standing financial instructions

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Appendix A

STANDING FINANCIAL INSTRUCTIONS

STANDING FINANCIAL INSTRUCTIONS

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1. INTRODUCTION General Terminology Responsibilities and Delegation 2. AUDIT Audit Committee Fraud, Bribery and Corruption Executive Director of Finance Role of Internal Audit External Audit 3. BUSINESS PLANNING, BUDGETS, BUDGETARY CONTROL AND MONITORING Preparation and approval of Business Plans and Budgets Budgetary Delegation Budgetary Control and Reporting Capital Expenditure Monitoring Returns 4. ANNUAL ACCOUNTS AND REPORTS 5. BANK ACCOUNTS General Bank Accounts Banking Procedures Tendering and Review 6. INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE INSTRUMENTS Income Systems Fees and Charges Debt Recovery Security of Cash, Cheques and other Negotiable Instruments 7. CONTRACTING FOR PROVISION OF SERVICES NHS Service Agreements NHS Non Commercial Agreements 8. TERMS OF SERVICE AND PAYMENTS OF DIRECTORS AND EMPLOYEES Remuneration and Terms of Service Funded Establishment Staff Appointments Payroll Contracts of Employment 9. NON PAY EXPENDITURE Delegation of Authority Choice, Requisitioning, Ordering, Receipt & Payment for Goods and

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Services 10. EXTERNAL BORROWING AND INVESTMENT Public Dividend Capital Commercial Borrowing and Investment Investment of Temporary Cash Surplus 11. CAPITAL INVESTMENT, PRIVATE FINANCING, FIXED ASSET REGISTERS AND SECURITY OF ASSETS Capital Investment Private Finance Asset Registers Protected Property Security of Assets 12. STORES AND RECEIPT OF GOODS 13. DISPOSALS & CONDEMNATIONS, LOSSES AND SPECIAL PAYMENTS Disposals and Condemnations Losses and Special Payments Insurance 14. INFORMATION TECHNOLOGY 15. PATIENTS’ PROPERTY 16. ACCEPTANCE OF GIFTS BY STAFF 17. RETENTION OF DOCUMENTS 18. RISK MANAGEMENT AND INSURANCE

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1. INTRODUCTION 1.1 General

1.1.1 These Standing Financial Instructions (SFIs) are issued in accordance with the

Financial Directions issued by the Secretary of State under the provisions of

Sections 99(3), 97(A)(4) and (7) of the National Health Service Act 1977 for the

regulation of the conduct of the Trust in relation to all financial matters. the Financial

Directions issued by the Secretary of State – under the provisions of the NHS Act

2006 (as amended by the Health and Social Care Act 2012) – for the regulation of

the conduct of the Trust in relation to all financial matters. They shall have effect as if

incorporated in the Standing Orders (SOs) of the Trust. 1.1.2 These SFIs detail the financial responsibilities, policies and procedures to be

adopted by the Trust. They are designed to ensure that its financial transactions are carried out in accordance with the law and Government policy in order to achieve probity, accuracy, economy, efficiency and effectiveness. They should be used in conjunction with the Reservations of Powers to the Board and the Scheme of Delegation to Group Committees in Common.

1.1.3 These SFIs identify the financial responsibilities that apply to everyone working for

the Trust and its constituent organisations including Trading Units These SFI’s also apply to the Services “Hosted” by the Trust as if they are a part of the core business. They do not provide detailed procedural advice. These statements should therefore be read in conjunction with the detailed departmental and financial procedure notes. All financial procedures in place within the Trust, both inside the Finance Department and in other Departments of the Trust, must be approved by the Chief Financial Officer.

1.1.4 Should any difficulties arise regarding the interpretation or application of any of the

SFIs then the advice of the Executive Director of Finance MUST BE SOUGHT BEFORE ACTING. The user of these SFIs should also be familiar with and comply with the provisions of the Trust's Standing Orders (SOs).

1.1.5 FAILURE TO COMPLY WITH SFIs AND SOs IS A DISCIPLINARY MATTER

WHICH COULD RESULT IN DISMISSAL. 1.1.6 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 Committee for referring action or ratification. All members of the Board of Directors and staff have a duty to disclose any non-compliance with these Standing Financial Instructions to the Executive Director of Finance as soon as possible.

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1.2 Terminology 1.2.1 Any expression to which a meaning is given in Health Service Acts, or in the Financial

Directions made under the Acts, shall have the same meaning in these instructions. The following terms apply equally to the SFI and the SORD:

a) “Principal Accounting Officer” means the Officer responsible and accountable

for funds entrusted to the Trust in accordance with the role of Accounting Officer

for Salford Royal NHS Foundation Trust role of Accountable Officer for The

Pennine Acute Hospitals NHS Trust . He shall be responsible for ensuring the

proper stewardship of public funds and assets. This shall be the Chief Executive.

b) "Board " means the Board of Directors of the Salford Royal NHS Foundation

Trust the Trust Board of The Pennine Acute Hospitals NHS Trust

c) "Budget" means a resource, expressed in financial terms, proposed by the Board

for the purpose of carrying out, for a specific period, any or all of the functions of the Trust;

d) "Budget Holder" means the director or employee with delegated authority to

manage finances for a specific area of the organisation;

e) "Care Organisation Management Board" means the most senior decision making committee of the Care Organisation;

f) "Chief Financial Officer" means the Chief Financial Officer of the Group

Committees in Common;

g) “Chief Executive" means the Chief Executive Officer of the Trust;

h) "Director of Finance" means the most senior financial officer of the Care Organisation;

i) "Executive Director of Finance" means the most senior financial officer of the

Trust;

j) “Funds held on trust” shall mean those funds which the Trust holds on the date of incorporation, receives on distribution by statutory instrument or chooses subsequently to accept under powers derived under S.90 of the NHS Act 1977, as amended. Such funds may or may not be charitable.

k) “Group CiC” – means Group Committees in Common l) “Hosted Services” means services that the Trust provides the full range of

support services to but which is not part of Trust core healthcare activity. m) “Independent Regulator” means NHS Improvement, Monitor and the Trust

Development Authority.

n) "Legal Adviser" means the properly qualified person appointed by the Trust to provide legal advice.

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o) “SFIs” – means Standing Financial Instructions.

p) "Trust" means the Salford Royal NHS Foundation Trust The Pennine Acute

Hospitals NHS Trust

1.2.2 Wherever the title Chief Executive, Chief Financial Officer, Executive Director of

Finance, or other nominated officer is used in these instructions, it shall be deemed to include such other Director or employee who have been duly authorised to represent them.

1.2.3 Wherever the term "employee" is used and where the context permits it shall be

deemed to include employees of third parties contracted to the Trust when acting on behalf of the Trust.

1.3 Responsibilities and Delegation 1.3.1 The Board exercises financial supervision and control by: (a) formulating the financial strategy, which is articulated through the Annual Plan, (b) setting the Standing Orders and Standing Financial instructions for the

regulation of its financial proceedings and business, and (c) defining specific responsibilities placed on directors and employees as

indicated in the Detailed Scheme of Delegation document. 1.3.2 The Board has resolved that certain powers and decisions may only be exercised by

the Board in formal session. These are set out in the “Reservations of Powers to the Board”.

1.3.3 The Board will delegate responsibility for the performance of its functions in

accordance with the Scheme of Delegation. 1.3.4 Within the SFIs, it is acknowledged that the Chief Executive is ultimately accountable

to the Board and as accountable office to the Secretary of State, for ensuring that the Board meets its obligations to perform its functions with the available financial resources. The Chief Executive has overall executive responsibility for the Trust's activities, is responsible to the Board for ensuring that its financial obligations and targets are met and has overall responsibility for the Trust’s system of internal control.

