and the Head of Internal Audit. The agreement shall be in writing. The reporting system shall be reviewed at least every three years.

7.3.7 The appointment and termination of the Head of Internal Audit and/or the Internal Audit Service must be approved by the Audit and Assurance Committee.

7.3.8 The Head of Internal Audit shall have right of access to the Auditor.

7.3.9 There shall be an annual review of the internal audit services which are paid for by the Trust. The Audit and Assurance Committee must ensure a cost-efficient service.

7.4External Audit

7.4.1 The External Auditor is appointed by the Council of Governors and paid for by the Trust. The Audit and Assurance Committee must ensure a cost-efficient service. If there are any problems relating to the service provided by the External Auditor, then this should be raised initially with the External Auditor and referred on to the Audit Commission (and if necessary the Council of Governors) if the issue cannot be resolved.

7.5Fraud and Corruption


7.5.1 In line with their responsibilities, the Trust Chief Executive and Director of Finance, Information and Strategy shall monitor and ensure compliance with NHS requirements on fraud and corruption.

7.5.2 The Trust shall nominate a suitable person to carry out the duties of the Local Counter Fraud Specialist (LCFS) as specified by NHS Protect requirements and guidance.

7.5.3 The Director of Finance, Information and Strategy will ensure that action to counter fraud and corruption is taken including the reporting to LCFS of all suspected fraud and corruption.

7.5.4 The LCFS shall report to the Director of Finance, Information and Strategy and shall work with staff in NHS Protect and their National Investigation Service in accordance with NHS Protect requirements and guidance.

7.5.5 The LCFS will provide a written report to the Audit and Assurance Committee, at least annually, on counter fraud work within the Trust.

7.6 Security Management

7.6.1 In line with their responsibilities, the Trust Chief Executive will monitor and ensure compliance by the Trust with relevant NHS counter fraud requirements.

7.6.2 The Trust shall nominate a suitable person to carry out the duties of the Local Security Management Specialist (LSMS) as specified by the national guidance on NHS security management.

7.6.3 The Trust shall nominate an Executive Director, to oversee the NHS security management service, who will report to the Board of Directors.

7.6.4 The Chief Executive has overall responsibility for controlling and coordinating security. However, key tasks are delegated to the Chief Nurse and the appointed Local Security Management Specialist (LSMS).

8. RESOURCE LIMIT CONTROL


Not Applicable

9. BUDGETS, BUDGETARY CONTROL AND MONITORING

9.1 Budgets

9.1.1 The Chief Executive with the assistance of the Director of Finance, Information and Strategy shall prepare, every five years, a statement of strategic direction for approval by the Board of Directors with an annual review.

9.2 Preparation and Approval of Budgets

(a) The Chief Executive with the assistance of the Director of Finance, Information and Strategy will compile and submit to the Board of Directors an annual business plan (the “Annual Plan”) in accordance with the business planning process which takes into account financial targets and forecast limits of available resources. The Annual Plan will contain:

(b) A statement of the significant assumptions on which the Annual Plan is based;

(c) Details of major changes in workload, delivery of services or resources required to achieve the plan.

9.2.2 Prior to the start of the financial year the Director of Finance, Information and Strategy will, on behalf of the Chief Executive, prepare and submit budgets (the “Budgets”) for approval by the Board of Directors.

9.2.3 The Director of Finance, Information and Strategy must review the basis and assumptions used to prepare the Budgets and

advise the Board of Directors whether they are realistic.

9.2.4 Such Budgets should relate to income and expenditure in that year and shall have supporting statements in order to explain any matter material to the understanding of those Budgets covering the following:

activities;

revenue and capital items.


Such Budgets will:

(a) Be in accordance with the aims and objectives set out in the Annual Plan;

(b) Accord with workload and workforce plans;

(c) Be produced following discussion with appropriate budget holders;

(d) Be prepared within the limits of available funds;

(e) Identify potential risks.

3.2.5 The Director of Finance, Information and Strategy shall monitor financial performance against budget and the Annual Plan, and shall periodically review them, and report to the Board of Directors.

3.2.6 All budget holders must provide information as required by the Director of Finance, Information and Strategy to enable budgets to be compiled.

3.2.7 All Budget Holders will sign up to their allocated Budgets at the commencement of each Financial Year.

9.2.8 The Director of Finance, Information and Strategy has a responsibility to ensure that adequate training is delivered on an on-going basis to budget holders to help them manage successfully.

9.3 Budgetary Delegation

9.3.1 The Chief Executive may delegate the management of a budget to permit the performance of a defined range of activities. This delegation must be in writing and be accompanied by a clear definition of:

(a) The amount of the budget;


(b) The purpose(s) of each budget heading;

(c) Individual and group responsibilities;

(d) Authority to exercise virement;

(e) Achievement of planned levels of service;

(f) The provision of regular reports.

9.3.2 Budgets shall be delegated as far as possible to the lowest level consistent with effective operational management.

9.3.3 The Chief Executive and delegated budget holders (“Budget Holders”) must not exceed the budgetary total or virement limits set by the Board of Directorsand detailed below :-

- Up to £50,000 – Associate / Assistant Directors- Up to £100,000 – Directors- £100,000 and above – Director of Finance, Information and Strategy

9.3.4 Any budgeted funds not required for their designated purpose(s) revert to the immediate control of the Chief Executive, subject to any authorised use of virement.

9.3.5 Non-recurring budgets should not be used to finance recurring expenditure without the authority in writing of the Chief Executive, as advised by the Director of Finance, Information and Strategy.

9.3.6 The management of income and expenditure will be in accordance with the Trust’s Budgetary Rules.

9.4 Budgetary Control and Reporting

9.4.1 The Director of Finance, Information and Strategy shall be responsible for ensuring that an adequate system of monitoring financial performance is in place to enable the Trust to fulfil its responsibilities.


9.4.2 The Director of Finance, Information and Strategy shall devise and maintain a system of budgetary control and all managers whom the Trust may empower to engage staff or otherwise incur expenditure, collect or generate income, shall comply with the requirements of those systems. The system of budgetary control shall incorporate the reporting of, and investigation into, financial workload or manpower variances from Budget. The Director of Finance, Information and Strategy shall also be responsible for providing budgetary information and advice to enable the Chief Executive and other operational managers to carry out their budgetary responsibilities and issue to all relevant staff, rules and procedures governing the operation of Budgets.

9.4.3 The Director of Finance, Information and Strategy is responsible for presenting financial reports to the Board of Directors giving details of underlying performance, financial efficiency, liquidity and achievement of plan, as well as details of the overall financial risk score.

(a) Monthly financial reports received by the Board of Directors shall therefore be produced containing at least the following detail:

(i) Income and expenditure to date showing trends and forecast year-end position;

(ii) Progress against Cost Improvement Programme(s);

(iii) Movements in working capital;

(iv) Capital project spend and projected outturn against plan;

(v) Explanations of any material variances from plan;

(vi) Details of any corrective action where necessary and the Chief Executive's and/or Director of Finance, Information and Strategy's view of whether such actions are sufficient to correct the situation;

(b) The issue of timely, accurate and comprehensible advice and financial reports to each budget holder, covering the areas for which they are responsible;

(c) Investigation and reporting of variances from financial, workload and manpower budgets;


(d) Monitoring of management action to correct variances;

(e) Arrangements for the authorisation of budget transfers.

9.4.4 The Chief Executive is responsible for identifying and implementing cost improvements and income generation initiatives in accordance with the requirements of the Integrated Business Plan and a balanced budget.

9.4.5 The Director of Finance, Information and Strategy shall devise and maintain adequate systems to ensure that the Trust can identify, implement and monitor opportunities for schemes to be included within Cost Improvement Programmes and Income Generating Programmes.

9.4.6 The Director of Finance, Information and Strategy has a responsibility to ensure that adequate training is delivered on an on-going basis to Budget Holders to help them manage their financial issues successfully.

9.4.7 Each Budget Holder is responsible for ensuring that:

(a) Any likely overspending or reduction of income which cannot be met by virement is not incurred without the prior consent of the Board of Directors;

(b) The amount provided in the approved budget is not used in whole or in part for any purpose other than that specifically authorised, subject to the rules of virement;

(c) No permanent Officers are appointed without the approval of the Chief Executive other than those provided for within the available resources and manpower establishment as approved by the Board of Directors.

9.5 Capital Expenditure

9.5.1 The general rules applying to delegation and reporting shall also apply to capital expenditure. (The particular applications relating to capital are contained in SFI 18).


9.6 Monitoring Returns

9.6.1 The Chief Executive is responsible for ensuring that the appropriate monitoring forms are submitted to the requisite monitoring organisation.

9.6.2 The Director of Finance, Information and Strategy will ensure that an adequate system of financial reporting and monitoring is in place to meet the requirements of the financial aspects of any monitoring return requirements.

9.7 Value for Money

9.7.1 The Chief Executive in conjunction with the Director of Finance, Information and Strategy shall be responsible for the efficient and effective use of the total financial resources available to the Trust and ensure that good value for money is achieved.

10. ANNUAL ACCOUNTS AND REPORTS

10.1 The Director of Finance, Information and Strategy, on behalf of the Trust, will:

(a) Prepare financial returns in accordance with the accounting policies, guidance and directions given by NHS Improvement and the Treasury, the Trust's accounting policies, and generally accepted accounting practice;

(b) Prepare and submit annual financial reports to NHS Improvement certified in accordance with current guidelines;

(c) Submit financial returns to NHS Improvement for each financial year in accordance with the timetable prescribed by NHS Improvement.

10.2 The Trust's annual accounts must be audited by an auditor appointed by the Council of Governors. The Trust's audited annual accounts must be presented to the Council of Governors and to the Annual Members’ Meeting, and must be made available as specified in the Constitution.

10.3 The Trust will publish an annual report, in accordance with guidelines on local accountability, and present it to the Council of


Governors and to the Annual Members’ Meeting. The document must comply with (and be made available in accordance with) the requirements specified in the Trust’s constitution.

11 BANK AND GOVERNMENT BANKING SERVICE ACCOUNTS

11.1 General

11.1.1 The Director of Finance, Information and Strategy is responsible for managing the Trust’s banking, working capital and investment arrangements and for advising the Board of Directors on the provision of banking services and operation of accounts. This advice will take into account any guidance, best practice advice or directions issued from time to time by the Department of Health and NHS Improvement.

11.1.2 The Board of Directors shall approve the banking, working capital and investment arrangements, and will review arrangements as appropriate including a review of the Trust's Treasury Management Policy on at least an annual basis.

11.1.3 No Officer may open or hold a bank account in the name of the Trust or any of its constituent hospitals/departments. Any Officer aware of the existence of such an account shall report the matter to the Director of Finance, Information and Strategy. Where an Officer holds funds or has an interest in a bank account that may or may not be held on trust and these funds are intended for use on health or health related expenditure, then the Officer should declare this annually as a financial interest under the Trust’s Standards of Business Conduct Policy.

11.2 Bank and GBS Accounts


(a) The operation of bank accounts and Government Banking Service (GBS) accounts, Working Capital Facilities and the appropriate investment of the Trust’s cash;

(b) Establishing separate bank accounts for the Trust's non-exchequer funds;


(c) Ensuring 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 Trust's bankers for accounts to be overdrawn (together with any remedial action to be taken);

(e) Monitoring compliance with any guidance issued by the Department of Health, NHS Improvement or any other relevant guidance on the level of cleared funds.

11.3 Investments

11.3.1 The Director of Finance, Information and Strategy is responsible for ensuring a Treasury Management Policy is in existence, which complies with Section 46 of the 2006 Act and NHS Improvements guidelines and that the Treasury Management Policy is regularly reviewed and approved by the Board of Directors.

11.3.2 The Trust will hold cash and make investments subject to any limitations contained in the terms of its Authorisation, and in accordance with its Treasury Management Policy and the guidance titled “Risk evaluation for investment decisions by NHS Foundation Trusts” (REID) and will aim to ensure:

11.3.2.1 A competitive rate within a minimal risk profile;

11.3.2.2 The availability of cash to meet operational requirements; and

11.3.2.3 The availability of flexible, competitively priced funding at all times.

11.3.3 The Director of Finance, Information and Strategy is responsible for advising the Board of Directors on investments and shall report regularly to the Board of Directors concerning the performance of all investments held.

11.3.4 The Board of Directors will report to NHS Improvement on investments.

11.3.5 The Board of Directors will report to NHS Improvement on any proposed major investments that could affect the Trust’s financial risk rating as part of the annual planning process or in year, prior to financial close. In determining whether any investment decision is to be reported to NHS Improvement, the Trust will take into account the REID guidance.


11.4 Banking Procedures

11.4.1 The Director of Finance, Information and Strategy has prepared detailed instructions on the operation of bank and GBS accounts, the Trust’s Working Capital Facility, and investment management which include:

11.4.1.1 The conditions under which each bank and GBS account is to be operated;

11.4.1.2 The limits to be applied to any overdraft or investment;

11.4.1.3 Those authorised to sign cheques or other orders drawn on the Trust’s accounts and the number of signatures required on each authority to pay;

11.4.1.4 Those authorised to invest monies or open new accounts for investment; and

11.4.1.5 Any records which must be maintained in respect of the above.

11.4.2 The Director of Finance, Information and Strategy must advise the Trust’s bankers in writing of the conditions under which each account will be operated.

11.4.3 The Director of Finance, Information and Strategy must advise the GBS in writing, including a copy of the Board of Directors resolution, of the conditions under which each account will be operated; the limits to be applied to any overdraft and the limitation on single signatory payments and any changes that may be required by financial regulations of the National Health Service or by resolution of the Board of Directors as may be necessary from time to time. In addition the Director of Finance, Information and Strategy shall advise the bankers and the GBS, in writing, of the Officer(s) and/or Directors authorised to release money from, and draw cheques on, each bank account of the Trust and shall notify promptly the cancellation of any such authorisation.

11.4.4 Where an agreement is entered into with any other body for payment to be made on behalf of the Trust from bank accounts maintained in the name of the Trust or other body, or by Electronic Funds Transfer (BACS), the Director of Finance, Information and Strategy shall ensure that satisfactory security regulations of the Trust/other body relating to bank accounts exist and are observed. This will be specified in an agreement with the appropriate body.

11.5 Tendering and Review


11.5.1 The Director of Finance, Information and Strategy will review the commercial banking arrangements of the Trust at regular intervals to ensure they reflect best practice and represent best value for money by periodically seeking competitive tenders for the Trust’s banking business.

11.5.2 Competitive tenders shall be sought at least every three years unless the Board of Directors determine otherwise. The results of the tendering exercise should be reported to the Board of Directors. This review is not necessary for the operation of GBS accounts required by the Department of Health.

11.5.3 The Trust’s Banking Procedure shall be reviewed annually to ensure that it complies with the current requirements of NHS Improvement and shall be approved by the Board of Directors.

12 INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE INSTRUMENTS

12.1 Income Systems

12.1.1 The Director of Finance, Information and Strategy is responsible for designing, maintaining and ensuring compliance with systems for the proper recording, invoicing, and collection and coding of all monies due.

12.1.2 The Director of Finance, Information and Strategy is also responsible for the prompt banking of all monies received.

12.1.3 All Officers shall inform the Director of Finance, Information and Strategy of money due to the Trust arising from transactions which they initiate involving all contracts, leases, tenancy agreements, private patient undertakings and other transactions.

12.1.4 The Director of Finance, Information and Strategy shall be consulted about the pricing of goods and services offered for sale and regional or national negotiated rates shall be observed.

12.1.5 The Trust may carry on activities for the purpose of making additional income available and/or to better carry out the Trust’s principal purpose under the 2006 Act subject any applicable legal or regulatory restrictions or guidance.

12.2 Fees and Charges


12.2.1 The Trust shall follow the Department of Health's advice in the "Costing" Manual and shall comply with the regional or national negotiated rates in setting prices for NHS service agreements.

12.2.2 The Director of Finance, Information and Strategy is responsible for approving and regularly reviewing the level of all fees and

charges other than those determined by the Department of Health, NHS Improvement or by law. Independent professional advice on matters of valuation shall be taken as necessary.

12.2.3 All employees must inform the Director of Finance, Information and Strategy promptly of money due arising from transactions which they initiate/deal with, including all contracts, leases, tenancy agreements, private patient undertakings and other transactions.

12.3 Debt Recovery

12.3.1 The Director of Finance, Information and Strategy is responsible for the appropriate recovery action on all outstanding debts. The Director of Finance, Information and Strategy shall establish the procedure for the issuing of credit notes and write-off of debts after all reasonable steps have been taken to secure payment.

12.3.2 Income not received should be dealt with in accordance with losses procedures.

12.3.3 Overpayments should be prevented wherever possible, but where detected recovery should be initiated.

12.3.4 Disposal of scrap material and items surplus to requirements shall be dealt with in accordance with the SOs.

12.4 Security of Cash, Cheques and other Negotiable Instruments


(a) Approving the form of all receipt books, agreement forms, or other means of officially acknowledging or recording monies received or receivable;

(b) Ordering and securely controlling any such stationery;


(c) The provision of adequate facilities and systems for Officers 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; and

(d) Prescribing systems and procedures for handling cash and negotiable securities on behalf of the Trust.

12.4.2 All Officers whose duty it is to collect or hold cash shall be provided with a safe or with a lockable cash box. The Officer concerned shall hold only one key and all duplicates shall be lodged with the Trust’s bankers or such other Officer authorised by the Director of Finance, Information and Strategy, and suitable receipts obtained. Keys for safes, cash boxes etc shall be carried on the person of the key holder and shall not be left unattended. The loss of any key shall be reported immediately to the Director of Finance, Information and Strategy. The Director of Finance, Information and Strategy shall, on receipt of a satisfactory explanation, authorise the release of the duplicate key. The Director of Finance, Information and Strategy shall arrange for all new safe keys to be despatched directly to him from the manufacturers. The Director of Finance, Information and Strategy shall be responsible for maintaining a register of authorised holders of safe keys.

12.4.3 All cash, postal orders and other forms of payment received by designated cashiers shall be immediately entered on the payments received documentation and a receipt issued. All cheques and postal orders shall be crossed immediately “Not negotiable – A/C Derbyshire Community Healthcare NHS Foundation Trust”. The remittances shall be passed to the cashier from whom a signature shall be obtained. Income received at any other approved location shall be dealt with in accordance with financial procedure notes approved by the Director of Finance, Information and Strategy.

12.4.4 An official receipt shall be made out by the cashier for every cash sum received (and for non-cash remittances where requested) and shall show:-

12.4.4.1 The amount and type of remittance (e.g. cash, cheque); and12.4.4.2 The reason for the payment (e.g. invoice/account number).

12.4.5 All other receipts, including cancelled receipts, shall be returned with the top copy of the income sheet to the Director of Finance, Information and Strategy, who shall be responsible for ensuring that all receipts have been accounted for. A special receipt will be issued for all charitable fund donations which will enable the donor to express their wishes as to the purpose of the donation.

12.4.6 The opening of coin operated machines (including telephones) and the transfer, counting and recording of the takings shall be undertaken by two Officers together both of whom should sign the record, except in instances as may be authorised in writing by the Director of Finance, Information and Strategy, and the coin box keys shall be held by a nominated Officer.


12.4.7 The Director of Finance, Information and Strategy shall prescribe the system for the transporting of cash and uncrossed pre-signed cheques.

12.4.8 Official monies shall not under any circumstances be used for the encashment of private cheques.

12.4.9 All cheques, postal orders, cash etc, shall be banked intact promptly in accordance with the Director of Finance, Information and Strategy’s procedures, to the credit of the Trust’s Main Account or, if appropriate, the relevant trust fund bank account. Disbursements shall not be made from cash received, except under arrangements approved by the Director of Finance, Information and Strategy.

12.4.10 The holders of safe keys shall not accept unofficial funds for depositing in their safes unless such deposits are in special sealed envelopes or locked containers. It shall be made clear to the depositors that the Trust is not to be held liable for any loss, and written indemnities must be obtained from the organisation or individuals absolving the Trust from responsibility for any loss.

12.4.11 During the absence (e.g. on holiday) of the holder of a safe or cash box key, the Officer who acts in his place shall be subject to the same controls as the normal holder of the key. There shall be written discharge for the safe and/or cash box contents on the transfer of responsibilities and the discharge document must be retained for inspection. Any alterations to the discharge document must be signed by each Officer.

12.4.12 All unused cheques and other orders shall be subject to the same security precautions as are applied to cash; bulk stocks of cheques shall normally be retained by the Trust’s bankers or printers and released by them only against a requisition signed by the Director of Finance, Information and Strategy or other authorised signatory.

12.4.13 The use of cheques with pre-printed signature included shall be subject to such special security precautions as may be required from time to time by the Director of Finance, Information and Strategy.

12.4.14 Staff shall be informed in writing on appointment, by the appropriate departmental or senior Officer, of their responsibilities and duties for the collection, handling or disbursement of cash, cheques etc.

12.4.15 Any loss or shortfall of cash, cheques or other negotiable instruments, however, occasioned, shall be reported immediately to the Director of Finance, Information and Strategy and dealt with in accordance with the agreed procedure for reporting losses.


12.4.16 No cash payment shall be accepted for any one off transaction involving the supply of goods or services where the value exceeds £10,000 and any such offer of payment shall be immediately referred to the Director of Finance, Information and Strategy.

13. TENDERING AND CONTRACTING PROCEDURE

13.1 Duty to comply with Standing Orders and Standing Financial Instructions

The procedure for making all contracts by or on behalf of the Trust shall comply with the SOs and these Standing Financial Instructions (except where Standing Order [No. 4.14 Suspension of Standing Orders is applied).

13.2 Public Procurement law and guidance

All procurement undertaken by the Trust, of whatever value, is subject to EU and UK legislation and rules. For the avoidance of doubt, where there is any conflict between UK and EU legislation and these SFIs, UK and EU law shall prevail.

13.3 Reverse eAuctions

The Trust should have policies and procedures in place for the control of all tendering activity carried out through Reverse eAuctions. For further guidance on Reverse eAuctions refer to https://www.gov.uk/guidance/buying-goods-and-services-options-for-public-sector-buyers.

13.4 Capital Investment Manual and other Department of Health and Social Care Guidance

The Trust shall, as far as is practicable, comply with the requirements of the Trust Investment policy, Health Building Note (HBN) 00-08 Parts A and B and associated relevant guidance in respect of capital investment and estate and property transactions.

13.5 Formal Competitive Tendering


https://www.gov.uk/guidance/buying-goods-and-services-options-for-public-sector-buyers

https://www.gov.uk/guidance/buying-goods-and-services-options-for-public-sector-buyers

13.5.1 Health Care Services

For the avoidance of doubt, where the Trust elects to invite tenders for the supply of healthcare services the SOs and these SFIs shall apply.

13.5.2 Exceptions and instances where formal tendering need not be applied

Subject to SFI 13.2, formal tendering procedures need not be applied where:

(a) The estimated expenditure or income does not, or is not reasonably expected to, exceed £20,000 excluding VAT; or

(b) Where the supply is proposed under special arrangements negotiated by the DH in which event the said special arrangements must be complied with;

(c) Regarding disposals as set out in Standing Financial Instructions No. 20;

Subject to SFI 13.2, formal tendering procedures may be waived in the following circumstances:

(13) In very exceptional circumstances where the Chief Executive decides that formal tendering procedures would not be practicable or the estimated expenditure or income would not warrant formal tendering procedures, and the circumstances are detailed in an appropriate Trust record;

(14) Where the requirement is covered by an existing contract;

(15) Where the contract would be pursuant to a national framework agreement;

(16) Where a consortium arrangement is in place and a lead organisation has been appointed to carry out tendering activity on behalf of the consortium members;

(17) Where the timescale genuinely precludes competitive tendering (but failure to plan the work properly would not be regarded as a justification for a single tender);


(18) Where specialist expertise is required and is available from only one source;

(19) When the task is essential to complete the project, and arises as a consequence of a recently completed assignment and engaging different consultants for the new task would be inappropriate;

(k) There is a clear benefit to be gained from maintaining continuity with an earlier project. However in such cases the benefits of such continuity must outweigh any potential financial advantage to be gained by competitive tendering;

(l) For the provision of legal advice and services providing that any legal firm or partnership commissioned by the Trust is regulated by the Law Society for England and Wales for the conduct of their business (or by the Bar Council for England and Wales in relation to the obtaining of Counsel’s opinion) and are generally recognised as having sufficient expertise in the area of work for which they are commissioned.

The Director of Finance, Information and Strategy will ensure that any fees paid are reasonable and within commonly accepted rates for the costing of such work.

The waiving of competitive tendering procedures should not be used to avoid competition or for administrative convenience or to award further work to a consultant originally appointed through a competitive procedure.

Where it is decided that competitive tendering is not applicable and should be waived, the fact of the waiver and the reasons should be documented and recorded in an appropriate Trust record and reported to the Audit and Assurance Committee at each meeting.

13.5.3 Fair and Adequate Competition

Where the exceptions set out in SFI Nos. 13.9 and 13.5.2 apply, the Trust shall ensure that invitations to tender are sent to a sufficient number of firms/individuals to provide fair and adequate competition as appropriate, and in no case less than two firms/individuals, having regard to their capacity to supply the goods or materials or to undertake the services or works required.


13.5.4 List of Approved Firms

The Board of Directors shall ensure that the firms/individuals invited to tender (and where appropriate, quote) are among those on approved lists. Where in the opinion of the Director of Finance, Information and Strategy it is desirable to seek tenders from firms not on the approved lists, the reason shall be recorded in writing to the Chief Executive (see SFI 17.6.8 List of Approved Firms).

13.5.5 Building and Engineering Construction Works

Competitive Tendering cannot be waived for building and engineering construction works and maintenance (other than in accordance with law, regulation or guidance applicable to building or engineering works) without approval of the Board of Directors.

13.5.6 Items which subsequently breach thresholds after original approval

Items estimated to be below the limits set in this Standing Financial Instruction for which formal tendering procedures are not used which subsequently prove to have a value above such limits shall be reported to the Chief Executive, and be recorded in an appropriate Trust record.

13.6 Contract/Tendering Procedure

13.6.1 Invitation to tender

(i) All invitations to tender shall state the date and time as being the latest time for the receipt of tenders.

(ii) All invitations to tender shall state that no tender will be accepted unless:

Submitted electronically through the Trusts eTender system portal and therefore fully auditable duly recording the latest date and time for the receipt of such tender addressed to the Chief Executive or nominated Manager;

(iii) Every tender for goods, materials, services or disposals shall embody such of the NHS Standard Terms and Conditions of Contract conditions as are applicable (any tenders for clinical services must use the NHS Standard Contract as released


by the NHS Commissioning Board from time to time).

(iv) Every tender for building or engineering works (except for maintenance work, when Estmancode guidance shall be followed) shall embody or be in the terms of the current edition of one of the Joint Contracts Tribunal Standard Forms of Building Contract or Department of the Environment (GC/Wks) Standard forms of contract amended to comply with relevant law, regulation or guidance in respect of building or engineering works; or, when the content of the work is primarily engineering, the General Conditions of Contract recommended by the Institution of Mechanical and Electrical Engineers and the Association of Consulting Engineers (Form A), or (in the case of civil engineering work) the General Conditions of Contract recommended by the Institute of Civil Engineers, the Association of Consulting Engineers and the Federation of Civil Engineering Contractors. These documents shall be modified and/or amplified to accord with Department of Health guidance and, in minor respects, to cover special features of individual projects.

(v) Every tenderer must have given, or give a written undertaking, not to engage in collusive tendering or other restrictive practice.

13.6.2 Receipt and safe custody of tenders

The Chief Executive or his/her nominated representative will be responsible for the receipt, endorsement and safe custody of tenders received until the time appointed for their opening.

The date and time of receipt of each tender shall be recorded within the eTender System

13.6.3 Opening tenders and Register of tenders

(i) As soon as practicable after the date and time stated as being the latest time for the receipt of tenders, they shall be electronically opened by two senior Officers/Managers designated by the Chief Executive and not from the originating department.

(ii) A member of the Board of Directors will be required to be one of the two approved persons present for the opening of tenders estimated above £100,000. The rules relating to the opening of tenders will need to be read in conjunction with any delegated authority set out in the Trust’s Scheme of Delegation.


(iii) The ‘originating’ department will be taken to mean the department sponsoring or commissioning the tender.

(iv) The involvement of Finance Directorate staff in the preparation of a tender proposal will not preclude the Director of Finance, Information and Strategy or any approved senior manager from the Finance Directorate from serving as one of the two senior managers to open tenders.

(v) All Executive Directors/members will be authorised to open tenders regardless of whether they are from the originating department provided that the other authorised person opening the tenders with them is not from the originating department.

The Trust’s Associate Director of Corporate Governance/Trust Secretary will count as a Director for the purposes of opening tenders.

(vi) Every tender received shall be marked with the date of opening and the identity recorded of those present at designated to open.

(vii) A system generated register shall be maintained, to show for each set of competitive tender invitations despatched:

- The name of all Bidders invited;

- The names of Bidders from which tenders have been received;

- The date the tenders were received and opened;

- The persons present at the opening;

- The price shown on each tender;

- A note where price alterations have been made on the tender and suitably initialled.


A record shall be maintained of all alterations on tenders, A note shall be made in the register if any one tender has had so many alterations that it cannot be readily read or understood.

(viii) Incomplete tenders, i.e. those from which information necessary for the adjudication of the tender is missing, and amended tenders should be dealt with in the same way as late tenders. (Standing Order No. 13.6.5 below).

13.6.4 Admissibility

(i) If for any reason the designated officers are of the opinion that the tenders received are not strictly competitive (for example, because their numbers are insufficient or any are amended, incomplete or qualified) no contract shall be awarded without the approval of the Chief Executive.

(ii) Where only one tender is sought and/or received, the Chief Executive and Director of Finance, Information and Strategy shall, as far practicable, ensure that the price to be paid is fair and reasonable and will ensure value for money for the Trust.

13.6.5 Late tenders

(i) Tenders received after the due time and date, but prior to the opening of the other tenders, may be considered only if the Chief Executive or his/her nominated officer decides that there are exceptional circumstances.

(ii) Only in the most exceptional circumstances will a tender be considered which is received after the opening of the other tenders and only then if the tenders that have been duly opened have not left the custody of the Chief Executive or his/her nominated officer or if the process of evaluation and adjudication has not started.

(iii) While decisions as to the admissibility of late, incomplete or amended tenders are under consideration, the tender documents shall be kept strictly confidential, recorded, and held in safe custody by the Chief Executive or his/her nominated Officer.


(iv) Accepted late tenders will be reported to the Board of Directors.

13.6.6 Acceptance of formal tenders (See overlap with SFI No. 13.7)

(i) Any discussions between the Trust and a tenderer which are deemed necessary to clarify technical aspects of his/her tender before the award of a contract will not disqualify the tender.

(ii) The lowest tender, if payment is to be made by the Trust, or the highest, if payment is to be received by the Trust, shall be accepted unless alternative award criteria have been established.

(iii) No tender shall be accepted which will commit expenditure in excess of that which has been allocated by the Trust and which is not in accordance with these SFIs except with the authorisation of the Chief Executive.

(iv) The use of these procedures must demonstrate that the award of the contract was:

(a) not in excess of the going market rate / price current at the time the contract was awarded;

(b) that best value for money was achieved.

(v) All Tenders should be treated as confidential and should be retained for inspection.

13.6.7 Tender reports to the Board of Directors

Reports to the Board of Directors will be made on an exceptional circumstance basis only.

13.6.8 List of approved firms (see SFI No. 13.5.4)

(a) Responsibility for maintaining list

A Manager nominated by the Chief Executive shall on behalf of the Trust maintain lists of approved firms from whom tenders


and quotations may be invited (subject to SFI 13.2). These shall be kept under frequent review. The lists shall include all firms who have applied for permission to tender and as to whose technical and financial competence the Trust is satisfied. All suppliers must be made aware of the Trust’s terms and conditions of contract.