1.3.5 The Chief Executive and Executive Director of Finance will, as far as possible,

delegate their detailed responsibilities but they remain accountable for financial control and the powers vested in them by the Board or the Independent Regulator.

1.3.6 It is a duty of the Chief Executive to ensure that existing directors and employees

and all new appointees are notified of and understand their responsibilities within these Instructions.

1.3.7 The Executive Director of Finance is responsible for:

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(a) implementing the Trust 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

transactions, in order to disclose, with reasonable accuracy, the financial position of the Trust at any time,

and, without prejudice to any other functions of directors and employees to the

Trust, the duties of the Executive Director of Finance include:

(d) the provision of financial advice to the Trust and its directors, employees and

governors.

(e) the design, implementation and supervision of systems of internal financial

control, and (f) 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.

1.3.8 All directors and employees, 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 Standing Orders, Standing Financial

Instructions, Financial Procedures and the Scheme of Delegation. 1.3.9 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.

1.3.10 For any and all directors and employees who carry out a financial function, the form

in which financial records are kept and the manner in which directors and employees discharge their duties must be to the satisfaction of the Executive Director of Finance.

SECTION 2 AUDIT

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2.1 Audit Committee 2.1.1 In accordance with Standing Orders, the Board shall formally establish an Audit

Committee, with clearly defined terms of reference, which will provide an independent and objective view of internal control by:

(a) overseeing Internal and External Audit services

(b) receiving the annual management letter received from the external auditor and agree proposed action,

(c) receiving an annual report from the Internal Auditor and agree action on recommendations where appropriate

(d) reviewing financial systems and monitoring the integrity of the financial statements and reviewing significant financial reporting judgments;

(e) reviewing the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the organisation’s activities (both clinical and non-clinical), that supports the achievement of the organisation’s objective.

(f) monitoring compliance with Standing Orders and Standing Financial Instructions,

(g) reviewing schedules of losses and compensations and making

recommendations to the Group CIC.

(h) reviewing schedules of debtors/creditors balances over 6 months old and £10k and explanations/action plans.

(i) reviewing and approving accounting policies

(j) review and approving write-off of non-NHS debtors

(k) reviewing the arrangements in place to support the Assurance Framework process prepared on behalf of the Group CiC and advising the Group CiC accordingly.

(l) reviewing the arrangements in place for Counter Fraud, Bribery and Corruption by receiving the annual work plan and report and by receiving information regarding on-going cases.

(m) reviewing the effective implementation of corporate governance measures to

enable the Trust to implement best practice as set out in appropriate guidance. This will include the Assurance Framework and control related disclosure statements, for example the Annual Governance Statement and supporting assurance process; together with any accompanying audit statements, prior to endorsement by the Board of Directors.

2.1.2 Where the Audit Committee feels there is evidence of ultra vires transactions,

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evidence of improper acts, or if there are other important matters that the committee wishes to raise, the Chairman of the Audit Committee should raise the matter at a full meeting of the Group CiC.

2.1.3 It is the responsibility of the Executive Director of Finance to ensure adequate

internal and external audit services are provided and the Audit Committee shall be

involved in the selection process when an audit service provider is changed, with the

selection process for External Auditors being the responsibility of the Council of

Governors, guided by the Executive Director of Finance and Audit Committee.

2.2 Fraud, Bribery and Corruption 2.2.1 The Trust shall take all necessary steps to ensure that NHS funds and resources are

protected and safeguarded against those minded to commit fraud, bribery and corruption and that appropriate measures to combat fraud, bribery and corruption are put in place in accordance with its requirement to comply with all the Standards for Providers for Fraud Conditions 24 of the NHS Standard Contract in accordance with;

a) the NHS Anti-Fraud Manual published by the NHS Protect; b) the policy statement “Applying appropriate sanctions consistently

published by NHS Protect;

c) any other reasonable guidance or advice issued by NHS Protect that affects efficiency, systemic and/or procedural matters.

The Chief Executive and Executive Director of Finance shall monitor and ensure compliance with the above.

2.2.2 In line with their responsibilities, the Chief Executive and Executive Director of Finance is responsible for overseeing and providing strategic management and support for all anti-fraud, bribery and corruption work..

2.2.3 The Trust shall contract in an accredited, nominated person (or persons) to undertake the full range of anti-fraud, bribery and corruption work as detailed in four key sections that follow NHS Protect’s strategy and shall report to the Executive Director of Finance regarding all aspects of anti-fraud, bribery and corruption wok carried out.

2.2.4 The Anti-Fraud Specialist will develop an Annual Workplan that details the activities to be undertaken across the four key areas and shall provide a written report, at least annually, detailing progress on anti-fraud, bribery and corruption work carried out.

2.3 Executive Director of Finance 2.3.1 The Executive Director of Finance 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,

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(b) ensuring that the internal audit is adequate and meets the NHS mandatory audit standards,

(c) ensuring that there are arrangements in place to involve the police, as

necessary, in cases of fraud, bribery, misappropriation, and other irregularities,

(d) ensuring that annual internal audit reports are prepared (which include the

Head of Internal Audit Opinion, Annual Report and Internal Audit Plans) for the consideration of the Audit Committee and the Board of Directors. These reports must cover:

(i) a clear statement on the overall adequacy and effectiveness of the

organisation’s framework of governance, risk management and internal control;

(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) strategic audit plan covering the coming three years, (vi) a detailed plan for the coming year. 2.3.2 The Executive Director of Finance and/or designated internal auditors are 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 employee of the Trust, (c) the production of any cash, stores or other property of the Trust under an

employee's control, and (d) explanations concerning any matter under investigation. 2.4 Role of Internal Audit 2.4.1 Internal Audit will review, appraise and report upon: (a) the extent of compliance with, and the financial effect of, relevant established

policies, plans and procedures, (b) the adequacy and application of financial and other related management

controls, (c) the suitability of financial and other related management data,

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(d) the extent to which the Trust’s assets and interests are accounted for and safeguarded from loss of any kind, arising from:

(i) fraud, bribery, corruption and other offences,

(ii) waste, extravagance, inefficient administration,

(ii) poor value for money or other causes.

2.4.2 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 Executive Director of Finance must be notified immediately.

2.4.3 The Head of Internal Audit will normally attend Audit Committee meetings and has a

right of access to all Audit Committee members, the Chairman and Chief Executive of the Trust.

2.4.4 The Head of Internal Audit shall be accountable to the Executive Director of

Finance. The reporting system for internal audit shall be agreed between the Executive Director of Finance, the Audit Committee and the Head of Internal Audit. The agreement shall be in writing and shall comply with the guidance on reporting contained in the Public Sector Internal Audit Standards. The reporting system shall be reviewed at least every 3 years.

2.4.5 Where, in exceptional circumstances, the use of normal reporting channels is

thought to limit the objectivity of the audit, the Head of Internal Audit shall have access to report direct to the Chairman or a non-executive member of the Trust’s Audit Committee.

2.4.5 Managers in receipt of audit reports referred to them have a duty to take appropriate

remedial action within the agreed time-scales specified within the reports. The Executive Director of Finance shall identify a formal review process to monitor the extent of compliance with the audit recommendations. Where appropriate remedial action has failed to take place within a reasonable time period the matter shall be reported to the Executive Director of Finance.