(b) Building and Engineering Construction Works

(i) Subject to SFI 13.2, invitations to tender shall be made only to firms included on the approved list of tenderers compiled in accordance with this Standing Financial Instruction or on the separate maintenance lists compiled in accordance with Health Building Note (HBN) 00-08 Parts A and B guidance.

(ii) Firms included on the approved list of tenderers shall ensure that when engaging, training, promoting or dismissing employees or in any conditions of employment, shall not discriminate against any person and shall act in accordance with all relevant employment legislation and guidance.

(iii) Firms shall conform at least with the requirements of the Health and Safety at Work Act and any amending and/or other related legislation concerned with the health, safety and welfare of workers and other persons, and to any relevant British Standard Code of Practice issued by the British Standard Institution. Firms must provide to the appropriate manager a copy of its safety policy and evidence of the safety of plant and equipment, when requested.

(c) Financial Standing and Technical Competence of Contractors

The Director of Finance, Information and Strategy may make or institute any enquiries he/she deems appropriate concerning the financial standing and financial suitability of approved contractors. The Director with lead responsibility for clinical governance will similarly make such enquiries as is felt appropriate to be satisfied as to their technical / medical competence.

13.6.9 Exceptions to using approved contractors

If in the opinion of the Chief Executive and the Director of Finance, Information and Strategy or the Director with lead responsibility for clinical governance, it is impractical to use a potential contractor from the list of approved firms/individuals (for


example where specialist services or skills are required and there are insufficient suitable potential contractors on the list), or where a list for whatever reason has not been prepared, the Chief Executive should ensure that appropriate checks are carried out as to the technical and financial capability of those firms that are invited to tender or quote.

An appropriate record in the contract file should be made of the reasons for inviting a tender or quote other than from an approved list.

13.7 Quotations: Competitive and non-competitive

13.7.1 General Position on quotations

Quotations are required where formal tendering procedures are not adopted and where the intended expenditure or income exceeds, or is reasonably expected to exceed £20,000 but not exceed £50,000.

13.7.2 Competitive Quotations

(i) Quotations should be obtained from at least 3 firms/individuals based on specifications or terms of reference prepared by, or on behalf of the Trust.

(ii) Quotations should be submitted electronically (iii) All quotations should be treated as confidential and should be retained for inspection.

(iv) The Chief Executive or his nominated officer should evaluate the quotation and select the quote which gives the best value for money. If this is not the lowest quotation if payment is to be made by the Trust, or the highest if payment is to be received by the Trust, then the choice made and the reasons why should be recorded in a permanent record.

13.7.3 Non-Competitive Quotations

Non-competitive quotations in writing may (subject to SFI 13.2) be obtained in the following circumstances:

(i) The supply of proprietary or other goods of a special character and the rendering of services of a special character, for which it is not, in the opinion of the responsible Officer, possible or desirable to obtain competitive quotations; and


(ii) The supply of goods or manufactured articles of any kind which are required quickly and are not obtainable under existing contracts. The approval of the Director of Finance, Information and Strategy or his nominated Officer will be required for this course of action.

Where the goods or services are for building and engineering maintenance the responsible works manager must certify that the first two conditions of this SFI (i.e.: (i) and (ii) of this SFI) apply.Where tenders or quotations are not required, because expenditure is below the limits set in these SFIs, the Trust shall procure goods and services in accordance with procurement procedures approved by the Board of Directors.The Chief Executive shall be responsible for ensuring that best value for money can be demonstrated for all services provided under contract or in-house. The Board of Directors may also determine from time to time that in house services should be market tested by competitive tendering.

13.7.4 Quotations to be within Financial Limits

No quotation shall be accepted which will commit expenditure in excess of that which has been allocated by the Trust and which is not in accordance with the SFIs except with the authorisation of either the Chief Executive or Director of Finance, Information and Strategy.

13.8 Authorisation of Tenders and Competitive Quotations

Providing all the conditions and circumstances set out in these Standing Financial Instructions have been fully complied with, the decision to bid or not regarding an individual tender will be made by the following Executive Directors up to the annual value of the contract as follows:

Director of Finance, Information and Strategy up to £250,000 Chief Executive up to £500,000Chief Executive and Director of Finance, Information and Strategy up to £1,000,000Board of Directors Over £1,000,000

Formal authorisation must be put in writing. In the case of authorisation by the Board of Directors, this shall be recorded in the minutes of the meeting.


13.9 Instances where formal competitive tendering or competitive quotation is not required

Where competitive tendering or a competitive quotation is not required, the Trust should adopt one of the following alternatives:

(a) The Trust shall use the NHS Supply Chain for procurement of all goods and services unless the Chief Executive or nominated officers deem it inappropriate. The decision to use alternative sources must be documented.

(b) If the Trust does not use the NHS Supply Chain - where tenders or quotations are not required, because expenditure is below £20,000 (excluding VAT), the Trust shall procure goods and services in accordance with procurement procedures approved by the Director of Finance, Information and Strategy.

13.10 Private Finance for capital procurement (see overlap with SFI No. 18)

The Trust should normally market-test for PFI (Private Finance Initiative funding) when considering a capital procurement. When the Board of Directors proposes, or is required, to use finance provided by the private sector the following should apply:

(a) The Chief Executive and Director of Finance, Information and Strategy shall demonstrate that the use of private finance represents value for money and genuinely transfers risk to the private sector.

(b) Where the sum exceeds delegated limits set out in the Trust's Scheme of Delegation, a business case must be referred to NHS Improvement and/or Secretary of State for Health for approval or treated as per current guidelines.

(c) The proposal must be specifically agreed by the Board of Directors in the light of such professional advice as should reasonably be sought in particular with regard to vires.

(d) The selection of a contractor/finance company must be on the basis of competitive tendering or quotations.

13.11 Compliance requirements for all contracts (including lease contracts)

The Board of Directors may only enter into contracts on behalf of the Trust within its statutory powers and shall comply with (or,


as appropriate, have regard to):

(a) The Trust’s SOs and SFIs

(b) EU Directives and other statutory provisions;

(c) Any relevant directions including guidance on the procurement and management of consultants;

(d) NHS Standard Contract conditions as are applicable;

(e) Appropriate NHS guidance;

(f) Any relevant guidance issued by NHS Improvement;

(g) Where appropriate, contracts shall be in or embody the same terms and conditions of contract as was the basis on which tenders or quotations were invited;

(h) Contracts shall include lease and hire purchase agreements; and

(i) In all contracts made by the Trust, the Board of Directors shall endeavour to obtain value for money by use of all systems in place. The Chief Executive shall nominate an Officer who shall oversee and manage each contract on behalf of the Trust.

Except in exceptional circumstances, contracts shall be in, or embody, the same terms and conditions of contract as was the basis on which tenders or quotations were invited.

References to contracts shall include lease and hire purchase agreements.

In all contracts made by the Trust, the Board of Directors shall endeavour to obtain best value for money by use of all systems in place. The Chief Executive shall nominate an officer who shall oversee and manage each contract on behalf of the Trust.


13.12 Personnel and Agency or Temporary Staff Contracts

The Chief Executive shall nominate Officers with delegated authority to enter into contracts for the employment of other Officers, agency staff or temporary staff service contracts.

13.13 Disposals (See overlap with SFI No. 20)

Competitive Tendering or Quotation procedures shall not apply to the disposal of:

(a) Any matter in respect of which a fair price can be obtained only by negotiation or sale by auction as determined (or pre-determined in a reserve) by the Chief Executive or his nominated Officer;

(b) Obsolete or condemned articles and stores, which may be disposed of in accordance with the supplies policy of the Trust;

(c) Items to be disposed of with an estimated sale value of less than £1,000, this figure to be reviewed on a periodic basis;

(d) Items arising from works of construction, demolition or site clearance, which should be dealt with in accordance with the relevant contract;

(e) Land or buildings concerning which Department of Health and Social Care guidance has been issued but subject to compliance with such guidance.

13.14 In-house Services

13.14.1 The Chief Executive shall be responsible for ensuring that best value for money can be demonstrated for all services provided on an in-house basis. The Trust may also determine from time to time that in-house services should be market tested by competitive tendering.

13.14.2 In all cases where the Board of Directors determines that in-house services should be subject to competitive tendering the


following groups shall be set up:

(a) Specification group, comprising the Chief Executive or nominated Officer(s) and specialist(s).

(b) In-house tender group, comprising a nominee of the Chief Executive and technical support.

(c) Evaluation team, comprising normally a specialist officer, a supplies officer and a Director of Finance, Information and Strategy representative. For services having a likely annual expenditure exceeding £100,000 a non-officer member should be a member of the evaluation team.

13.14.3 All groups should work independently of each other and individual officers may be a member of more than one group but no member of the in-house tender group may participate in the evaluation of tenders.

13.14.4 The evaluation team shall make recommendations to the Board of Directors.

13.14.5 The Chief Executive shall nominate an officer to oversee and manage the contract on behalf of the Trust.

13.15 Applicability of SFIs on Tendering and Contracting to funds held in trust (see overlap with SFI No. 25)

Contracts involving funds held on trust shall do so individually to a specific named fund. Such contracts involving charitable funds shall comply with all applicable laws relating to dealings with charitable funds.

These SFIs shall not only apply to expenditure from exchequer funds but also to works, services and goods purchased from the Trust’s charitable funds and private resources.

13.16 Cancellation of Contracts

Except where specific provision is made in model forms of contracts or standard schedules of conditions approved for use within the NHS, and where practicable, there shall be inserted in every written contract a clause empowering the Trust to cancel the contract and to recover from the contractor the amount of any loss resulting from such cancellation, if;


(a) the contractor shall have offered, or given or agreed to give, any person any gift or consideration of any kind as an inducement or reward for doing or forbearing to do or for having done or forborne to do any action in relation to the obtaining or execution of the contract or any other contract with the Trust;

(b) the contractor shall have shown undue favour or disfavour to any person in relation to the contracts or any other contract

with the Trust, or if the like acts shall have been done by any person employed by him or acting on his behalf (whether with or without the knowledge of the contractor);

(c) in relation to any contract with the Trust the contractor or any person employed by him or acting on his behalf shall have committed any offence under the Bribery Act 2010 and such other appropriate legislation as may be in force from time to time.

13.17 Determination of Contracts for Failure to Deliver Goods or Material

13.17.1 Where practicable there shall be inserted in every written contract for the supply of goods or materials a clause to secure that, should the contractor fail to deliver the goods or materials or any portion thereof within the time or times specified in the contract, the Trust may without prejudice determine the contract either wholly or to the extent of such default and purchase other goods, or material of similar description to make good (a) such default, or (b) in the event of the contract being wholly determined the goods or materials remaining to be delivered.

13.17.2 The SFI referred to at 13.17.1 above shall further secure that the amount by which the cost of so purchasing other goods or materials exceeds the amount which would have been payable to the contractor in respect of the goods or materials shall be recoverable from the contractor.

14. TERMS OF SERVICE, ALLOWANCES AND PAYMENT OF MEMBERS OF THE BOARD OF DIRECTORS AND EMPLOYEES

14.1 Remuneration and Terms of Service (see overlap with [SO No. 6])

14.1.1 In accordance with the SOs the Board of Directors shall establish a Remuneration and Terms of Service Committee, with clearly defined terms of reference, specifying which posts fall within its area of responsibility, its composition, and the arrangements for reporting.

14.1.2 The Committee will:


(a) determine appropriate remuneration and terms of service for the Chief Executive and other Executive Directors including:

(i) All aspects of salary (including any performance-related elements/bonuses);

(ii) Provisions for other benefits, including pensions and leased vehicles;

(iii) Arrangements for termination of employment and other contractual terms;

(iv) ensuring they are fairly rewarded for their individual contribution to the Trust - having proper regard to the Trust's circumstances and performance and to the provisions of any national arrangements for such members and staff where appropriate.

14.1.3 The Council of Governors at a general meeting shall decide the remuneration and allowances, and the other terms and conditions of office, of the Chairman and the other Non-Executive Directors.

14.1.4 The Board of Directors will consider and need to approve proposals presented by the Chief Executive for the setting of remuneration and conditions of service for those employees and officers not covered by the Remuneration and Terms of Service Committee or the Council of Governors.

14.2 Funded Establishment

14.2.1 The workforce plans incorporated within the annual budget will form the funded establishment of each department within the Trust.

14.2.2 The funded establishment of any department may not be varied without the approval of the Chief Executive.

14.3 Staff Appointments

14.3.1 Except as provided in the Trust’s Constitution or these SFIs no Director or other employee may engage, re-engage, or re-grade employees, either on a permanent or temporary nature, or hire agency staff, or agree to changes in any aspect of


remuneration:

(a) Unless authorised to do so by the Chief Executive; and

(b) Within the limit of their approved budget and funded establishment.

14.3.2 The Board of Directors will approve procedures presented by the Chief Executive for the determination of commencing pay rates, condition of service, etc, for employees.

14.4 Processing Payroll


(a) Specifying timetables for submission of properly authorised time records and other notifications;

(b) The final determination of pay and allowances;

(c) Making payment on agreed dates;

(d) Agreeing method of payment.

14.4.2 The Director of Finance, Information and Strategy will issue instructions regarding:

(a) Verification and documentation of data;

(b) The timetable for receipt and preparation of payroll data and the payment of employees and allowances;

(c) Maintenance of subsidiary records for superannuation, income tax, social security and other authorised deductions from pay;

(d) Security and confidentiality of payroll information;


(e) Checks to be applied to completed payroll before and after payment;

(f) Authority to release payroll data under the provisions of the Data Protection Act;

(g) Methods of payment available to various categories of employee and officers;

(h) Procedures for payment by cheque, bank credit, or cash to employees and officers;

(i) Procedures for the recall of cheques and bank credits;

(j) Pay advances and their recovery;

(k) Maintenance of regular and independent reconciliation of pay control accounts;

(l) Separation of duties of preparing records and handling cash;

(m) A system to ensure the recovery from those leaving the employment of the Trust of sums of money and property due by them to the Trust.

(n) Appropriately nominated managers have delegated responsibility for:

(o) Submitting time records, and other notifications in accordance with agreed timetables;

(p)Completing time records and other notifications in accordance with the Director of Finance, Information and Strategy’s instructions and in the form prescribed by the Director of Finance, Information and Strategy;

(q)Submitting termination forms in the prescribed form immediately upon knowing the effective date of an employee’s or officer’s resignation, termination or retirement.


14.4.4 Regardless of the arrangements for providing the payroll service, the Director of Finance, Information and Strategy shall ensure that the chosen method is supported by appropriate (contracted) terms and conditions, adequate internal controls and audit review procedures and that suitable arrangement are made for the collection of payroll deductions and payment of these to appropriate bodies.

14.4.5 All time records, pay sheets, and other pay records and notifications shall be certified and submitted in accordance with the instructions of the Director of Finance, Information and Strategy. A list of designated authorising Officers shall be maintained, detailing the limits of authorisation and shall contain specimen signatures of such Officers.

14.4.6 The Director of Finance, Information and Strategy shall determine the dates on which the payment of salaries, wages, expenses, allowances, termination or compensation payments, and any other form of remuneration are to be made, having regard to the general rule that it is undesirable to make payments in advance, except in special circumstances. Payment to an individual shall not be made in advance of the normal pay day except;

(a) to cover a period of authorised leave involving absence on the normal pay day; or

(b) as authorised by the Director of Finance, Information and Strategy to meet special circumstances and limited to the net pay due at the time of payment;

14.4.7 Advance payments of one month or more will require the express consent of the Director of Finance, Information and Strategy or Chief Executive.

14.5 Contracts of Employment

14.5.1 The Board of Directors shall delegate responsibility to an Officer for:

(a) Ensuring that all employees are issued with a Contract of Employment in a form approved by the Board of Directors (or in accordance with SFI 14.1) and which complies with employment legislation;

(b) Dealing with variations to, or termination of, contracts of employment (subject to the Constitution);

(c) Ensuring that a certified appointment form and such other documents upon the Officer commencing duty are signed and a copy of the contract held by the Trust.


14.5.2 A variation form shall be sent to the Director of Finance, Information and Strategy, with a copy to the Director of People and Organisational Effectiveness if appropriate, immediately upon the effective date of any change in the state of employment of personal circumstances of an Officer being known.

15. NON-PAY EXPENDITURE

15.1 Delegation of Authority

15.1.1 The Board of Directors will approve the level of non-pay expenditure on an annual basis and the Chief Executive will determine the level of delegation to budget managers.

15.1.2 The Chief Executive will set out:

(b) The list of managers who are authorised to place requisitions for the supply of goods and services;

(c) The maximum level of each requisition and the system for authorisation above that level.

15.1.3 The Chief Executive shall set out procedures on the seeking of professional advice regarding the supply of goods and services.

15.1.4 The Chief Executive shall set out procedures on visits to or provided by organisations regarding the supply of goods, services or training. Approval may be delegated to Directorates

15.2 Choice, Requisitioning, Ordering, Receipt and Payment for Goods and Services (see overlap with Standing Financial Instruction No. 13)

15.2.1 Requisitioning

The requisitioner, in choosing the item to be supplied (or the service to be performed) shall always obtain the best value for money for the Trust.

It should be the duty of the Manager with responsibility for supplies (Supplies Manager) to exercise general supervision over


all purchases, except for drugs and pharmaceutical supplies. After making reasonable efforts to resolve conflicts, and having due regard to materiality, he shall inform the Director of Finance, Information and Strategy of any requisition which appears to be in conflict with the Trust’s SOs and these SFIs.

15.2.2 System of Payment and Payment Verification

The Director of Finance, Information and Strategy shall be responsible for the prompt payment of accounts and claims. Payment of contract invoices shall be in accordance with contract terms, or otherwise, in accordance with national guidance.

15.2.3 The Director of Finance, Information and Strategy will:

(a) Advise the Board of Directors if the thresholds in these SFIs for quotations (competitive or otherwise) or formal tenders need to be reviewed;

(b) Prepare procedural instructions or guidance within the Scheme of Delegation on the obtaining of goods, works and services incorporating the thresholds;

(c) Be responsible for the prompt payment of all properly authorised accounts and claims;

(d) Be responsible for designing and maintaining a system of verification, recording and payment of all amounts payable. The system shall provide for:

(i) A list of Directors and Officers (including specimens of their signatures) authorised to certify invoices.

(ii) Certification that:

- Goods have been duly received, examined and are in accordance with specification and the prices are correct;

- Work done or services rendered have been satisfactorily carried out in accordance with the order, and, where applicable, the materials used are of the requisite standard and the charges are correct;


- In the case of contracts based on the measurement of time, materials or expenses, the time charged is in accordance with the time sheets, the rates of labour are in accordance with the appropriate rates, the materials have been checked as regards quantity, quality, and price and the charges for the use of vehicles, plant and machinery have been examined;

- Where appropriate, the expenditure is in accordance with regulations and all necessary authorisations have been obtained;

- The account is arithmetically correct;

- The account is in order for payment.

(iii) A timetable and system for submission to the Director of Finance, Information and Strategy of accounts for payment; provision shall be made for the early payment of accounts subject to cash discounts or otherwise requiring early payment.

(iv) Instructions to Officers regarding the handling and payment of accounts within the Finance Department.

(b) Be responsible for ensuring that payment for goods and services is only made once the goods and services are received. The only exceptions are set out in SFI No. 15.2.4 below.

(c) Be responsible for preparing and issuing procedures regarding Value Added Tax (VAT).

15.2.4 Prepayments

Prepayments are only permitted where exceptional circumstances apply. In such instances:

(a) Prepayments are only permitted where the financial advantages outweigh the disadvantages (i.e. cash flows must be discounted to NPV using the National Loans Fund (NLF) rate plus 2%).


(b) The appropriate Officer must provide, in the form of a written report, a case setting out all relevant circumstances of the purchase. The report must set out the effects on the Trust if the supplier is at some time during the course of the prepayment agreement unable to meet his commitments;

(c) The Director of Finance, Information and Strategy will need to be satisfied with the proposed arrangements before contractual arrangements proceed (taking into account SFI 13.2);

(d) The budget holder is responsible for ensuring that all items due under a prepayment contract are received and they must immediately inform the appropriate Director or Chief Executive if problems are encountered.

15.2.5 Official orders

No goods, services or works, other than works and services executed in accordance with a contract and those purchases made with a procurement card or by petty cash in accordance with the relevant approved procedure, shall be ordered except on an official order and contractors shall be notified that they should not accept orders unless in an official form other than in an emergency or case of urgent necessity (see below).

Verbal orders shall be issued only by an Officer designated by the Chief Executive and only in cases of emergency or urgent necessity. These shall be confirmed by an official order issued as soon as possible and ideally the next working day. The order should be clearly marked “Confirmation Order”.

Official Orders must:

(a) Be consecutively numbered;

(b) Be in a form approved by the Director of Finance, Information and Strategy;

(c) State the Trust's terms and conditions of trade;

(d) Only be issued to, and used by, those duly authorised by the Chief Executive.


Order/requisition forms shall only be issued to and signed by Officers so authorised by the Chief Executive. Lists of authorised Officers shall be maintained detailing the limits of authorisation and a copy of each list or amendments thereto shall be provided to the Director of Finance, Information and Strategy for management control purposes.

15.2.6 Duties of Managers and Officers

Managers and Officers must ensure that they comply fully with the guidance and limits specified by the Director of Finance, Information and Strategy and that:

(a) All contracts (except as otherwise provided for in the Scheme of Delegation), leases, tenancy agreements and other commitments which may result in a liability are notified to the Director of Finance, Information and Strategy in advance of any commitment being made;

(b) Contracts are awarded in accordance with these SFIs;

(c) Where consultancy advice is being obtained, the procurement of such advice must be in accordance with guidance issued by the Department of Health;

(d) No order shall be issued for any item or items to any firm which has made an offer of gifts, reward or benefit to Directors or employees, other than as allowed in the Trust’s Standards of Business Conduct Policy.

(This provision needs to be read in conjunction with Standing Order No. 9)

(e) No requisition/order is placed for any item or items for which there is no budget provision unless authorised by the Director of Finance, Information and Strategy on behalf of the Chief Executive;

(f) All goods, services, or works are ordered on an official order except works and services executed in accordance with a contract and purchases from petty cash;

(g) Verbal orders must only be issued very exceptionally - by an employee designated by the Chief Executive and only in cases of emergency or urgent necessity. These must be confirmed by an official order and clearly marked "Confirmation


Order";

(h) Orders are not split or otherwise placed in a manner devised so as to avoid the financial thresholds;

(i) Goods are not taken on trial or loan in circumstances that could commit the Trust to a future uncompetitive purchase;

(j) Changes to the list of members/employees and officers authorised to certify invoices are notified to the Director of Finance, Information and Strategy;

(k) Purchases from petty cash and those made by purchasing card are restricted in value and by type of purchase in accordance with instructions issued by the Director of Finance, Information and Strategy;

(l) Petty cash and purchasing card records are maintained in a form as determined by the Director of Finance, Information and Strategy.

15.2.7 No Officer shall place a requisition, purchase from petty cash, by procurement card or require an official order to be raised with an individual to whom he is related or with any person or organisation with whom/which he has a financial interest or from whom/which he has, is, or is likely to receive any payment, gift or other consideration, without first making a disclosure of the circumstances in writing to the Chief Executive and receiving his written authority to proceed. A copy of an authority so given must be lodged with the Director of Finance, Information and Strategy in accordance with the Trust’s Standards of Business Conduct Policy.

15.2.8 The Trust should meet the costs of inspection visits for staff advising on the purchase of equipment etc. See the Trust’s Standards of Business Conduct for NHS Staff Policy. Visits at supplier’s expense to inspect equipment etc. must not be undertaken without the prior approval of the Chief Executive.

15.2.9 The Chief Executive and Director of Finance, Information and Strategy shall ensure that the arrangements for financial control and financial audit of building and engineering contracts and property transactions comply with the guidance contained within the Health Building Note (HBN) 00-08 Parts A and B and any law, regulation or guidance in respect of building or engineering works. The technical audit of these contracts shall be the responsibility of the relevant Director.


16. EXTERNAL BORROWING

16.1 Public Dividend Capital

The Director of Finance, Information and Strategy will ensure that procedures are in place to comply with national guidelines on the payment of dividends.

The Trust will pay over two dividend payments per year in September and March, remitting half the Trust debt remuneration on each date.

The Director of Finance, Information and Strategy will implement policies and procedures to ensure that cash balances are held in accordance with guidelines issued by NHS Improvement.

17. FINANCIAL FRAMEWORK

17.1.1 The Director of Finance, Information and Strategy should ensure that members of the Board of Directors are aware of the Financial Framework. This document contains directions which the Trust must follow. The Director of Finance, Information and Strategy should also ensure that the direction and guidance in the framework is followed by the Trust.

18. CAPITAL INVESTMENT, PRIVATE FINANCING, FIXED ASSET REGISTERS AND SECURITY OF ASSETS

18.1 Capital Investment

18.1.1 The Chief Executive:

(a) Shall ensure that there is an adequate appraisal and approval process in place for determining capital expenditure priorities and the effect of each proposal upon plans;

(b) Is responsible for the management of all stages of capital schemes and for ensuring that schemes are delivered on time


and to budget;

(c) Shall ensure that the capital investment is not undertaken without confirmation of appropriate support and the availability of resources to finance all revenue consequences, including capital charges.

18.1.2 For every capital expenditure proposal the Chief Executive shall ensure:

(18) That a business case is produced setting out:

(i) an option appraisal of potential benefits compared with known costs to determine the option with the highest ratio of benefits to costs;

(ii) the involvement of appropriate Trust personnel and external agencies;

(iii) appropriate project management and control arrangements;

(b) That the Director of Finance, Information and Strategy has certified professionally to the costs and revenue consequences detailed in the business case and involved appropriate Trust personnel and external agencies in the process.

18.1.3 For capital schemes where the contracts stipulate stage payments, the Chief Executive will issue procedures for their management, incorporating the recommendations of Health Building Note (HBN) 00-08 Parts A and B.

18.1.4 The Director of Finance, Information and Strategy shall assess on an annual basis the requirement for the operation of the construction industry tax deduction scheme in accordance with HM Revenue and Customs guidance.

18.1.5 The Director of Finance, Information and Strategy shall issue procedures for the regular reporting of expenditure and commitment against authorised expenditure.

18.1.6 The approval of a capital programme shall not constitute approval for expenditure on any scheme.


The Chief Executive shall issue to the manager responsible for any scheme:

(a) Specific authority to commit expenditure;

(b) Authority to proceed to tender (see overlap with SFI No. 13.6);

(d) Approval to accept a successful tender (see overlap with SFI No. 13.6).

The Chief Executive will issue a scheme of delegation for capital investment management in accordance with Health Building Note (HBN) 00-08 Parts A and B guidance and the Trust’s SOs.

18.1.7 The Director of Finance, Information and Strategy shall issue procedures governing the financial management, including variations to contract, of capital investment projects and valuation for accounting purposes. These procedures shall fully take into account the delegated limits for capital schemes included in Annex C of HSC (1999) 246.

18.1.8 The Director of Finance, Information and Strategy shall issue procedures for the use of capital receipts from the sale of assets. The Director of Finance, Information and Strategy will ensure that the Trust’s financial plans incorporate any expected capital receipts.

18.1.9 The Board of Directors will approve details of capital expenditure programmes as part of the Annual Plan.

18.2 Private Finance (see overlap with SFI No. 13.10)

18.2.1 The Trust should consider testing for PFI when considering capital procurement. When the Trust proposes to use finance which is to be provided other than through its [allocation/own internally generated resources], the following procedures shall apply:

(a) The Director of Finance, Information and Strategy shall demonstrate that the use of private finance represents value for money and genuinely transfers significant risk to the private sector.

(b) Where the sum involved exceeds delegated limits, the business case must be referred to NHS Improvement or in line with any current guidelines.


(c) The proposal must be specifically agreed by the Board of Directors.

18.3 Asset Registers

18.3.1 The Chief Executive is responsible for the maintenance of registers of assets, taking account of the advice of the Director of Finance, Information and Strategy 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.

18.3.2 The Trust shall maintain an asset register recording fixed assets.

18.3.3 Additions to the fixed asset register must be clearly identified to an appropriate budget holder and be validated by reference to:

(a) Properly authorised and approved agreements, architect's certificates, supplier's invoices and other documentary evidence in respect of purchases from third parties;

(b) Stores, requisitions and wages records for own materials and labour including appropriate overheads;

(c) Lease agreements in respect of assets held under a finance lease and capitalised.

18.3.4 Where capital assets are sold, scrapped, lost or otherwise disposed of, their value must be removed from the accounting records and each disposal must be validated by reference to authorisation documents and invoices (where appropriate).

18.3.5 The Director of Finance, Information and Strategy shall approve procedures for reconciling balances on fixed assets accounts in ledgers against balances on fixed asset registers.

18.3.6 The value of each asset shall be periodically reviewed and revalued to current values in accordance with the requirements of the Annual Reporting Manual issued by NHS Improvement.

18.3.7 The value of each asset shall be depreciated in accordance with the requirements of the Annual Reporting Manual issued by NHS Improvement.


18.3.8 The Director of Finance, Information and Strategy of the Trust shall calculate and pay such capital charges as specified in any

relevant guidance.

18.4 Security of Assets

18.4.1 The overall control of fixed assets is the responsibility of the Chief Executive.

18.4.2 Each Officer has a responsibility to exercise a duty of care over the assets of the Trust and it shall be the responsibility of senior staff in all disciplines to apply such appropriate routine security practices in relation to NHS assets. Persistent or substantial breach of agreed security practices shall be reported to the Chief Executive.

18.4.3 Asset control procedures (including fixed assets, cash, cheques, negotiable instruments and donated assets) must be approved by the Director of Finance, Information and Strategy. This procedure shall make provision for:

(a) Recording managerial responsibility for each asset;

(b) Identification of additions and disposals;

(c) Identification of all repairs and maintenance expenses;

(d) Physical security of assets;

(e) Periodic verification of the existence of, condition of, and title to, assets recorded;

(f) Identification and reporting of all costs associated with the retention of an asset;

(g) Reporting, recording and safekeeping of cash, cheques and negotiable instruments.

18.4.4 All discrepancies revealed by verification of physical assets to fixed asset register shall be notified to the Director of Finance, Information and Strategy.


18.4.5 Whilst each Officer has a responsibility for the security of property of the Trust, it is the responsibility of Board of Directors and senior Officers in all disciplines to apply such appropriate routine security practices in relation to NHS property as may be determined by the Board of Directors. Any breach of agreed security practices must be reported in accordance with agreed procedures.

18.4.6 Any damage to the Trust’s premises, vehicles and equipment, or any loss of equipment, stores or supplies must be reported by Directors and employees in accordance with the procedure for reporting losses.

18.4.7 Where practical, assets should be marked as “Trust Property”.

18.4.8 The up-to-date maintenance and annual checking of asset records shall be the responsibility of designated departmental managers or Budget Holders for all items for which the initial purchase or replacement is within their delegated responsibilities.

18.4.9 Registers shall be maintained to record all controlled items issued to individuals, and where practicable, receipts shall be obtained.

18.4.10 Records shall also be maintained and receipts obtained for:

equipment on loan to patients; and

all contents of furnished lettings.

18.4.11 On the closure of a department or Trust property, a check shall be carried out and a designated Officer shall certify a list of items held showing eventual disposal.


19. STORES AND RECEIPT OF GOODS

19.1 General position

19.1.1 Stores, defined in terms of controlled stores and departmental stores (for immediate use) should be:

(a) Kept to a minimum;

(b) Subjected to annual stock take;

(c) Valued at the lower of cost and net realisable value.

19.2 Control of Stores, Stocktaking, condemnations and disposal

19.2.1 Subject to the responsibility of the Director of Finance, Information and Strategy for the systems of control, overall responsibility for the control of stores shall be delegated to an Officer by the Chief Executive. The day-to-day responsibility may be delegated by him/her to departmental employees and stores managers/keepers, subject to such delegation being entered in a record available to the Director of Finance, Information and Strategy. The control of any pharmaceutical stocks shall be the responsibility of a designated Officer (the Pharmaceutical Officer); the control of any fuel oil and coal of a designated Estates Manager.