2.5 External Audit

2.5.1 The external auditor is appointed by the Council of Governors the Trust Board

and paid for by the Trust. 2.5.2 The Code of Audit Practice (“The Audit Code”) contains directions of the

Comptroller and Auditor General under Schedule 13(3)(1) and Schedule 6 of the

Local Audit and Accountability Act 2014 with respect to the standards, procedures and techniques to be adopted by the auditor.

2.5.3 The Trust shall comply with Schedule 10 of the NHS Act 2006 (Audit of Accounts

of NHS Foundation Trusts) and the specific provisions within Monitor’s NHS

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Foundation Trust Code of Governance C3. Audit Committee and Auditors.

2.5.4 The Auditor shall comply with the Audit Code. 2.5.5 References 2.4.3 and 2.4.5. relate equally to internal and external audit. 2.5.6 In the event of the Auditor issuing a Public Interest report the Auditor shall send

the report as soon as reasonably practical after it is made to the Trust and the

Secretary of State immediately or within 14 days of the conclusion of the audit

where not an immediate report to the Council of Governors of the Trust, the Board

of Directors of the Trust and NHS Improvement.

2.6 Security Management 2.6.1 In line with their responsibilities, the Trust Chief Executive will monitor and ensure

compliance with Directions issued by the Secretary of State for Health on NHS security management.

2.6.2 The Trust shall nominate a suitable person to carry out the duties of the Local

Security Management Specialist (LSMS) as specified by the Secretary of State for Health guidance on NHS security management.

2.6.3 The Trust shall nominate a Non-Executive Director to be responsible to the Board for NHS security management.

2.6.4 The Chief Executive has overall responsibility for controlling and coordinating security. However, key tasks are delegated to the Director of Estates and Facilities and the Areas Security Management Specialist (ASMS) together with the appointed Local Security Management Specialist (LSMS).

SECTION 3 SERVICE PLANNING, BUDGETS, BUDGETARY CONTROL, AND MONITORING 3.1 Preparation and approval of Business Plans and Budgets 3.1.1 The Chief Executive will compile and submit to the Board of Directors an Annual

Plan document which encompasses an annual business plan and takes into account financial targets and forecast limits of available resources. The annual business plan will contain:

(a) a statement of the significant assumptions on which the plan is based;

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

3.1.2 Prior to the start of the financial year, the Executive Director of Finance will, on

behalf of the Chief Executive, prepare and submit budgets for approval by the Board. Such budgets will:

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(a) be in accordance with the aims and objectives set out in the Trust’s annual business plan, and the local commissioning intentions (or equivalent documents).

(b) accord with workload and manpower plans, (c) be produced following discussion with appropriate budget holders,

(d) be prepared within the limits of available funds, and

(e) identify potential risks

(f) be based on reasonable and realistic assumptions. (g) enable the Trust to comply with the requirements set out by the independent

regulator. 3.1.3 The Chief Financial Officer shall monitor financial performance against budget and

business plan, periodically review them, and report to the Group CiC. Any significant variances should be reported by the Chief Financial Officer to the Group CiC as soon as they come to light and the Group CiC shall be advised of actions to be taken in respect of such variances.

3.1.4 All budget holders must provide information as required by the Executive Director of

Finance to enable budgets to be compiled. On completion of the budget setting all budget holders will be asked to confirm in writing their acceptance of their allocated budgets at the start of the financial year.

3.1.5 The Executive Director of Finance has a responsibility to ensure that adequate

training is delivered on an on-going basis to budget holders to help them manage successfully.

3.2 Budgetary Delegation 3.2.1 The Chief Executive may delegate the management of a budget to permit the

performance of a defined range of activities, including pooled budget arrangements under Section 75 of the 2006 Act. 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, and (f) the provision of regular reports.

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3.2.2 The Chief Executive and delegated budget holders must not exceed the budgetary total or virement limits set by the Board.

3.2.3 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. 3.2.4 Non-recurring budgets should not be used to finance recurring expenditure without

the authority in writing of the Chief Executive. 3.3 Budgetary Control and Reporting 3.3.1 The Executive Director of Finance will devise and maintain systems of budgetary

control. These will include: (a) monthly financial reports to the Group CiC in a form approved by the Group

CiC containing: ‐ income and expenditure to date showing trends and forecast year-

end position ‐ movements in working capital ‐ movements in cash and capital ‐ capital project spend and projected outturn against plan ‐ expectations of any material variances from plan ‐ details of any corrective action where necessary and the Chief

Executives and/or Chief Financial Officer’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, and

(e) arrangements for the authorisation of budget transfers.

(n) advising the Chief Executive of the consequences of changes in policy, pay awards and other events and other trends affecting budgets and shall advise on the economic and financial impact of future plans and projects; and

(o) review of the bases and assumptions used to prepare the budgets.

In performance of these duties the Executive Director of Finance will have access to

all budget holders and budget managers on budgetary matters and shall be provided with such financial and statistical information as is necessary.

3.3.2 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,

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(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, and

(c) no permanent employees are appointed without the approval of the Chief

Executive other than those provided for in the budgeted establishment as approved by the Board of Directors.

(d) that any proposal to increase revenue spending has an appropriate funding

stream identified and that this has been agreed by the Chief Executive. Proposals to increase revenue spending should also be signed off by the Executive Director of Finance. This applies to all revenue developments whether part of the Commissioning Intentions [or other appropriate plans of commissioners] discussions or separate initiatives, however funded.

3.3.3 The Chief Executive is responsible for identifying and implementing cost

improvements and income generation initiatives in accordance with the requirements of the Annual Plan and in accordance with the financial plan.

3.4 Capital Expenditure 3.4.1 The general rules applying to delegation and reporting shall also apply to capital

expenditure. (The particular applications relating to capital are contained in Section 11.)

3.5 Monitoring Returns 3.5.1 The Chief Executive is responsible for ensuring that the requisite monitoring forms

are submitted to the appropriate monitoring organisation within the required time-scale.

SECTION 4 ANNUAL ACCOUNTS AND REPORTS 4.1 The Executive Director of Finance, on behalf of the Trust, will: (a) keep accounts, and in respect of each financial year must prepare annual

accounts, in such form as the Independent Regulator may, with the approval of the Treasury, direct.

(b) ensure that, in preparing the annual accounts, the Trust complies with any

directions given by the Independent Regulator Department of Health with the

approval of the Treasury as to;

the methods and principles according to which the accounts are to be prepared and

the information given in the accounts (c) ensure that a copy of the annual accounts and any report by the external

auditor on them, are laid before Parliament and that copies of these

documents are sent to the Independent Regulator Department of Health,

within the prescribed timetable.

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4.2 The Trust will prepare annual reports as required by the NHS Foundation Trust Annual

Reporting Manual Department of Health Group Accounting Manual. This will be

received by the Council of Governors at a public meeting. The Trust will publish an

annual report, in accordance with guidelines on local accountability, and present it at a

public meeting. A copy will be forwarded to the Independent Regulator Department of

Health.

SECTION 5 BANK ACCOUNTS 5.1 General 5.1.1 The Executive Director of Finance is responsible for managing the Trust’s banking

arrangements and for advising the Trust on the provision of banking services and operation of accounts. This advice will take into account guidance/ directions issued from time to time by the Independent Regulator.

5.1.2 The Group CiC shall approve the banking arrangements other than mandated

government banking service accounts where any proposed changes will be reported to the Audit Committee.

5.1.3 No employee may open or hold a bank account in the name of the Trust or of its

constituent hospitals/departments. Any employee aware of the existence of such an account shall report the matter to the Executive Director of Finance.

5.2 Bank Accounts 5.2.1 The Executive Director of Finance is responsible for: (a) bank accounts and Government Banking Services (GBS) [accounts and other

forms of working capital that may be available]. (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. The GBS accounts (one for payments and one for receipts) are treated as one account for the purposes of calculating the overall balance,

(d) reporting to the Group CiC of any external borrowing requirements

(e) ensuring that best value is obtained in securing loan finance and other sources of external funding, including Working Capital funding.

(f) monitoring compliance with DH guidance on the level of cleared funds. 5.3 Banking Procedures

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5.3.1 The Executive Director of Finance will prepare detailed instructions on the operation

of bank and GBS accounts, which must include: (a) the conditions under which each bank and GBS account is to be operated, (b) the limit to be applied to any overdraft, and

(c) those authorised to sign cheques or other orders drawn on the Trust’s accounts.

(d) the policy and terms of operation of any Working Capital facility or working

capital funding support in place

5.3.2 The Executive Director of Finance must advise the Trust’s bankers in writing of the conditions under which each account will be operated.

5.4 Tendering and Review of Banking Services 5.4.1 The Executive Director of Finance will review the 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.

5.4.2 Competitive tenders should be sought at least every 5 years unless the Board

determines otherwise. The results of the tendering exercise should be reported to the Group CiC.

SECTION 6 INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND OTHER

NEGOTIABLE INSTRUMENTS

6.1 Income Systems 6.1.1 The Executive Director of Finance is responsible for designing, maintaining and

ensuring compliance with systems for the proper recording, invoicing, collection and coding of all monies due.

6.1.2 The Executive Director of Finance is also responsible for the prompt banking of all

monies received. 6.1.3 Self-funding private patients and overseas visitors (who are required to pay for their

treatment) will be required to make a pre-payment equal to the estimated cost of treatment prior to admission.

6.2 Fees and Charges 6.2.1 The Trust shall follow the Department of Health advice in the Payment by Results

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(PBR) guidelines and code of conduct in setting prices for NHS Service contracts. 6.2.2 The Executive Director of Finance is responsible for approving and regularly

reviewing the level of all fees and charges other than those determined by the Department of Health or by Statute. Independent professional advice on matters of valuation may be taken as necessary.

6.2.3 All employees must inform the Executive Director of Finance promptly of money due

arising from transactions which they initiate/deal with, including all contracts, leases, tenancy agreements, private patient undertakings and other transactions.

6.3 Debt Recovery 6.3.1 The Executive Director of Finance is responsible for the appropriate recovery action

on all outstanding debts. 6.3.2 Income not received should be dealt with in accordance with losses procedures. 6.3.3 Overpayments should be detected (or preferably prevented) and recovery initiated in

line with Trust policy. 6.4 Security of Cash, Cheques and other Negotiable Instruments 6.4.1 The Executive Director of Finance is responsible for: (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 employees whose duties

include collecting and holding cash, including the provision of safes or lockable cash boxes, the procedures for keys, and for coin operated machines, and

(d) prescribing systems and procedures for handling cash and negotiable

securities on behalf of the Trust. 6.4.2 Official money shall not under any circumstances be used for the encashment of

private cheques. 6.4.3 All cheques, postal orders, cash etc., shall be banked intact. Disbursements shall

not be made from cash received, except under arrangements approved by the Executive Director of Finance. Organisations/Individuals owing monies to the Trust should be encouraged, wherever practical to make payment in the form of cheques rather than cash, such cheques should be crossed and made payable to the Trust.

6.4.4 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,

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and written indemnities must be obtained from the organisation or individuals absolving the Trust from responsibility for any loss.

6.4.5 Any loss or shortfall of cash, cheques or other negotiable instruments, however

occasioned, shall be monitored and recorded within the Finance Department. Any significant trends should be reported to the Executive Director of Finance and Internal Audit. Where there is prima facie evidence of fraud or corruption this should be dealt with using the Trust’s Anti Fraud, Bribery and Corruption Policy and the guidance provided by the NHS Protect. Where there is no evidence of Fraud, Bribery or Corruption it should be dealt with under the Trust’s Losses and Compensations procedures.

SECTION 7 CONTRACTING FOR PROVISION OF SERVICES 7.1 NHS Service Agreements 7.1.1 The Chief Executive of the Trust shall regularly review and shall at all times maintain

and ensure the capacity and capability of the Trust to provide mandatory goods and

services referred to in the Trust’s Licence Establishment Order.

7.1.2 The Chief Executive, as the accounting officer, is responsible for ensuring the Trust

enters into suitable legally binding Service Level Agreements with CCGs, NHS England and other commissioners for the provision of NHS services. The Trust will follow the priorities contained within the schedules of the contract, and wherever possible, be based upon integrated care pathways to reflect expected patient experience. In discharging this responsibility, the Chief Executive should take into account:

(a) the standards of service quality expected; (b) the relevant national service framework and other national guidance (if any);

(c) the provision of reliable information on cost and volume of services;

(d) the Performance Assessment Framework contained within the Trust Service

Level Agreements

(e) that Trust Service Level Agreements builds where appropriate on existing partnership arrangements;

7.1.3 A good Trust Service Level Agreement will result from a dialogue with clinicians,

users, carers, public health professionals and managers. It will reflect knowledge of local needs and inequalities. This will require the Chief Executive to ensure that the Trust works with all partner agencies involved in both the delivery and the commissioning of the service required.

7.1.4 The Chief Executive, as the accounting officer, will need to ensure that regular

reports are provided to the Group CiC detailing actual and forecast income from the Trust Service Level Agreements. This will include appropriate payment by results performance information, and other such information as deemed appropriate by the

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Executive Director of Finance

7.1.5 The Chief Executive, will ensure that Trust has in place suitable Service Level Agreements with other NHS Providers for both the delivery and receipt of services (known locally as Provider to Provider agreements). These agreements should be based upon the actual levels of service provided (or received) at an appropriate price to ensure all costs are covered). The Executive Director of Finance will ensure that appropriate systems are in place to agree and monitor such SLA’s on a regular basis.

7.2.1 Non Commercial Contracts 7.2.1 Where the Trust enters into a relationship with another organisation for the supply or

receipt of other services – clinical or non-clinical, the responsible officer should ensure that an appropriate non-commercial contract is present and signed by both parties.

7.2.2 This should incorporate:

(a) indicative activity levels and a description of the service

(b) the term of the agreement

(c) the value of the agreement

(d) the lead officers

(e) performance and dispute resolution procedures

(f) risk management and clinical governance arrangements

7.2.3 Non-commercial contracts should be reviewed and agreed on an annual basis or as determined by the term of the agreement so as to ensure value for money and to minimise the potential loss of income.

SECTION 8 TERMS OF SERVICE AND PAYMENT OF DIRECTORS AND EMPLOYEES 8.1 Remuneration and Terms of Service 8.1.1 In accordance with Standing Orders the Board of Directors shall establish a

Nominations, 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.

8.1.2 The Committee will:

(a) advise the Board on the appropriate remuneration options and terms of service for the Chief Executive and other Executive Directors (and any other

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employees specified within the Terms of Reference), including: (i) all aspects of salary (including any performance-related elements /

bonuses), (ii) provisions for other benefits, including pensions and cars,

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

(b) determine on behalf of the Board, noting that the terms of reference for the Nominations, Remuneration and Terms of Service Committee provide for the Chairman and all Non-Executive Directors to participate, the remuneration and terms of service of Executive Directors and any other employees specified within the Terms of Reference to ensure 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 staff where appropriate;

(c) monitor and evaluate the performance of individual Executive Directors (and

other senior employees); and (d) advise on and oversee appropriate contractual arrangements for such staff

including the proper calculation and scrutiny of termination payments taking account of such national guidance as is appropriate.