19.2.2 The responsibility for security arrangements and the custody of keys for all stock locations shall be clearly defined in writing by the designated manager/ Pharmaceutical Officer. Wherever practicable, stocks should be marked as “Trust Service Property”.

19.2.3 The Director of Finance, Information and Strategy shall set out procedures and systems to regulate the stores including records for receipt of goods, issues, and returns to stores and losses.

19.2.4 Stocktaking arrangements shall be agreed with the Director of Finance, Information and Strategy and there shall be a physical check covering all items in store at least once a year.

19.2.5 Where a complete system of stores control is not justified, alternative arrangements shall require the approval of the Director of


Finance, Information and Strategy.

19.2.6 The designated Officer shall be responsible for a system approved by the Director of Finance, Information and Strategy for the identification of excess stock, for a review of slow moving and obsolete items and for condemnation, disposal, and replacement of all unserviceable articles. The designated Officer shall report to the Director of Finance, Information and Strategy any evidence of significant overstocking and of any negligence or malpractice (see also overlap with SFI No. 20 Disposals and Condemnations, Losses and Special Payments). Procedures for the disposal of obsolete stock shall follow the procedures set out for disposal of all surplus and obsolete goods.

19.2.7 Stocks shall be valued at the lower of cost or net realisable value. The cost of stock, with the exception of finished stock arising from manufacturing, shall be the purchase price without any overheads. For manufacturing finished stock, direct overheads should be included. The cost basis used must be clearly stated in any returns and accounts.

19.2.8 Stocks which have deteriorated, or are not usable for any other reason than for their intended purposes, or may become obsolete, shall be written down to their net realisable value. The write down shall be approved by the Director of Finance, Information and Strategy and recorded.

19.3 Goods supplied by NHS Logistics

19.3.1 For goods supplied via the NHS Logistics central warehouses, the Chief Executive shall identify those authorised to requisition and accept goods from the store. The authorised person shall check receipt against the delivery note before forwarding this to the Director of Finance, Information and Strategy who shall satisfy himself that the goods have been received before accepting the recharge.

20. DISPOSALS AND CONDEMNATIONS, LOSSES AND SPECIAL PAYMENTS

20.1 Disposals and Condemnations

20.1.1 Procedures


The Director of Finance, Information and Strategy must prepare detailed procedures for the disposal of assets including condemnations, and ensure that these are notified to managers.

20.1.2 When it is decided to dispose of a Trust asset, the head of department or authorised deputy will determine and advise the Director of Finance, Information and Strategy of the estimated market value of the item, taking account of professional advice where appropriate.

20.1.3 All unserviceable articles shall be:

(a) Condemned or otherwise disposed of by an Officer authorised for that purpose by the Director of Finance, Information and Strategy (the Condemning Officer);

(b) Recorded by the Condemning Officer in a form approved by the Director of Finance, Information and Strategy which will indicate whether the articles are to be converted, destroyed or otherwise disposed of. All entries shall be confirmed by the countersignature of a second employee authorised for the purpose by the Director of Finance, Information and Strategy.

20.1.4 The Condemning Officer shall satisfy himself as to whether or not there is evidence of negligence in use and shall report any such evidence to the Director of Finance, Information and Strategy who will take the appropriate action.

20.2 Losses and Special Payments

20.2.1 Procedures

The Director of Finance, Information and Strategy must prepare procedural instructions on the recording of and accounting for condemnations, losses, and special payments.

20.2.2 Any Officer discovering or suspecting a loss of any kind must either immediately inform their head of department, who must immediately inform the Chief Executive and the Director of Finance, Information and Strategy or inform an Officer charged with responsibility for responding to concerns involving loss. This Officer will then appropriately inform the Director of Finance, Information and Strategy and/or Chief Executive.


20.2.3 Where a criminal offence is suspected, the Director of Finance, Information and Strategy must immediately inform the police if theft or arson is involved. In cases of fraud and corruption or of anomalies which may indicate fraud or corruption, the Director of Finance, Information and Strategy must inform the LCFS in accordance with Secretary of State for Health’s Directions.

20.2.4 Suspected fraud

The Director of Finance, Information and Strategy must notify the LCFS and the external auditor of all cases of suspected fraud.

20.2.5 For losses apparently caused by theft, arson, neglect of duty or gross carelessness, except if trivial, the Director of Finance, Information and Strategy must immediately notify:

(a) The Board of Directors, and

(b) The external auditor.

20.2.6 Within the normal delegation limits the Board of Directors shall approve the writing-off of losses.

20.2.7 The Director of Finance, Information and Strategy shall be authorised to take any necessary steps to safeguard the Trust's interests in bankruptcies and company liquidations.

20.2.8 For any loss, the Director of Finance, Information and Strategy should consider whether any insurance claim can be made.

20.2.9 The Director of Finance, Information and Strategy shall maintain a Losses and Special Payments Register in which write-off action is recorded.

20.2.10 No special payments exceeding delegated limits shall be made without the prior approval of NHS Improvement.

20.2.11 The Director of Finance, Information and Strategy must review and evidence his review of the register on a quarterly basis.

20.2.12 A quarterly summary of the losses and compensations register must be reported to the Board of Directors, or delegated


committee.

21. INFORMATION TECHNOLOGY

21.1 Responsibilities and duties of the Director of Finance, Information and Strategy

21.1.1 The Director of Finance, Information and Strategy, who is responsible for the accuracy and security of the computerised financial data of the Trust and shall:

(a) Devise and implement any necessary procedures to ensure adequate (reasonable) protection of the Trust's data, programs and computer hardware for which the Director is responsible from accidental or intentional disclosure to unauthorised persons, deletion or modification, theft or damage, having due regard for the Data Protection Act 1998 and any subsequent legislation;

(b) Ensure that adequate (reasonable) controls exist over data entry, processing, storage, transmission and output to ensure security, privacy, accuracy, completeness, and timeliness of the data, as well as the efficient and effective operation of the system, including such controls in the use of any external agency arrangements.

(c) Ensure that adequate controls exist such that the computer operation is separated from development, maintenance and amendment;

(d) Ensure that an adequate management (audit) trail exists through the computerised system and that such computer audit reviews as the Director of Finance, Information and Strategy may consider necessary are being carried out.

21.1.2 The Director of Finance, Information and Strategy shall need to ensure that new financial systems and amendments to current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. Where this is undertaken by another organisation, assurances of adequacy must be obtained from them prior to implementation.

21.1.3 The Associate Director of Transformation shall publish and maintain a Freedom of Information (FOI) Scheme, or adopt a model publication scheme approved by the Information Commissioner. A publication scheme is a complete guide to the information


routinely published by a public authority. It describes the classes or types of information about our Trust that we make publicly available.

21.1.4 The Associate Director of Transformation shall ensure that risks to the Trust arising from the use of IT are effectively identified and considered and appropriate action taken to mitigate or control risk. This shall include the preparation and testing of appropriate disaster recovery and business continuity plans.

21.1.5 The Director of Finance, Information and Strategy will devise procedures which ensure that orders for the acquisition of computer hardware, software and services (other than consumables) are placed in accordance with the Trust’s information technology strategy.

21.1.6 The Director of Finance, Information and Strategy will ensure that separate control procedures are put in place for computer systems. This procedure will include:

the acquisition and disposal of IT, systems and equipment;

the decommissioning of systems containing confidential data; and in accordance with any guidance issued by the Department of Health.

21.2 Responsibilities and duties of other Directors and Officers in relation to computer systems of a general application

21.2.1 In the case of computer systems which are proposed by other Directors and Officers the relevant individual shall provide the Director of Finance, Information and Strategy with the following information:

(a) Details of the outline design of the system; and

(b) In the case of packages acquired either from a commercial organisation, from the NHS, or from another public sector organisation, the operational requirement.

21.3 Contracts for computer services with other health bodies or outside agencies

The Director of Finance, Information and Strategy shall ensure that contracts for computer services for financial applications with another health organisation or any other agency shall clearly define the responsibility of all parties for the security, privacy,


accuracy, completeness, and timeliness of data during processing, transmission and storage. The contract should also ensure rights of access for audit purposes.

Where another health organisation or any other agency provides a computer service for financial applications, the Director of Finance, Information and Strategy shall periodically seek assurances that adequate controls are in operation.

21.4 Requirements for computer systems which have an impact on corporate financial systems

Where computer systems have an impact on corporate financial systems the Director of Finance, Information and Strategy shall need to be satisfied that:

(a) Systems acquisition, development and maintenance are in line with corporate policies such as an informatics Strategy;

(b) Data produced for use with financial systems is adequate, accurate, complete and timely, and that a management (audit) trail exists;

(c) Officers undertaking work for the Director of Finance, Information and Strategy have access to such data;

(d) Such computer audit reviews as are considered necessary are being carried out.

22 PATIENTS' PROPERTY

22.1 The Trust has a responsibility to provide safe custody for money and other personal property (hereafter referred to as "property") handed in by patients, in the possession of unconscious or confused patients, or found in the possession of patients dying in hospital or dead on arrival.

22.2 The Chief Executive is responsible for ensuring that patients or their guardians, as appropriate, are informed before or at admission by:

- Notices and information booklets (subject to sensitivity guidance);


- Hospital admission documentation and property records;- The oral advice of administrative and nursing staff responsible for admissions.

that the Trust will not accept responsibility or liability for patients' property brought into Trust premises, unless it is handed in for safe custody and a copy of an official patients' property record is obtained as a receipt.

22.3 The Director of Finance, Information and Strategy must 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 patients.

22.4 These instructions shall cover the necessary arrangements for withdrawal of cash or disbursement of money held in accounts of patients who are incapable of handling their own financial affairs. Due care should be exercised in the management of a patient's money in order to maximise the benefits to the patient.

22.5 Where Department of Health instructions require the opening of separate accounts for patients' moneys, these shall be opened and operated under arrangements agreed by the Director of Finance, Information and Strategy.

22.6 In all cases where property of a deceased patient is of a total value in excess of £5,000 (or such other amount as may be prescribed by any amendment to the Administration of Estates, Small Payments, Act 1965), the production of Probate or Letters of Administration shall be required before any of the property is released. Where the total value of property is £5,000 or less, forms of indemnity shall be obtained.

22.7 Staff should be informed, on appointment, by the appropriate departmental or senior manager of their responsibilities and duties for the administration of the property of patients.

22.8 Where patients' property or income is received for specific purposes and held for safekeeping the property or income shall be used only for that purpose, unless any variation is approved by the donor or patient in writing.

25. FUNDS HELD ON TRUST


25.1 Corporate Trustee

(a) SOs No. 1.4 and 3.2 to 3.4 (inclusive) outline the Trust’s responsibilities as a corporate trustee for the management of funds it holds on trust.

(b) The discharge of the Trust’s corporate trustee responsibilities are distinct from its responsibilities for exchequer funds and may not necessarily be discharged in the same manner, but there must still be adherence to the overriding general principles of financial regularity, prudence and propriety. Trustee responsibilities cover both charitable and non-charitable purposes.

(c) The Director of Finance, Information and Strategy shall ensure that each trust fund which the Trust is responsible for managing is managed appropriately with regard to its purpose and to its requirements.

25.2 Accountability to Charity Commission and Secretary of State for Health and Social Care

(a) The trustee responsibilities must be discharged separately and full recognition given to the Trust’s dual accountabilities to the Charity Commission for charitable funds held on trust and to the Secretary of State for all funds held on trust.

(b) The Schedule of Matters Reserved to the Board of Directors and the Scheme of Delegation make clear where decisions regarding the exercise of discretion regarding the disposal and use of the funds are to be taken and by whom. All Directors and Officers must take account of that guidance before taking action.

25.3 Applicability of Standing Financial Instructions to funds held on Trust

(a) In so far as it is possible to do so, most of the sections of these SFIs will apply to the management of funds held on trust. (See overlap with SFI No. 13.15).

(b) The over-riding principle is that the integrity of each Trust must be maintained and statutory and Trust obligations met. Materiality must be assessed separately from Exchequer activities and funds.

26. ACCEPTANCE OF GIFTS BY STAFF AND LINK TO STANDARDS OF BUSINESS CONDUCT (see overlap with SO No. 9


and SFI No. 15.2.6)

The Associate Director of Corporate Governance/Trust Secretary shall ensure that all staff are made aware of the Trust’s policy on Standards of Business Conduct (see overlap with SO No. 9).

27. RETENTION OF RECORDS

27.1 The Chief Executive shall be responsible for maintaining archives for all records required to be retained in accordance with NHS Code of Practice - Records Management.

27.2 The records held in archives shall be capable of retrieval by authorised persons.

27.3 Records held in accordance with NHS Code of Practice - Records Management, shall only be destroyed at the express instigation of the Chief Executive. Detail shall be maintained of records so destroyed.

28. RISK MANAGEMENT AND INSURANCE

28.1 Programme of Risk Management

The Chief Executive shall ensure that the Trust has a programme of risk management, in accordance with current Department of Health assurance framework requirements, which must be approved and monitored by the Board of Directors.

The programme of risk management shall include:

(a) A process for identifying and quantifying risks and potential liabilities;

(b) Engendering among all levels of Officers a positive attitude towards the control of risk;

(c) Management processes to ensure all significant risks and potential liabilities are addressed including effective systems of internal control, cost effective insurance cover, and decisions on the acceptable level of retained risk;


(d) Contingency plans to offset the impact of adverse events;

(e) Audit arrangements including; internal audit, clinical audit, health and safety review;

(f) A clear indication of which risks shall be insured through arrangements with either the Risk Pooling Schemes ("Risk Pooling Schemes") administered by the NHS Resolution or commercial insurance.

(g) Arrangements to review the risk management programme.

The existence, integration and evaluation of the above elements will assist in providing a basis to make a statement on the effectiveness of internal control within the Annual Report and Annual Accounts as required by current applicable guidance.

28.2 Insurance: Risk Pooling Schemes administered by NHS Resolution

The Board of Directors shall decide if the Trust will insure through the risk pooling schemes administered by the NHSResolution, self-insure for some or all of the risks covered by the risk pooling schemes, or obtain commercial insurance. If the Board of Directors decides not to use the risk pooling schemes for any of the risk areas (clinical, property and employers/third party liability) covered by the scheme this decision shall be reviewed annually.

28.3 Arrangements to be followed by the Board of Directors in agreeing Insurance cover

(a) Where the Board of Directors decides to use the risk pooling schemes administered by NHS Resolution the Director of Finance, Information and Strategy shall ensure that the arrangements entered into are appropriate and complementary to the risk management programme. The Director of Finance, Information and Strategy shall ensure that documented procedures cover these arrangements.

(b) Where the Board of Directors decides not to use the risk pooling schemes administered by the NHSResolution, the Director of Finance, Information and Strategy shall ensure that the Board of Directors is informed of the nature and extent of the commercial insurance sought or the risks that are self insured as a result of this decision. The Director of Finance, Information and Strategy 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.


(c) All the risk-pooling schemes require Scheme members to make some contribution to the settlement of claims (the ‘deductible’). The Director Finance should ensure documented procedures also cover the management of claims and payments below the deductible in each case.


7. SCHEME OF DELEGATION OF POWERS FROM THE NHS FOUNDATION TRUST ACCOUNTING OFFICER MEMORANDUM (August 2015)

PARA REF DELEGATED TO AUTHORITIES/DUTIES DELEGATED

3 CHIEF EXECUTIVE (AS ACCOUNTING

OFFICER)

Duty to prepare the accounts in accordance with the NHS Act 2006. Duty to personally sign the accounts. Duty of being a 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.


OFFICER)

Responsible to Parliament for resources under their control.