8.1.3 The Committee shall report in writing to the Group CiC the basis for its

recommendations. The Group CiC will report these to the Board of Directors who shall use the report as the basis for requirements for public disclosure in the Annual Report.

8.1.4 The Board of Directors is responsible for ensuring appropriate systems and

processes are in place for setting remuneration and conditions of service for those employees not covered by the Committee.

8.1.5 The Council of Governors at the General Meeting will decide the remuneration and

allowances and other terms and conditions of office of the Chairman and Non-

Executive Directors. The Trust will remunerate the Chairman and Non-Executive

Directors in accordance with instructions issued by the Secretary of State.

8.2 Funded Establishment 8.2.1 The workforce plans incorporated within the annual budget will form the funded

establishment. 8.2.2 The funded establishment of any department may not be varied without the approval

of the Chief Executive (subject to the limits set out in the Scheme of delegation). 8.3 Staff Appointments 8.3.1 No director or employee may engage, re-engage, or regrade employees, either on a

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permanent or temporary basis, or hire agency staff, or agree to changes in any aspect of remuneration unless:

(a) authorised to do so by the Chief Executive , or

(b) within the limit of the approved budget and funded establishment

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

8.4 Payroll 8.4.1 The Executive Director of Finance (via the Shared Services Provider) is responsible

for: (a) specifying timetables for submission of properly authorised time records and

other notifications, (b) the final determination of pay, (c) making payment on agreed dates, and (d) agreeing method of payment. 8.4.2 The Executive Director of Finance (via the shared services provider) 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, (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, (h) procedures for payment by cheque, bank credit, or cash to employees, (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

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accounts, (l) separation of duties of preparing records and handling cash, and (m) a system to ensure the recovery from leavers of sums of money and property

due by them to the Trust. 8.4.3 Appropriately nominated managers have delegated responsibility for: (a) submitting time records, and other notifications in accordance with agreed

timetables, (b) completing time records and other notifications in accordance with the

Executive Director of Finance's instructions and in the form prescribed by the Executive Director of Finance, and

(c) submitting termination forms in the prescribed form immediately upon knowing

the effective date of an employee's resignation, termination or retirement. Where an employee fails to report for duty in circumstances that suggest they have left without notice, the Executive Director of Finance must be informed immediately.

8.4.4 Regardless of the arrangements for providing the payroll service, the Executive

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

8.5 Contracts of Employment 8.5.1 The Board of Directors shall delegate responsibility to the Chief of Organisational

Development and Strategy for: (a) ensuring that all employees are issued with a Contract of Employment in a

form approved by the Board and which complies with employment legislation,

(b) dealing with variations to, or termination of, contracts of employment. SECTION 9 NON-PAY EXPENDITURE 9.1 Delegation of Authority 9.1.1 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 (via the Scheme of Delegation).

9.1.2 The Chief Executive will set out:

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(a) the list of managers who are authorised to place requisitions for the supply of goods and services, and

(b) the maximum level of each requisition and the system for authorisation above

that level. 9.1.3 The Executive Director of Finance shall set out procedures on the seeking of

professional advice regarding the supply of goods and services. 9.2 Choice, Requisitioning, Ordering, Receipt and Payment for Goods and

Services 9.2.1 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. In so doing, the advice of the Trust’s adviser on procurement shall be sought. Where this advice is not acceptable to the requisitioner, the Executive Director of Finance (and/or the Chief Executive) shall be consulted.

9.2.2 The Executive Director of Finance shall be responsible for the prompt payment of

accounts and claims. Payment of invoices shall be in accordance with contract terms, or otherwise, in accordance with national guidance.

9.2.3 The Executive Director of Finance will: (a) advise the Board of Directors regarding the setting of thresholds above which

quotations (competitive or otherwise) or formal tenders must be obtained; and, once approved, the thresholds should be incorporated in standing orders and regularly reviewed,

(b) ensure that procedural instructions on the obtaining of goods, works and

services (incorporating the thresholds) are prepared, distributed and regularly reviewed,

(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/employees (including safe procedures to accept

electronic authorisation) 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,

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- 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 Executive Director of

Finance of accounts for payment; provision shall be made for the early submission of accounts subject to cash discounts or otherwise requiring early payment.

(iv) instructions to employees regarding the handling and payment of

accounts within the Finance Department. (e) be responsible for ensuring that payment for goods and services is only made

once the goods and services are received (except as below). 9.2.4 Prepayments are only permitted where exceptional circumstances apply. In such

instances:

(a) Prepayments should demonstrate that the financial advantages outweigh the disadvantages

(b) the appropriate Executive Director 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 Executive Director of Finance will need to be satisfied with the proposed

scheme before contractual arrangements proceed (taking into account the EU public procurement rules where the contract is above the stipulated financial threshold) and

(d) the budget holder is responsible for ensuring that all items due under a

prepayment contract are received and he/she must immediately inform the appropriate Director or Chief Executive if problems are encountered.

9.2.5 Official Orders must: (a) be consecutively numbered, (b) be in a form approved by the Executive Director of Finance, and

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(c) state the Trust terms and conditions of trade 9.2.6 Managers must ensure that they comply fully with the guidance and limits specified

by the Executive Director of Finance and that: (a) all contracts other than for a simple purchase permitted within the Scheme of

Delegation or delegated budget, leases, tenancy agreements and other commitments which may result in a liability are notified to the Executive Director of Finance in advance of any commitment being made,

(b) contracts above specified thresholds are advertised and awarded in

accordance with EU rules on public procurement (c) where consultancy advice is being obtained, the procurement of such advice

must be in accordance with good practise, (d) no order shall be issued for any item or items to any company (or individual)

which has made an offer of gifts, reward or benefit to directors or employees, other than:

(i) isolated gifts of a trivial character or inexpensive seasonal gifts, such as

calendars,

(iv) conventional hospitality, such as lunches in the course of working visits, provided that any such gift / hospitality is in line with the guidance contained

within the Trust’s Standards of Business Conduct

(e) no requisition/order is placed for any item or items for which there is no budget

provision unless authorised by the Executive Director of Finance 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 an existing 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. Any equipment on loan to the Trust and/or on Trust property must be notified to the Executive Director of Finance, together with any conditions attached to the loan of that equipment.

(j) changes to the list of directors/employees authorised to certify invoices are

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notified to the Executive Director of Finance, (k) purchases from petty cash are restricted in value and by type of purchase in

accordance with instructions issued by the Executive Director of Finance, and (l) petty cash records are maintained in a form as determined by the Executive

Director of Finance. 9.2.7 The Executive Director of Finance shall ensure that the arrangements for financial

control and financial audit of building and engineering contracts and property transactions comply with current guidance. The technical audit of these contracts shall be the responsibility of the relevant Director.

9.2.8 Under no circumstances should goods or services be ordered through the Trust

for personal or private use. 9.3 Joint Finance Arrangements with Local Authorities and Voluntary Bodies 9.3.1 Payments to Local Authorities and voluntary organisations shall comply with

procedures laid down by the Executive Director of Finance which shall be in accordance with the relevant Acts.

SECTION 10 EXTERNAL BORROWING AND INVESTMENTS

10.1 Public Dividend Capital

10.2.1 On authorisation as a Foundation Trust the Public Dividend Capital held

immediately prior to authorisation continues to be held on the same conditions.