OFFICER)

Responsible for overall organisation, management and staffing of the Foundation Trust and for it procedures in financial and other matters. Ensure that:

a) there is a high standard of financial management in the Foundation Trust as a whole;

b) financial systems and procedures promote the efficient and economical conduct of business and safeguard financial propriety and regularity throughout the Foundation Trust; and

c) financial considerations are fully taken into account in decisions by the Foundation Trust


OFFICER)

Required to:a) personally sign the accounts and accept personal responsibility for their proper

form and content as prescribed by NHS Improvement;

b) comply with the financial requirements of the Trust’s 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;



d) ensure that the resources for which they are responsible are properly well managed and safeguarded, with independent and effective checks of cash balances in the hands of any official;

e) ensure that assets for which they 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 protected property (or interest in) is not disposed of without the consent of NHS Improvement;

g) ensure that conflicts of interest are avoided, whether in the proceedings of the Board of Directors, the Council of Governors or the actions of advice of Foundation Trust staff, including the Accounting Officer; and

h) ensure that, in the consideration of policy proposals relating to the expenditure for which they are responsible, 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.




OFFICER)

Ensure that effective management systems appropriate for the achievement of the Foundation 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 clinical scrutiny of output and value for money; and

c) have the information (particularly about costs), training and access to the expert advice which they need to exercise their responsibilities effectively.


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. Arrangements for internal audit should accord with the objectives, standards and practices set out in the Public Sector Internal Audit Standards.


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 regulation, 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.




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 NHS Improvement 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 the decision is overruled, and the proposal is one which they would not feel able to defend to the Public Accounts Committee as representing value for money, seek a written instruction before proceeding. Inform NHS Improvement 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.


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 they are Accounting Officer.


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 their attention has been drawn by the Comptroller and Auditor General or about which they may wish to question to Accounting Officer.


OFFICER)

Ensure that they are adequately and accurately briefed on matters which are likely to arise at any hearing of the Public Accounts Committee.




OFFICER)

Ensure that they are 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 their behalf if required.

22 BOARD OF DIRECTORS

Where it becomes clear that the Accounting Officer is so incapacitated that he or she will be unable to discharge their responsibilities over a period of four weeks or more, appoint an acting Accounting Officer (usually the Finance Director), until their return.

23 ACTING ACCOUNTING

OFFICER

Sign accounts where the Accounting Officer is unable to sign in time for printing.


8. Statement of Roles and Responsibilities of Council of Governors

1.0 Context:

The NHS Foundation Trust Code of Governance requires the schedule of matters reserved for the Board include a clear statement detailing the roles and responsibilities of the Council of Governors and their responsibilities towards members, other stakeholders and how Governors will seek their views and keep them informed. In addition, the statement should describe how any disagreements between the Council of Governors and the Board of Directors will be resolved.

2.0 Statutory Duties:

The concept of an NHS Foundation Trust rests on local accountability, which Governors perform a pivotal role in providing. The Council of Governors, collectively, is the body that binds a Trust to its patients, service users, staff and stakeholders. It consists of elected members and appointed individuals who represent members and other stakeholder organisations. The NHS Act 2006 and the Health and Social Care Act 2012 set out Governors statutory responsibilities:

Appoint and if appropriate, remove the Chair Appoint and if appropriate, remove the other Non-Executive Directors Decide the remuneration and allowances and other terms and conditions of office of the

Chair and Non-Executive Directors Approve (or not) any new appointment of a Chief Executive Appoint and if appropriate remove the NHS Foundation Trust Auditor Receive the Trust’s Annual Accounts, any report of the Auditor on them and the Annual

Report at a general meeting of the Council of Governors Hold the Non-Executive Directors individually and collectively to account for the

performance of the Board of Directors Represent the interests of the members of the Trust as a whole and the interest of the

public Approve Significant Transactions Approve an application by the Trust to enter into a merger, acquisition, separation or

dissolution Decide whether the Trust’s non-NHS work would significantly interfere with its principle

purpose which is to provide goods and services in England or performing its other functions

Approve amendments to the Trust’s Constitution (where there has been an amendment to the Constitution which relates to the powers, duties or roles of the Council of Governors, at least one Governor must attend the next annual members meeting and present the amendment to members. Members have the right to vote on and veto these types of constitutional amendments

Approve proposed increases of non-NHS income of more than 5% Ensure we operate in accordance with our legal framework

2.1 Additional Powers:

The Board of Directors must have regard to the views of the Council of Governors when preparing the Trust’s forward plan

The Council of Governors may require one or more of the Directors to attend a Council of Governors meeting to obtain information about the performance of the Trust’s functions or the Directors performance of their duties and to help the Council of Governors decide whether to propose a vote on the Trust’s or Director’s performance

3.0 Roles and Responsibilities:

Governors may become involved in many areas not covered by the legislation, however they should remember they do not play an operational role within the Trust.

Governors are expected to attend bi-monthly meetings of the Council of Governors.Governors will also be invited to:

Cast a critical eye over the experience that our patients have, in areas such as accessibility, cleanliness and the environment, and overall ‘patient care’

Become members of informal governor sub-groups of the Council in order to be involved in key areas of the Trust’s work and to meet with the Executives and Non-Executives that lead that work. Governors report back to the full Council meetings regarding the work of each of the groups

Join DCHS governance and working groups Attend ad hoc meetings, workshops and training sessions throughout the course of the

year and receive updates regarding important matters such as strategic developments Attend Open Days and service related meetings and events

Within the Council of Governors meetings, Governors will receive and review reports on: The performance of the Trust against agreed key financial, operational, quality and

regulatory compliance indicators and stated objectives Patient experience in areas such as accessibility, cleanliness and the environment, and

overall ‘customer care’ Staff experience such as Staff Surveys including quarterly “Pulse Checks”, campaigns

such as smoking, alcohol, nutrition, drug abuse and accident prevention Summary Reports from sub-committees of the Council of Governors Working groups formed by Governors with selected Non-Executive Directors, each led

by an Executive Director and targeted at the key areas of the Trust’s activity and strategic planning.

The Membership Strategy and the development of plans for growing and developing the membership

Other areas of activity of interest to Governors

In addition, the Governors will: Hold an Annual Governors’ Meeting/Annual Members’ Meeting to present and receive

feedback on the overall strategic aims of the Trust and receive:o The annual accountso Any report of the auditor on themo The Annual Quality report

Commission an annual review of its effectiveness and efficiency in the discharge of its responsibilities and achievement of objectives

The Council of Governors will establish the following committees:o Nomination and Remuneration Committeeo Such other committees as required from time to timeo Task and finish working groups as necessary.

4.0Responsibilities under the Main Principles of the Code of Governance:The Council of Governors has a duty to hold the Non-Executive Directors individualVersion 5:July 2018

lly and collectively to account for the performance of the Board of Directors. This includes ensuring the Board of Directors acts so that the Foundation Trust does not breach the conditions of its licence. It remains the responsibility of the Board of Directors to design and then implement agreed priorities, objectives and the overall strategy of the NHS Foundation Trust.

The Council of Governors is responsible for representing the interests of NHS Foundation Trust members and the public and staff in the governance of the NHS Foundation Trust. Governors must act in the best interests of the NHS Foundation Trust and should adhere to its values and code of conduct.

Governors are responsible for regularly feeding back information about the Trust, its vision and its performance to members and the public and the stakeholder organisations that either elected or appointed them. The Trust should ensure Governors have appropriate support to help them discharge this duty.

There are a range of options available for staff and public Governors to engage with their constituent members. These include:

Direct/tailored email to members Use of the members’ newsletter; The Community, to carry articles and messages Use of the staff newsletter; Our Voice, for staff Governors to share news Profession-specific email distribution list to aid tailored communications Social media and digital channels Open days at our sites Member recruitment within constituencies

All Directors and Governors should receive appropriate induction on joining the Board of Directors or the Council of Governors and should regularly update and refresh their skills and knowledge. Both Directors and Governors should make every effort to participate in training that is offered.

The Board of Directors and the Council of Governors should be supplied in a timely manner with relevant information in a form and of a quality appropriate to enable them to discharge their respective duties.

The Council of Governors, which is responsible for the appointment and re- appointment of Non-Executive Directors, should take the lead on agreeing a process for the evaluation of the Chair and the Non-Executives, with the Chair and the Non-Executives. The outcomes of the evaluation of the Non-Executive Directors should be agreed with them by the Chair. The outcomes of the evaluation of the Chair should be agreed by him or her with the Senior Independent Director. The outcomes of the evaluation of the Non-Executive Directors and the Chair should be reported to the Governors. The Governors should bear in mind that it may be desirable to use the Senior Independent Director to lead the evaluation of the Chair.

The Council of Governors should assess its own collective performance and its impact on the NHS Foundation Trust.

All Non-Executive Directors and elected Governors should be submitted for re- appointment or re-election at regular intervals. The performance of Executive Directors of the Board should be subject to regular appraisal and review. The Council of Governors should ensure planned and progressive refreshing of the Non-Executive Directors.

Version 5:July 2018

The Council of Governors must represent the interest of Trust members and the public. In their stewardship of the Trust's affairs, Governors will bring an appropriate perspective of the constituency or organisation by which they were elected or appointed, and act collectively and not in pursuit of sectional or personal interests.

5.0 Responsibilities under the Code of Conduct:

Governors are required to adhere to the highest standards of conduct in the performance of their duties. In respect of their interaction with others, they are required to:

Adhere to good practice in respect of the conduct of meetings and respect the views of their fellow elected and appointed members

Be mindful of conduct which could be deemed to be unfair or discriminatory Treat the Trust’s executives, other employees and fellow members with respect and in

accordance with the Trust’s policies Recognise that the Council of Governors and management have a common purpose,

i.e. the success of the Trust and adopt a team approach Act collectively and not in pursuit of sectional or personal interests. Conduct themselves in such a manner as to reflect positively on the Trust. When

attending external meetings or any other events at which they are present, it is important for Governors to be ambassadors for the Trust

Adhere to the Trust’s rules and policies Act in the best interests of the Trust at all times Contribute to the workings of the Council of Governors in order for it to fulfill its role and

function as defined in the Trust Constitution Comply with the Trust’s Code of Conduct for Governors and any guidance or best

practice advice issued by NHSI and behave in accordance with the seven Nolan Principles of Behaviour in Public Life

Comply with the Standing Financial Instructions prepared by the Director of Finance, Information and Strategy and approved by the Board of Directors for the guidance of all staff employed by the Trust

6.0 Lead Governor Role:

NHSI have asked all NHS Foundation Trusts to nominate a Lead Governor to support communication between NHS Improvement (NHSI) and the Council of Governors in the limited number of circumstances when it may not be appropriate to communicate through the normal channels of the Trust Chair and Associate Director of Corporate Governance / Trust Secretary.

NHSI expect direct contact with a Council of Governors to be rare. The main circumstances in which NHSI will contact a Lead Governor are when NHSI has concerns about the Board’s leadership, which could potentially lead to NHSI using its formal powers to remove the Chair or Non-Executive Directors (NEDs).

If there is a real risk that an NHS foundation Trust may be in significant breach of its licence, the likely issue is one of board leadership and NHSI will wish to have direct contact with the Governors through the Trust's nominated Lead Governor. The Lead Governor should take steps to understand NHSI role, the available guidance and the basis on which NHSI may take regulatory action. The Lead Governor will then be able to communicate more widely with other governors.

Similarly, where individual governors wish to contact NHSI, this would be expected to be through the Lead Governor.

Version 5:July 2018

The other circumstance where NHSI may wish to contact a Lead Governor is where, as the regulator, they have been made aware that the process for the appointment of the Chair or other members of the Board, or elections for Governors, or other material decisions, may not have complied with the NHS Foundation Trust's constitution, or alternatively, whilst complying with the Trust's constitution, may be inappropriate.

In such circumstances, where the Chair, other members of the Board of Directors or the Associate Director of Corporate Governance / Trust Secretary may have been involved in the process by which these appointments or other decisions were made, a Lead Governor may provide a point of contact for NHSI.

If the Lead Governor should receive any communication directly from NHSI then this should be passed on within five days. This should be done via the Chair, Associate Director Corporate Governance / Trust Secretary or the Senior Independent Director depending on the issue and who the most appropriate person is

Should the communications received from NHSI require a Council of Governors meeting to be convened then this should be done via the Chair of the Council of Governors. If the Chair is conflicted, the Lead Governor should convene a meeting of the Council of Governors via the Vice Chair

Where any Governor – including the Lead Governor - wishes to contact NHSI, this should be first discussed with the Chair, or if this is not appropriate, the Senior Independent Director. The Senior Independent Director is one of the Non-Executive Directors who will act as the point of contact with the Board, if Governors cannot use the normal channels

It should be noted the Lead Governor does not have greater power or responsibilities than the other Governors and should not assume the power or responsibility of the Council. The power of the Council of Governors rests with the Council itself.

In line with many NHS Foundation Trusts, DCHS have chosen to broaden the Lead Governor’s role, which includes:

To consult routinely with the Governors regarding the planning and preparation the Council of Governors agenda

To provide input into the Chair and Non-Executive Director appraisals on behalf of the Council of Governors

To be an external point of contact for NHSI when appropriate To take an active role in the activities of the Council of Governors

o Deputise for the Chair/Vice Chair at Members’ eventso Chair pre-meetings of the Council of Governorso Present reports to the Council of Governors as Lead Governoro Become a member of the Nominations and Remuneration Committeeo Support the process to review the performance of the Chair and the Non-

Executive Directors, from the Council of Governor’s perspective. Attend meetings of the Nominations Committee to discuss the outcome of the reviews

o Provide leadership and guidance; mentor new or less experienced governorso Meet regularly with the Chair; be a point of contact through which channels of

communication flow between Chair/Board of Directors and Council of Governors so as to foster good relations and openness

o Liaise regularly with the Associate Director of Corporate Governance/Trust Secretary in relation to meetings, minutes, follow up action, progress chasing

o Provide a sounding board for the Chair and members of the Executive Teamo Attend regular Governor Constituency meetings led by the Chair

Version 5:July 2018

o Provide a Lead Governor report to the Annual Governors’ Meeting/Annual Members’ Meeting

On certain occasions it might not be appropriate for the Chair or Vice Chair to preside at meetings of the Council of Governors (such as when the Governors are considering the remuneration and appointment of these individuals).

In these circumstances, the Lead Governor would chair the part of a Council of Governors meeting that the Chair and Vice Chair are either absent or disqualified from participating in. This would only be in a limited number of circumstances.

7.0 Disagreements between the Council of Governors and the Board of Directors

The Council of Governors and the Board of Directors are committed to developing and maintaining a constructive and positive relationship. The aim, at all times, is to resolve any potential or actual differences of opinion quickly, through discussion and negotiation.

If the Chair cannot achieve resolution of a disagreement or dispute between the Council of Governors and the Board of Directors through informal efforts, the Chair will follow this dispute resolution procedure. The aim is to resolve the matter at the first available opportunity and only to follow the dispute resolution procedure if initial action fails to achieve resolution:

The Chair will call a joint meeting (“Resolution Meeting”) of equal numbers of Governors and Directors, to take place as soon as possible, but no later than twenty working days following the date of the request by the Chair. The Resolution Meeting will be held in private. The aim of the Resolution Meeting will be to achieve resolution of the conflict. The Chair will have the right to appoint, at his/her absolute discretion, an independent facilitator to assist the process. Every reasonable effort must be made to reach resolution.

If the Resolution Meeting fails to resolve the conflict, the dispute will be referred back to the Board of Directors who shall make the final decision. Any final decision by the Board of Directors is without prejudice to the statutory powers of the Council of Governors.

8.0 References and Supporting Documents:

NHSI - The NHS Foundation Trust Code of Governance (Updated July 2014)

NHSI - Your Statutory Duties; A Reference Guide for NHS Foundation Trust Governors (August 2013)

DCHS Constitution (July 2017)

DCHS Code of Conduct for Governors (November 2016)

Council of Governors Terms of Reference (May 2017)

DCHS Engagement Policy (September 2017)

Version 5:July 2018

APPENDIX 1 – POLICY DELEGATION TABLE1. Under Standing Order 5.1 (Annex 7) DCHS has exercised its authority to delegate to properly constituted committees the function of approving policies.

SO Ref Delegated to Authorities/Duties Delegated

5.1 General delegation

The Board delegates authority to approve and performance manage the implementation of policies to its main committees as set out in the specific delegations that follow. In making this delegation the Board requires of the relevant sub-committee to report on the policies that the sub-committee has approved; any significant risk issues arising from the policy approvals and their implementation; and any other matters requiring the Board’s consideration and action via the summary report.

The Board also grants authority for each of the sub-committees specified below to further delegate authority for the approval and performance management of the implementation of policies to sub-committees of the main committee, should that be deemed appropriate for the efficient management of the policy approvals process. Where such delegations are granted it is the responsibility of the committee granting the delegation to require a report on the policies that the group has approved; any significant risk issues arising from the policy approvals and their implementation; and any other matters requiring the committee’s consideration and action via the summary report.

Where a policy or class of policies is not listed in the following delegations it shall either be approved by the Board, or by the most appropriate sub-committee.

5.1 Audit and Assurance Committee

Review and approval of the following policies:

Counter Fraud, Bribery and Corruption Policy Corporate policies Financial policies

SO Ref Delegated to Authorities/Duties Delegated

5.1 Quality Service Committee

Approval and performance management of the following policies:

Clinical policies including:SafeguardingInfection Prevention and ControlSexual HealthPharmacyHome of ChoiceChild Health

Safety policies

Corporate policies includingAdminLegal

Information Governance policies

5.1 Quality People Committee

Approval and performance management of the following categories of policies:

Human Resources

5.1 Quality Business Committee

Approval and performance management of the following policies:

Estates and Finance

5.1 Mental Health Act Committee

5.1Remuneration and Terms of Service Committee

5.1 Charitable Funds Committee


2. Exercising the powers granted under the delegations set out in section 1 above the Trust Board’s sub-committees have approved the following delegations:

Committee Delegated to: Authorities/Duties Delegated

Quality Service Committee

Clinical Safety Group

Clinical Safety policies including:SafeguardingIP&CPatient Safety

Clinical Effectiveness Group (including audit)

Clinical policies includingSafeguardingInfection Prevention and ControlSexual HealthPharmacyHome of ChoiceChild Health

Patient Experience and Engagement Group

Information Governance Group Information Governance

Safeguarding Group

Records Management Group

Equality, Diversity and Inclusion Leadership Forum

Quality Always Strategy Group

Quality People Committee Staff Partnership Committee


Committee Delegated to: Authorities/Duties Delegated

Strategic Workforce Development and Education Group

Staff Health Wellbeing and Safety GroupEquality, Diversity and Inclusion Leadership Forum

Quality Business Committee

Plan Delivery Group

Security Emergency Preparedness, Resilience and Response Group

Emergency Preparedness, Resilience and Response Plans including:Framework for Responding to Industrial ActionSite Contingency PlanFuel Disruption Contingency PlanMajor Incident & Business Continuity Plan

Polices relating to:SecurityEmergency Preparedness Resilience and Response

Information Management and Technology Strategy Group

Capital and Estate Programme Group


APPENDIX - 2DERBYSHIRE COMMUNITY HEALTH SERVICES NHS FOUNDATION TRUSTAUTHORISATION STATUS RESPONSIBILITIES

Document/ Form name

Chief Executive

Director of Finance,

Information and

Strategy

Director (Budget Holder )

Assistant / Associated Directors

Budget Manager

Authorising Officer Level 1

Authorising Officer

Level 2

Deputy Director

of Finance

Senior Finance Officer

Finance

Officer

Charitable Fund

Manager

Staff related

Vacancy requisition form

√ √ √ √ √ √ √

Appointment form √ √ √ √ √ √ √

New starter form √ √ √ √ √ √ √

Amendment to contract

√ √ √ √ √ √ √

Amendment to Registration/ Qualification details

√ √ √ √ √ √ √

Termination of employment

√ √ √ √ √ √ √

Payment on Account Request

√ √ √ √ √ √ √

Salary Return √ √ √ √ √ √ √

Travelling and subsistence claim

√ √ √ √ √ √ √

Authorisation of official car user

√ √ √ √ √ √ √

Application for lease vehicle

√ √ √ √ √ √ √

Document/ Form name

Chief Executive


Information and

Strategy



Budget Manager


Authorising Officer

Level 2

Deputy Director

of Finance


Finance

Officer

Charitable Fund

Manager

Lease car mileage record

√ √ √ √ √ √ √

Study/ Examination leave application

√ √ √ √ √ √ √

Pay budget virements

√£250,000

√£100,000

Non Pay Expenditure

Authorisation of expenditure – by requisition or invoice authorisation

√Value up

to £250,000

for all responsible budgets

√Value up to £250,000

for all responsible

budgets

√ Value up

to £100,000


√ Value up to £50,000 for

all responsible

budgets

√ Value up

to £20,000 for all

responsible budgets

√ Value up to £2,000


Chief Executive Office (Trust Secretary and Deputy Secretary) £250,000 for all responsible budgets

Debtor/ Credit Note request

√ √ √ √ √ √ √ √

Petty Cash authorisation

√ √ √ √ √ √


Document/ Form name

Chief Executive


Information and

Strategy



Budget Manager


Authorising Officer

Level 2

Deputy Director

of Finance


Finance

Officer

Charitable Fund

Manager

Non pay budget virements

√£250,000

√£100,000

Charitable Fund expenditure

√ Value up to £10,000

√ Acting individually value up to £2,000 and with

Director of Finance value up

to £10,000

Finance/ Supplies functions

PGO account signatory

√ √ √

BACS/ CHAPS/ foreign currency signatory

√ √ √

Authorisation of GL journal voucher

√ √ √ √

Amendments to chart of accounts

√ √

Condemning certificate

√ √ √ √

Certification of order

√ √ √

Losses & Special Payments

√ √ √ √



CORPORATE FRAMEWORK FOR GOVERNANCE AND ASSOCIATED COMMITTEES

Document HistoryModified Date: July 2018

Version Number: 9.0 Reference Number:

Next Revision Due: July 2021 (or earlier as part of the DCHS FT Scheme of Delegation)

Author: Corporate Governance Manager

Policy Sponsor: Associate Director of Corporate Governance/Trust Secretary

Approved by: Board as part of the Foundation Trust Scheme of Delegation Date:

Category: Corporate

Type of Document: FrameworkHave you assessed the Equality Impact of this policy?

Yes

Please indicate which groups have discussed this policy:Date(s) discussed:

Has this Policy previously been known under another title? If so please state previous title.Date changed:

Revision HistoryVersion Revision

dateSummary of Changes

6 November 2014

Updated following Foundation Trust status

7 April 2015 Section 4 - Definitions - updated definition of “Committee” Section 5.7 - Reporting to the Parent Committee - updated the

definition of the Summary Report Appendix A - Terms of Reference - inclusion of “Key Deliverables”

within the template Appendix C - Cover Sheet - updated the monitoring questions,

amended the Risk Register section Appendix G - Summary Report - amended the template and

included instructions on how to complete8 January

2016Minor changes made to document

9 July 2018 General guidance sections removed Details added on updating action matrix’s Detail added on recording Levels of Assurance

To help ensure that this policy is as accessible as possible, it has been left-aligned and is available in alternative formats and languages. To obtain a copy of the policy in large print, audio, Braille (or other format) or in a different language, please contact The Communications Team, by Tel: 01246 515224 or email [email protected]

Derbyshire Community Health Services NHS Foundation Trust 135

TABLE OF CONTENTS

1. AIM/PURPOSE ..........................................................................................................1382. INTENDED USERS ....................................................................................................1384. DEFINITIONS AND AN EXPLANATION OF TERMS USED .....................................1385. FULL DETAILS OF THE FRAMEWORK ...................................................................1396. SUPPORT AND ADDITIONAL CONTACTS .............................................................1487. SUPPORTING DOCUMENTS OR RELEVANT REFERENCES ................................1488. APPROVAL AND RATIFICATION ROUTE ...............................................................1499. MONITORING/AUDIT ................................................................................................14910. EQUALITY IMPACT .................................................................................................14911. APPENDICES ..........................................................................................................149

1. AIM /PURPOSE

This document aims to provide guidance to assist with the formulation of terms of reference, agendas and minutes, to assist with the general management of the committee process to ensure a consistent approach and to ensure that they add value to the overall governance of DCHS.

Whilst this guidance is aimed at formal governance committees it is equally applicable to other committee meetings including ‘task and finish’ groups etc wherever possible such committees/groups are expected to adhere to these guidelines.

2. INTENDED USERS

Table of Intended Users:

Include the table and wording below

DCHSChief Executive’s Department YES

Finance,Information and Strategy YESQuality YES

Operations YESPeople and Organisational Effectiveness YES

Within this policy where it states “all employees”, please note, that it relates to all the employees who are highlighted in the table above

N.B If the policy also applies to people who are not directly employed by DCHS, they should also be listed here

3. DISCLAIMER STATEMENT

It is a requirement that the reader follows this policy and accepts professional accountability and maintains the standards of professional practice as set by the appropriate regulatory body applicable to their professional role and to act in accordance with the express and implied terms of your contract of employment, in accordance with the legal duties outlined in the NHS Staff Constitution (section 3b). If there are any concerns with this document then the reader should initially discuss the specific issue with their line manager or raise it through appropriate “raising concerns” channels. The line manager should agree a course of action that is appropriate and reflect this in the patients notes and with the policy sponsor.

4. DEFINITIONS AND AN EXPLANATION OF TERMS USED

Committee – within DCHS, a Committee is defined as a high-level meeting which reports directly into the Board and is chaired by a Non-Executive Director, with the exception of the Staff Partnership Committee, which reports into the Quality People Committee.


Group – a group is any other meeting which is held within DCHS with a Governance remit and reports through the Committee structure to Board.

N.B. within the Corporate Framework where it states “committee” please read it to be applicable to committees and groups.

5. FULL DETAILS OF THE FRAMEWORK

Good governance is important within Derbyshire Community Health Services NHS Foundation Trust (DCHS) as it is concerned with:

How the organisation is led and structured How the organisation is able to demonstrate that it is operating in line with the

fundamental principles of openness, integrity and accountability How DCHS is meeting the statutory objective of providing high quality healthcare Ensuring that the organisation’s objectives are delivered economically, efficiently

and effectively

Managers and other staff throughout DCHS spend a considerable amount of their time attending committee meetings. It is essential that this resource is an effective use of time.Consideration should also be given to whether a face to face meeting needs to be held or whether the meeting could take place via conference call, which considerable reduces the time and cost of a meeting.

Each committee should have clear Terms of Reference related to the organisation’s objectives so that its role is unambiguous and to ensure that it makes a relevant contribution. Committees should function effectively i.e. meet with appropriate frequency, be well attended and produce minutes that reflect the terms of reference.

Committees should make decisions with clear actions and recommendations that are followed throughout subsequent meetings (with timescales for implementation where appropriate).

5.1 Terms of Reference (Appendix A)Each committee should have clear Terms of Reference which normally will include most of the following:

Introduction: It is useful to provide an Introduction to the Committee/Group What: A summary of the purpose of the committee Who: A list of the membership and their titles, who the Chair is, details of other

managers/staff who are not part of the formal membership but will be in attendance, the details of the admin/secretarial support that will be provided

Quoracy: Details of the number and type of members that make up the quorum, i.e. ‘four members, one of whom should have a clinical background’

When: How often the committee will meet Where: Where will the meeting be held Why: Why is the committee needed How: A summary of the main functions of the committee Policy Approval: A summary of the policy approval rights of the committee Sub Committees/Groups: A list of any sub-committee that report in to the

committee and the method by which they report in


Communication Links: Details of any communication links or methods or communication

Reporting to: A description of the where/who the committee reports to, and the method it uses to report i.e. summary report and the frequency with which it reports

Key Performance Indicators/Key Deliverables: It is recommended that each committee develop a set of Key Performance Indicators (KPI’s) as a method of measuring the committee’s progress in achieving its overall aims. Where possible these should link to the Board Assurance framework

The review date for the Terms of Reference – it is recommended the terms of reference are reviewed at least annually

5.2 Agendas (Appendix B)Each meeting should have an agenda which would include the following:

Title: The agenda should begin by stating the committee’s title, the date, time and location of the meeting

Content of the Agenda: The agenda should normally follow the order below:o Apologieso Declarations of Interesto Presentations/regular reports such as Patient’s Storyo Minutes of the previous meetingo Matters arisingo Actions Matrix: Any action points recorded in the previous minutes should be

reported back to the committee. The item title and the minute number should be listed as well as the individual responsible

The substantive agenda items, including presentations/regular reports: All agenda items to be presented/received should have an agenda number which is included on the cover sheet. The numbers should be consecutive throughout the year to allow for ease of reference.

Matters referred to or from other committees Issues arising from meeting for Board Briefing Matters referred to the Council of Governors Any Other Business: At the end of the agenda members should be reminded that

the Committee Secretary must be notified of any items to be taken under Any Other Business (AOB) at least 24 hours before the meeting. Normally, no resolutions or actions may be approved under Any Other Business. If a decision is needed the item should be carried over to the next meeting and taken as a substantive agenda item. All agenda items should be presented in writing. Only in exceptional circumstances should a verbal update be given and only with agreement from the Chair (see 5.4).

Review of the meeting – a final agenda item to review how effective the meeting was.

Board Assurance Framework: Does anything discussed at the meeting affect the BAF or the associated risk scores.

Date and venue of Next Meeting along with papers deadline

5.3 Virtual Policy Approval


Several DCHS committees have delegated authority from the Board to approve policies – this is documented in DCHS’ Corporate Governance Manual and the terms of reference of the appropriate committees.

It is not always possible to approve policies during the meeting and so it may be necessary to approve the policies virtually rather than wait for the next committee meeting.

The following steps should be taken when approving policies virtually:

The policies should be sent out to all committee members via e-mail with a reasonable deadline to allow the policies to be read and commented upon

A positive response must be received back from committee members via e-mail to allow for the policy to be approved – the policy cannot be approved until, as a minimum, the quoracy for the meeting has responded

The responses should be kept with the committee papers so an audit trail can be produced if required

The committee members may respond with comments, if this is the case and they are simple amendments, the policy should be approved subject to the amendments being made

If the amendments are more complex or there is a conflict in the responses from the committee members, the chair of the committee should make a decision whether it is appropriate to have a conference call to resolve the issues or whether it needs to wait until the next committee meeting where a full discussion can be held

A written note of the outcome of the policies which have been sent out for virtual approval, should be an agenda item on the next committee meeting so that it can be formally minuted

5.4 Committee Papers and ReportsAll papers received by a committee must have a Cover Sheet (See Appendix C). Papers for the Council of Governors meeting must also have a Cover Sheet (See Appendix D).

The Cover Sheet helps the author identify the key pieces of information the committee needs to be aware of; the text included in italics on the cover sheet is there to provide the author with guidelines for what should be included.

Where possible authors of papers are encouraged to incorporate the main body of the report under the headings outlined in the Cover Sheet.

Committee Reports Most reports will be requested by the Chair of the committee, via the Committee Secretary, because they appear on the annual Forward Plan or were requested at a previous meeting. Committees should normally have in place a Forward Plan of agenda items (regular reports) for the year. This is an agenda planning tool which enables reports to be scheduled in advance throughout the year.

Members of committees, as well as members of staff more generally, may also request that reports are submitted for consideration. Anyone wishing to make such a request is advised to consult with the relevant Committee Secretary/Chair well in advance of the deadline for receipt of reports.


The Forward plan should be reviewed by the Committee regularly.

In general terms, the reports received by committees are:

For assurance – e.g. reports to the committee about the level of confidence and evidence that a particular course of action has been taken

For information – e.g., reports which do not require any formal action or decision For decision – e.g. where a particular course of action is proposed and requires

official sanction, or where policy, strategy, or regulation requires approval Or a combination of the above

Each paper should clearly identify what action it requires the committee to take.

Reports should seek to add value to DCHS, by providing important information, prompting high-level discussion and seeking approval for a course of action. Reports should be aligned to, and contribute to the achievement of DCHS’ objectives, The DCHS Way and the DCHS Board Assurance Framework.