10.2.2 Additional Public Dividend Capital may be made available on such terms the

Secretary of State (with the consent of the Treasury) decides. 10.2.3 Draw down of Public Dividend Capital should be authorised in accordance with the

mandate held by the Department of Health Cash Funding Team, and is subject to approval by the Secretary of State.

10.2.4 The Trust shall be required to pay annually to the Department of Health a dividend

on its Public Dividend Capital at a rate to be determined from time to time, by the Secretary of State.

10.3 Commercial Borrowing and Investment

10.3.1 The Trust may borrow money from any commercial source for the purposes of or in

connection with its functions, subject to Board approval..

10.3.2 The Trust may invest money for the purposes of or in connection with its functions.

Such investment may include forming, or participating in forming, or otherwise

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acquiring membership of bodies corporate.

10.3.3 The Trust may also give financial assistance (whether by way of loan guarantee or

otherwise) to any person for the purposes of or in connection with its functions. This

must only be given under specific approval of the Executive Director of Finance on a

case by case basis.

10.4 Investment of Temporary Cash Surpluses 10.4.1 Temporary cash surpluses must be held only in such public and private sector

investments as set out in the approved Group policy. 10.4.2 The Care Organisations’ Finance and Information and Capital Committee is

responsible for monitoring compliance with the Group investment strategy and policy.

10.4.3 The Chief Financial Officer is responsible for advising on investments and shall

report periodically to the Group CiC concerning the performance of investments held.

10.4.4 The Chief Financial Officer will prepare detailed procedural instructions on

investment operations and on the records to be maintained. The Group’s Treasury Management Policy will incorporate guidance from the Independent Regulator as appropriate.

10.5 Working Capital Facility 10.5.1 The Trust may choose to have funds are available for short-term cash flow

management by negotiating an irrevocable Working Capital Facility with a lender.

SECTION 11

CAPITAL INVESTMENT, PRIVATE FINANCING, FIXED ASSET REGISTERS AND SECURITY OF ASSETS 11.1 Capital Investment 11.1.1 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 business plans,

(b) shall ensure that management arrangements are in place in line with the

Capital Development Booklet Series (c) is responsible for the management of all stages of capital schemes and for

ensuring that schemes are delivered on time and to cost, and (d) shall ensure that the capital investment is not undertaken without confirmation

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of commissioners support and the availability of resources to finance all revenue consequences, including capital charges.

11.1.2 For every major capital expenditure proposal (as defined in the Scheme of

Delegation) the Chief Executive shall ensure: (a) 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, and (ii) appropriate project management and control arrangements, and (b) that the Executive Director of Finance has certified professionally the costs

and revenue consequences detailed in the business case. 11.1.3 For capital schemes where the contracts stipulate stage payments, the Chief

Executive will issue procedures for their management The Executive Director of Finance shall issue procedures for the regular reporting of

actual expenditure and commitment against authorised expenditure. 11.1.4 The Group CiC approves the capital programme. In year monitoring will be will be

undertaken by the relevant Group and Care Organisation capital committee on a monthly basis. Should a tender value be in excess of the value in the approved capital then this will be taken back to the Group CiC for Approval

The Chief Executive shall issue to the manager responsible for any scheme (within

the framework set out above): (a) specific authority to commit expenditure, (b) authority to proceed to tender, (c) approval to accept a successful tender. The Chief Executive will issue a scheme of delegation for capital investment

management in accordance with the Trust’s Standing Orders. 11.1.5 The Chief Financial Officer shall issue procedures governing the financial

management, including variations to contract, of capital investment projects and valuation for accounting purposes.

11.2 Private Finance 11.2.1 The Group CiC should normally test for PFI when considering capital procurement.

When the Group CiC proposes to use finance that is to be provided other than through its allocations, the following should apply:

(a) The Chief Financial Officer shall demonstrate that the use of private finance

represents value for money and genuinely transfers significant risk to the private sector.

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(b) The proposal must be specifically agreed by the Group Group CiC.

(c) Where the sum involved exceeds delegated limits, the business case must be

referred to the appropriate external reviewer. 11.3 Asset Registers 11.3.1 The Chief Executive is responsible for the maintenance of registers of assets, taking

account of the advice of the Chief Financial Officer concerning the form of any register and the method of updating, and arranging for a physical check of assets against the asset register to be conducted once a year.

11.3.2 The Trust will maintain an asset register recording fixed assets. The minimum data

set to be held within these registers shall be as specified in the Capital Charges Manual as issued by the Independent Regulator.

11.3.3 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, and (c) lease agreements in respect of assets held under a finance lease and

capitalised. 11.3.4 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).

11.3.5 The Chief Financial Officer shall approve procedures for reconciling balances on

fixed assets accounts in ledgers against balances on fixed asset registers. 11.3.6 The value of each equipment asset shall be indexed to current values using

current Department of Health published indices. 11.3.7 The value of each asset shall be depreciated using methods and rates as specified

in the relevant Annual Reporting Manual issued by the Independent Regulator. 11.3.8 The Chief Financial Officer shall calculate and pay capital charges as specified by

the Department of Health and / or Independent Regulator

11.4 Property used to deliver Commissioner Requested Services

11.4.1 A register of property is maintained setting out property used to deliver commissioner

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requested services (“protected” property). 11.4.2 The Trust must have regard to Independent Regulator’s current guidance on

arrangements to dispose of protected property should it decide that such property is surplus to requirement

11.5 Security of Assets 11.5.1 The overall control of fixed assets is the responsibility of the Chief Executive. 11.5.2 Asset control procedures (including fixed assets, cash, cheques and negotiable

instruments, and also including donated assets) must be approved by the Chief Financial Officer. 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, and (g) reporting, recording and safekeeping of cash, cheques, and negotiable

instruments. 11.5.3 The up to date maintenance and annual checking of asset records is the

responsibility of the designated budget holder for all items for which the initial purchase or replacement is within their responsibility. All discrepancies revealed by verification of physical assets to fixed asset register shall be notified to the Executive Director of Finance.

11.5.4 Whilst each employee has a responsibility for the security of property of the Trust, it

is the responsibility of directors and senior employees in all disciplines to apply such appropriate routine security practices in relation to NHS property as may be determined by the Group CiC. Any breach of agreed security practices must be reported in accordance with instructions.

11.5.5 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.

11.5.6 Where practical, assets should be marked as Trust property.

SECTION 12

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STORES AND RECEIPT OF GOODS 12.1 Stores, defined in terms of controlled stores and departmental stores (for immediate

use) should be:

(a) kept to a minimum, (b) subjected to annual stocktake, (c) valued at the lower of cost and net realisable value. 12.2 Subject to the responsibility of the Executive Director of Finance for the systems of

control, overall responsibility for the control of stores shall be delegated to an employee by the Chief Executive. The day-to-day responsibility may be delegated to departmental employees and stores managers/keepers, subject to such delegation being entered in a record available to the Executive Director of Finance. The control of Pharmaceutical stocks shall be the responsibility of a designated Head of Pharmacy; the control of fuel oil and coal of a designated Estates Manager.

12.3 The responsibility for security arrangements and the custody of keys for all stores

and locations shall be clearly defined in writing by the designated manager / Head of Pharmacy. Wherever practicable, stocks should be marked as health service property.

12.4 The Chief Financial Officer shall set out procedures and systems to regulate the

stores including records for receipt of goods, issues, and returns to stores, and losses.

12.5 Stocktaking arrangements shall be agreed with the Executive Director of Finance

and there shall be a physical check covering all items in store at least once a year. 12.6 Where a complete system of stores control is not justified, alternative arrangements

shall require the approval of the Executive Director of Finance. 12.7 The designated Manager / Head of Pharmacy shall be responsible for a system

approved by the Executive Director of Finance 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 Executive Director of Finance any evidence of significant overstocking and of any negligence or malpractice (see also 13 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.