Timetables should be agreed for the submission of reports and the distribution of committee papers:

Agendas for Board and Committees are agreed approximately 2-3 weeks prior to the meeting, following which

Authors of scheduled reports are contacted and asked to submit their reports and provide an update regarding outstanding actions in line with the agreed deadline

The deadline for receipt of papers and actions update by the Committee Secretary is normally 9 days before the meeting

The complete agenda with papers is distributed to the committee 7 days prior to the meeting so that the members have opportunity to fully read and consider all the papers

Agendas for Council of Governors are agreed approximately 3 - 4 weeks prior to the meeting

For Council of Governors, the deadline for receipt of papers and actions update by the Committee Secretary is normally 17 days before the meeting

For Council of Governors, the complete agenda with papers is distributed to the committee 14 days prior to the meeting so that the members have opportunity to fully read and consider all the papers.

The most consistent difficulty faced in achieving the timely distribution of papers is the late submission of reports. Authors have a duty to ensure that papers are delivered by the deadline date.1

1Board and its Sub-Committees: Executives have a duty to ensure that papers and action updates are delivered by the deadline date. Late papers will not be included unless in exceptional circumstances that have been agreed by the Associate Director of Corporate Governance/Trust Secretary in advance.

Executive Directors are responsible for the quality of the papers presented to the meetings.

5.5 Minutes (Appendix E)


The purpose of minutes is to provide a formal record of the decisions and substantive discussion occurring in a meeting and provides a record of the integrity of the meeting. The substantive discussion should be recorded in a clear and concise manner.

Title: The name of the committee and the date of the meeting should be clearly stated at the beginning of the minutes. Start and finish times should also be stated.

Present: When listing those present the name of the individual and the position they are representing on the committee should be given. Members should be listed in alphabetical order (by surname) with the Chair identified by (Chair) written after the name. If a person joins or leaves the meeting the times should be noted against their names for auditing purposes. If there are groups of member constituencies, then they can be listed alphabetically within the group:

if the member was present if the member was not present but gave apologies to the committee’s officer

before the meeting if not present and apologies were not received

Where individuals are present at the meeting but are not part of the formal membership of the committee they should be recorded under “In attendance”. This would include the Committee Secretary, any co-opted members and those presenting a paper/item to the committee: in this instance the item number they are present for should be recorded.

Minutes do not need to be very long, they must however contain: what decisions were made, including the level of assurance agreed by the

committee and any new risk identified; who proposed and supported items for decision; the result of any votes (the numbers in favour, against and any abstentions); what action was agreed; who was given responsibility to carry out the action and by when

Minutes should include a short summary of the opinions or challenges raised during the discussion, along with the reason why a certain decision was reached. Minutes should state the level of assurance the Committee took from an agenda item and its relevant paper. If a paper is given Limited or No Assurance the minutes should record the reasons why the level of Assurance was given and what action needs to be taken.

Good minutes are accurate, brief and clear. The minutes should be written in the order that the items appeared on the agenda and the minute numbers must correspond with the agenda numbers. If items were discussed in a different order at the meeting, then that should be explained at the start of the minutes (for example, “the committee noted that ‘Registered Student Numbers’ (item SMG.05.11) would be discussed at the start of the meeting).

Minutes should be written in a consistent style, from one meeting to the next. This is usually the Committee Secretary’s responsibility. During the meeting, if the person writing the minutes is unsure of a decision or action, they should ask the Chair for clarification so that their notes are accurate.

The draft minutes should be approved by the Chair and then circulated by the Committee Secretary to members as soon as possible after the meeting.2


2Board and its Sub-Committees: The draft minutes should be approved by the Chair and the Lead Executive.

5.6 Actions Matrix It is good practice to ensure the actions agreed at the committee are completed. It is recommended that the actions are summarised from the minutes into an Actions Matrix. (See Appendix F).

The Actions Matrix should be circulated along with the Minutes of the previous meeting. Updates should normally be provided to the Committee Secretary 9 days before the meeting. Updates should clearly show if the action has been completed or, if incomplete, whether the target date has changed.

The matrix will ensure that if the person responsible for the action is not able to attend and feedback to the following meeting or if an action takes longer to implement than anticipated, the action is not “lost” and the committee can receive assurance it has been implemented.

The actions matrix should show the outcome of the action rather than stating whether the action has been completed or closed. It is important to see what steps were taken to address the action which will then be considered by the committee. The Chair will determine whether the actions taken are sufficient or whether anything further is required.

Every action should have an agreed deadline date for completion. The deadline date can be extended on agreement with the Chair however the original deadline date should still be shown in the matrix. An update as to progress can be recorded for the committee to review and to allow for discussion as to how the action is progressing. You should avoid lengthy updates and as a rule the action should be closed as soon as possible.

5.7 Reporting to the Parent Committee/GroupEach committee/group should provide summary reports to the ‘parent’ committee/group (this is the committee/group that it reports to or is responsible to). Following the meeting the Committee Secretary should prepare a summary report for the Chair to check prior to submission to the parent committee/group.3

3 Board Sub-Committees: The Chair and the Lead Executive should approve the summary report prior to submission to the Board.

Forwarding copies of minutes to the parent committee/group is not a sufficient report. Minutes may be forwarded in addition to completing the summary report. The summary report should:

Summarise the key issues and levels of assurance (including their Board Assurance Framework reference numbers) taken from the meeting.

Record the reasons for any items of limited or no Assurance together with key actions agreed.

Report the key decisions made, including policies approved and issues referred to the parent committee/group

Not replicate the minutes by quoting discussions and naming individuals Be clear, keep matters simple - using bullet points where appropriate

Order of Summary Report Presentation


Begin with exceptionally positive matters, not just positive assurances Items of limited assurance – include key agreed actions Positive and negative exceptions (negative assurance to positive or positive

assurance to negative) List papers with Significant Assurance Issues beyond the scope of the Committee/group that need escalating or referring What was approved New risks identified

When Summary Reports are presented to the “parent” Committee, then the parent Committee has the opportunity to: challenge the levels of assurance against each item of business and reach a conclusion regarding the overall level of assurance that the reporting Committee is providing.

Levels of Assurance- DefinitionsFull Assurance - the system of internal control has been effectively designed to meet the system’s objectives, and controls are consistently applied in all areas reviewed.

Significant Assurance - there is a generally sound system of control designed to meet the system’s objectives. However, some weakness in the design or inconsistent application of controls put the achievement of particular objectives at risk.

Limited Assurance - weaknesses in the design or inconsistent application of controls put the achievement of the system’s objectives at risk in the areas reviewed.

No Assurance - weaknesses in control, or consistent non-compliance with key controls, could result (have resulted) in failure to achieve the system’s objectives in the areas reviewed.

The template for the summary report is attached at Appendix G.

5.8 The Role of the Committee Secretary/Meeting OrganiserThe role of the Committee Secretary varies depending on the Terms of Reference, size and composition of the committee, and the chairing skills/style of the Chair. There are, however, certain basic roles which can be identified:

To make all the domestic arrangements for the meeting To prepare and distribute all documentation To present material impartially To record all decisions/recommendations of the committee To advise the meeting on procedural matters and past precedent To provide minutes and summary reports for approval by the Chair and Lead

Executive To update the Forward Agenda and Actions Matrix Establish a timetable of when papers are due to be submitted. (See Appendix H).

Good preparation for a meeting by the Committee Secretary helps to ensure that business runs smoothly and the following checklist will help the Secretary to carry out their duties efficiently and effectively:


Induction of new membersThe Committee Secretary should send the following documents to newly appointed members:

Dates and venues of future committee meetings Terms of Reference and membership of that committee and its related (sub)

committees The minutes of the previous 3 meetings Contact details of the Chair and Committee Secretary

The Committee Secretary should also check whether new members have any special needs to enable them to participate fully in meetings and, if so, make provision accordingly.

5.9 Layout and Format of Committee PapersPrinted information, including all committee papers, should be accessible to people with sight problems, the following is general guidance and further information is available from the Royal National Institute for the Blind website (www.rnib.org.uk): should be used whenever documents are likely to be accessed by the public. Type size should be between 12 and 14 points There should be good contrast between background and the text, black text on a

white background provides best contrast Arial font should be used Blocks of capital letters, underlined or italicised text are difficult to read and should

be avoided The space between each line (known as leading) should be 1.5 to 2 times the

space between words on a line. Numbers (including page numbers) should be printed in a typeface which is easy

to read. Readers with sight problems can misread 3, 5, 8 & 0 Text should be aligned to the left margin as it makes it easier for readers to find

the start of the next line and keeps the spaces even between words and makes it easier to read for people with sight problems

Avoid glossy paper or paper that is very thin

5.10 Be Aware of Your AudienceIt is important to be aware that it is relatively easy for members of the public, including the press, to access committee papers, either because the meetings are held in public ie the Board, or as a result of a ‘Freedom of Information’ request. Authors of papers need to be mindful of this particularly when conveying sensitive information. Further advice can be obtained from the following departments:

Communications; contact 01246 515224 Information Governance contact: 01773 824171 ext 5521

6. SUPPORT AND ADDITIONAL CONTACTS

Further guidance regarding committee papers can be obtained from the Chief Executive’s Department at Babington Hospital, Belper; contact 01773 599466.


7. SUPPORTING DOCUMENTS OR RELEVANT REFERENCES

DCHS NHS Foundation Trust Scheme of Delegation www.rnib.org.uk


8. APPROVAL ROUTE

This policy will be approved by the Trust Board on a three yearly basis, or when the Scheme of Delegation is updated.

9. MONITORING/AUDIT

The Chief Executive’s Department are responsible for the monitoring and performance management of the Corporate Framework for Governance and Associated Committees. Where relevant committees are failing to adhere to this framework it will be reported to the Audit and Assurance Committee and the Committee Chair will be required to provide a report stating how they intend to rectify the situation.

10. EQUALITY IMPACT

To help populate this section, please refer to the Policy Development Framework (Section 5.3.2.1) and complete the DCHS’ Equality Impact Assessment ‘Assessing Equality Relevance’ forms, which can be found here.

11. APPENDICES

A – Terms of Reference templateB – Agenda templateC – Report Cover Sheet templateD – Council of Governors Cover Sheet templateE – Minutes templateF – Actions Matrix templateG – Summary Report templateH –Timetable template


What effect or impact will the new/changed policy have on each of the Protected Characteristics (age, gender, disability, gender reassignment, marriage or civil partnership, pregnancy or maternity, race, religion or belief, sexual orientation)?

Level 1 EIA in place

If this effect or impact is negative or disadvantages one or more of the Protected Characteristics, what changes are going to be made to either remove entirely or minimise this effect or impact? (Note: if the policy could be discriminatory, seek immediate advice from the Head of Equality, Diversity and Inclusion

Level 1 EIA in place

Appendix A

Title of MeetingTerms of Reference

Date

Introduction This is not a mandatory section however an introduction to the Committee/Group can be provided here

What A summary of the purpose of the committee

WhoA list of the membership and their titles, who the Chair is, details of other managers/staff who are not part of the formal membership but will be in attendance, the details of the admin/secretarial support that will be provided

Quoracy Details of the number and type of members that make up the quorum, i.e. ‘four members, one of whom should have a clinical background’

When How often the committee will meet

Where Where the meeting will be held

Why The reason the committee is needed

How How the committee will conduct its business, this can include bullet points on how the purpose of the committee will be achieved

Sub Committees /

Groups

A list of any sub groups that report into the committee and the method by which they report in

Communication Links

List the formal mechanisms in place to commuicate the business of the committee and to who

Policy Approval State what, if any, approval rights the Committee has.

Reporting To A description of the where/who the committee reports to, and the method it uses to report i.e. summary report and the frequency with which it reports

Key Performance

Indicators/Key Deliverables

It is recommended that each committee develop a set of Key Performance Indicators (KPI’s) as a method of measuring the committee’s progress in achieving its overall aims

Review Date It is recommended the terms of reference are reviewed at least annually


Appendix BMeeting Name

Date of meetingStart timeEnd timeLocationDeadline

AGENDAItem Subject Description Owner

ApologiesDeclarations of InterestPresentations/regular reportsMinutes of the previous meetingMatters arisingActions MatrixThe substantive agenda items, including presentations/regular reportsIssues Arising from meeting for Board briefingMatters referred to or from other committeesAny Other BusinessReview of meetingTime, Date and Venue of Next Meeting


Appendix CNAME OF MEETING

Document Title:

Presenter/Title:Contents of Paper were previously discussed by:

If this issue been discussed at another Committee meeting – include dates and details. This is particularly pertinent for policies

Author/Title:Contact Email and Telephone Number:

Date of Meeting: Date goes here AgendaItem No:

No of pagesinc. this one:

Has an Equality Impact Assessment been undertaken Yes No

Document is for:(more than one box can be ticked) Information Decision Assurance

Purpose of Paper

Very brief statement regarding purpose of the paper

Recommendations

If the box above has been crossed for “Decision” then state clearly what decision is being requested of the Committee.

Board Assurance Framework Risk Reference

Financial Impact

Further Information and Appendices

What is the issue? Include analysis and insight.What actions are being taken to address the issue? Include evidence.What impact are the actions expected to have?


Monitoring Information Brief Summary

What are the Governor Involvement implications?

What are the Equality, Diversity and Inclusion implications?

What are the Patient, Public, Staff, Member and Stakeholder Involvement implications?

Risk Register

Is the issue on the current Risk Register?

Yes/ No(Delete as appropriate)

If yes, what is the Risk Number?

Does this update recommend a change in the current risk score? (If so, please provide your rationale below)

Yes/ No(Delete as appropriate)


Appendix D

COUNCIL OF GOVERNORS MEETING COVER SHEETTitle of Paper:

Paper for: Information/Discussion/Approval/Decision/Other

Presenter:

Author:

Date of Meeting: Date goes here AgendaItem No:

No of pagesinc. this one:

Appendices:

Purpose of Paper

Summary

Recommendations


Appendix E

Minutes of the (name of meeting) Meeting held on (date of meeting) in the (name of room and/or venue), at (start and finish times)

Present Name Job titleNote : If a person has joined or left the meeting at different time to the start and finish times, this should be noted

Apologies

Not Present

In Attendance

Item Description Action

Date and Time of Future meetings


Appendix F

NAME OF MEETINGACTIONS MATRIX

DATE:Date/Item No:

Item/subject: Decision takenand/or action required:

Progress: Responsible Person:

Deadline: Outcome:

Derbyshire Community Health Services NHS Foundation Trust ~ Corporate Governance Manual 154

Appendix GSummary Report from …………………………….Committee/Group

Report To:Date:Name of Reporting Committee / Group:Date of Meeting:Presenter:Author:

This paper is for Assurance

Key Issues discussed at meeting:Include:

Brief summary of issue Decision made/action to be taken Agenda number and title of paper Risks identified

Board Assurance Framework Reference and Level of Assurance Agreed

Examples:

Care Quality Commission ProgressThe Committee was updated regarding the current position of the CQC action plan. DCHS are now fully compliant with the CQC requirements. (1/15 CQC Progress Report)

1.2.1 - There is a risk to patients due to failure to provide services that are clinically effective and of high quality. Full Assurance.

Pressure Ulcer PerformanceInsufficient information was available for the Committee to understand the causes of the performance.Action: the Committee requested further detailed information to fully understand the issue – to be presented to the next QSC meeting. (2/15 Quality Report 2/15)

1.1.2: There is a risk to patients due to exposure to unsafe care resulting in harmLimited Assurance

Policies Approved

Issues to be escalated to Board or a Committee


Appendix HDCHS xxxxxxxxxxxxxxxxxxxx COMMITTEE – TIMETABLE

xxxxxxxxxxxxxxxxxxx Committee meetings are held on a xxxxxxxxxxx basis commencing xxxxxxxxx on the xxxxxxxxxxx

The following timetable shows the dates of the meetings throughout xxxxxx and the dates when agenda papers are issued. Please ensure that papers and accompanying front sheets are e-mailed to xxxxxxxxxxxxxxxxxxxx by the dates shown in the table below.

Agenda Setting Request Papers Papers Deadline Agenda and papers sent out

Date ofMeeting