12.8 For goods supplied via the NHS Supply Chain, 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 Executive Director of Finance who shall satisfy himself that the goods have been received before accepting the recharge.

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DISPOSALS AND CONDEMNATIONS, LOSSES AND SPECIAL PAYMENTS 13.1 Disposals and Condemnations 13.1.1 The Executive Director of Finance must prepare detailed procedures for the disposal

of assets including condemnations, and ensure that these are notified to managers. 13.1.2 When it is decided to dispose of a Trust asset, the head of department or authorised

deputy will determine and advise the Executive Director of Finance of the estimated market value of the item, taking account of professional opinion including that of the Trust’s supply adviser where appropriate.

13.1.3 Where it is proposed to dispose or sell an asset that may impact on the delivery of a

protected service, then prior Authorisation is required from key stakeholders. 13.1.4 All unserviceable articles shall be: (a) condemned or otherwise disposed of by an employee authorised for that

purpose by the Executive Director of Finance, (b) recorded by the Condemning Officer in a form approved by the Executive

Director of Finance 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 Executive Director of Finance.

13.1.5 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 Executive Director of Finance who will take the appropriate action.

13.2 Losses and Special Payments 13.2.1 The Chief Financial Officer must prepare procedural instructions on the recording of

and accounting for condemnations, losses, and special payments. The Executive Director of finance must also prepare a ‘fraud response plan’ that sets out the action to be taken both by persons detecting a suspected fraud and those persons responsible for investigating it.

13.2.2 Any employee discovering or suspecting a loss of any kind must either immediately

inform their head of department, who must immediately inform the Chief Executive. In the case of discovering or suspecting fraud, bribery or corruption, the employee mustcontact the Trust’s Anti- Fraud Specialist who will ensure that the Executive Director of Finance is informed in accordance with the Trust’s Anti-Fraud, Bribery and Corruption Policy and Response Plan. Where a criminal offence is suspected, the Executive Director of Finance must immediately inform the police if theft or arson is involved. In cases of fraud, bribery or corruption the Anti-Fraud Specialist will record the allegation on the NHS Protect’s Fraud Investigation and Reporting System Toolkit (FIRST) in accordance with the Standards for Providers for Fraud, Bribery and Corruption and conduct investigations in accordance with the NHS Anti-Fraud Manual in consultation with the Executive Director of Finance to ensure the

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most appropriate course of action is taken. 13.2.3 The Executive Director of Finance must notify NHS Protect and the External Auditor

of all frauds subject to the provisions of the Trust’s Anti-Fraud, Bribery and Corruption Policy and Response Plan.

13.2.4 For losses apparently caused by theft, fraud, bribery, corruption, arson, neglect of

duty or gross carelessness, except if trivial and where fraud, bribery or corruption is not suspected, the Executive Director of Finance must immediately notify:

(a) the Board of Directors, and (b) the External Auditor. 13.2.5 Within limits delegated to it by the Department of Health, the Group CiC shall

approve the writing-off of losses. For losses below the level set out in the Scheme of Delegation this function may be delegated to the Audit Committee (6 monthly report to be made to the committee on Losses and Special Payments).

13.2.6 The Executive Director of Finance shall be authorised to take any necessary steps to

safeguard the Trust's interests in bankruptcies and company liquidations. 13.2.7 For any loss, the Executive Director of Finance should consider whether any

insurance claim could be made. 13.2.8 The Executive Director of Finance shall maintain a Losses and Special Payments

Register in which write-off action is recorded. 13.2.9 No special payments exceeding delegated limits shall be made without the prior

approval of the Department of Health, or in the case of non-contractual payments to employees relating to loss of employment, without prior approval of HM Treasury.

13.3 Insurance 13.3.1 The Executive Director of Finance shall ensure that insurance arrangements exist in

accordance with the risk management programme. SECTION 14 INFORMATION TECHNOLOGY 14.1 The Executive Director of Finance, who is responsible for the accuracy and security

of the computerised financial data of the Trust, shall:

(a) be responsible for ensuring the design, implementation and documentation of effective information systems.

(b) devise and implement any necessary procedures to ensure adequate

(reasonable) protection of the Trust's data, programs and computer hardware, for which he/she is responsible, from accidental or intentional disclosure to unauthorised persons, deletion or modification, theft or damage, having due

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regard for the Data Protection Act 1998, (c) 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,

(d) ensure that adequate controls exist such that the computer operation is

separated from development, maintenance and amendment, (f) ensure that an adequate management (audit) trail exists through the

computerised system and that such computer audit reviews, as he/she may consider necessary are being carried out.

(g) maintain a ‘Freedom of Information Publication Scheme’ 14.2 The Executive Director of Finance shall satisfy him/herself 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 will be obtained from them prior to implementation.

14.3 In the case of computer systems which are proposed general applications (i.e.

normally those applications which the majority of organizations in the NHS locally or nationally wish to sponsor jointly) all responsible directors and employees will send to the Executive Director of Finance:

(a) details of the outline design of the system, (b) in the case of packages acquired either from a commercial organisation, from

the NHS, or from another public sector organisation, the operational requirement.

14.4 The Executive Director of Finance 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.

14.5 Where another health organisation or any other agency provides a computer service

for financial applications, the Executive Director of Finance shall periodically seek assurances that adequate controls are in operation.

14.6 Where computer systems have an impact on corporate financial systems the

Executive Director of Finance shall satisfy him/herself that: (a) systems acquisition, development and maintenance are in line with corporate

policies such as an Information Technology Strategy, (b) data produced for use with financial systems is adequate, accurate, complete

and timely, and that a management (audit) trail exists,

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(c) Executive Director of Finance staff have access to such data, and

(d) such computer audit reviews as are considered necessary are being carried out.

14.7 The Trust shall disclose to the Independent Regulator and directly to any third

parties, as may be specified by the Secretary of State, the information, if any, specified in the Terms of Authorisation, Schedule 6. Other information, as requested shall be provided to the Independent Regulator.

SECTION 15 PATIENTS' PROPERTY 15.1 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.

15.2 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, - 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 Health Service premises, unless it is handed in for safe custody and a copy of an official patients' property record is obtained as a receipt.

15.3 The Executive Director of Finance 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. Due care should be exercised in the management of a patient's money in order to maximise the benefits to the patient.

15.4 Where NHS instructions require the opening of separate accounts for patients'

moneys, these shall be opened and operated under arrangements agreed by the Executive Director of Finance.

15.5 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.

15.6 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.

of 62

37

15.7 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.

SECTION 16 ACCEPTANCE OF GIFTS BY STAFF 16.1 The Executive Director of Finance (via the Trust Secretary) shall ensure that all staff

are made aware of the Trust policy on acceptance of gifts and other benefits in. This policy should follow the guidance contained in the Department of Health Standards of Business Conduct for NHS staff. (see Governance Framework Manual)

SECTION 17 RETENTION OF DOCUMENTS 17.1 The Chief Executive shall be responsible for maintaining archives for all documents

required to be retained under the direction contained in Department of Health: NHS Code of Practice.

17.2 The documents held in archives shall be capable of retrieval by authorised persons. 17.3 Documents held under Department of Health: NHS Code of Practise shall only be

destroyed at the express instigation of the Chief Executive. Records shall be maintained of documents so destroyed.

SECTION 18 RISK MANAGEMENT & INSURANCE 18.1 Risk Management 18.1.1 The Chief Executive shall ensure that the Trust has a programme of risk

management, which must be approved and monitored by the Group CIC.

18.1.2 The programme of risk management shall include:

(a) a process for identifying and quantifying risks and potential liabilities; (b) engendering among all levels of staff 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

Item

14

of 62

38

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) decision on which risks shall be insured. (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 Accounts as required by current Department of Health guidance.

18.2 Insurance 18.2.1 The Group CiC shall decide if the Trust (bearing in mind the Trusts independent

legal status) will insure through the risk pooling schemes administered by the NHS Litigation Authority or self insure for some or all of the risks covered by the risk pooling schemes, along with those risks not covered by the pooling scheme. If the Group CiC 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.

18.2.2 Where the Group CiC decides to use the risk pooling schemes administered by

the NHS Litigation Authority the Chief Financial Officer shall ensure that the arrangements entered into are appropriate and complementary to the risk management programme. The Chief Financial Officer shall ensure that documented procedures cover these arrangements.

18.2.3 Where the Group CiC decides not to use the risk pooling schemes administered

by the NHS Litigation Authority for one or other of the risks covered by the schemes, the Chief Financial Officer shall ensure that the Group CiC is informed of the nature and extent of the risks that are self-insured as a result of this decision. The Executive Director of Finance will draw up formal documented procedures for the management of any claims arising from third parties and payments in respect of losses that will not be reimbursed.

18.2.4 All the risk-pooling schemes require members to make some contribution to the

settlement of claims (the ‘deductible’). The Executive Director Finance should ensure documented procedures also cover the management of claims and payments below the deductible in each case.

End.

of 62

39

DE

TA

ILE

D S

CH

EM

E O

F D

EL

EG

AT

ION

A

PP

EN

DIX

B

Th

is d

ocum

en

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rovid

es a

fra

me

wo

rk f

or

de

cis

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-ma

kin

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s w

ith

in t

he

Tru

st.

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ire

cto

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re r

esp

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le f

or

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su

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ha

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ll sta

ff o

pe

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s w

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in t

he

Sch

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f D

ele

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in a

cco

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inancia

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lo

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f th

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role

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ina

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Ch

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by t

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re

leva

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the

C

ha

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an

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(Gro

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Dire

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In th

e a

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f th

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CO

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)

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Oth

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Ma

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Th

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ch

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to a

ll se

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ste

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by S

RF

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tail

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au

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in t

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d

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tho

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d s

ign

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t fo

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ose

se

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It i

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ir D

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th

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ire

cto

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ce a

nd

po

ste

d o

n th

e in

tra

net.

Item

14

of 62

40

1.

Pa

y a

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Up

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CiC

2.

Ma

inte

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pe

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of

Ba

nk A

ccou

nts

of 62

41

Ma

inte

na

nce/O

pe

ration

of

Ba

nk A

ccou

nts

G

rou

p C

iC

3.

Ma

na

ge

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dgets

– G

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Is S

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Re

sp

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sib

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or

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pro

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lega

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an

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th

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sfe

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fun

ds b

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n s

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ith

in

a b

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t o

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ts.

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en

t of

fun

ds is a

va

ilab

le

with

in t

he

de

lega

ted lim

its p

rovid

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th

at

the

re is n

o a

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eff

ect o

n t

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Tru

sts

fin

an

cia

l po

sitio

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is a

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ilab

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be

twe

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pa

y a

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rovid

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th

at

it is a

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by t

he

Dire

cto

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Fin

an

ce

As p

er

the

bud

ge

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lim

its d

ete

rmin

ed

a

bo

ve

***

3.1

Ma

na

gem

en

t of

Bud

ge

ts –

Pa

y

Pa

y b

ud

ge

ts a

re b

ased

upo

n a

pp

rove

d e

sta

blis

hm

ents

an

d th

ese

are

an e

ssen

tia

l a

sp

ect of

the m

an

agem

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t of

the

pa

y b

ud

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ts.

(a)

A

uth

orisa

tio

n o

f T

ime

sh

ee

ts /

clo

ck c

ard

s /

cla

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ove

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etc

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Ca

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(H

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ill w

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with

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’s t

o

define

de

lega

tio

n r

equ

ire

men

ts)

Item

14

of 62

42

(b)

Au

tho

risa

tio

n o

f W

aitin

g L

ists

In

itia

tive

s (

with

in t

he

cu

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pa

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ond

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of

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Age

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cla

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or

med

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l se

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ym

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inte

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nk /

ca

su

al sta

ff.

i.

Cle

rica

l ii.

M

ed

ica

l lo

cum

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iii.

Nu

rsin

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Le

ad

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Off

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r fo

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O lis

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Ca

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(H

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A

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Ma

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A

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A

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h a

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acke

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y

ad

ditio

na

l in

co

me

Va

lue

to

be

ap

pro

ve

d b

y D

ire

cto

r o

f F

ina

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(C

O).

A

lloca

tio

n to

in

div

idu

al

bu

dge

t lin

es b

y M

an

agin

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air o

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pro

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incre

ase

in

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blis

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en

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so

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ntly w

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in t

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CO

’s o

wn

b

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ge

t.

Ch

ief

Fin

an

cia

l O

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S

FI

Se

ctio

n 8

3.3

Ma

na

gem

en

t of

Bud

ge

ts –

No

n P

ay

S

FIs

Se

ctio

n 9

S

tand

ing O

rde

rs

Se

c.9

S

tand

ing O

rde

rs –

A

nn

ex A

of 62

43

(Th

e lim

its s

et

ou

t be

low

ap

ply

equ

ally

to

Ca

pita

l E

xp

en

ditu

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Re

quis

itio

nin

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Ord

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Pa

ym

en

t of

Go

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s

& S

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ific

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o a

s to

circu

mve

nt fin

an

cia

l lim

its.

All

ord

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sin

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the

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va

lue

fo

r m

on

ey.

In

all

ca

se

s, a

dvic

e f

rom

th

e P

rocu

rem

ent

De

pa

rtm

en

t m

ust b

e s

ou

gh

t

Ap

pro

va

l lim

its a

s p

er

se

ctio

n 1

Be

twe

en

th

e E

U p

rocure

men

t th

resh

old

, a

s d

eta

iled a

bo

ve

, &

£

2,9

99

,99

9 a

fu

lly c

om

plia

nt

EU

pro

cu

rem

en

t p

roce

ss m

ust b

e

follo

we

d.

Whe

re p

ossib

le,

a m

inim

um

of

5 t

en

de

rs s

ho

uld

be

so

ugh

t to

en

su

re b

est va

lue

is o

bta

ine

d.

Ap

pro

va

l lim

its a

s p

er

se

ctio

n 1

Item

14

of 62

44

Ove

r £

3,0

00

,00

0 a

fu

lly c

om

plia

nt E

U p

rocu

rem

en

t p

roce

ss m

ust

be

fo

llow

ed

. W

he

re p

ossib

le,

a m

inim

um

of

5 te

nde

rs s

hou

ld b

e

so

ugh

t to

en

su

re b

est va

lue

is o

bta

ine

d

Gro

up

CiC

/Boa

rd o

f D

ire

cto

rs

a)

Sig

nin

g o

f co

ntr

acts

fo

r go

od

s &

se

rvic

es a

nd

su

bse

qu

en

t va

ria

tio

ns t

o c

on

tra

cts

, (f

ollo

win

g t

he

co

nclu

sio

n o

f th

e

pro

cu

rem

ent

with

in t

he le

ve

ls s

et

at 1

.2 a

bo

ve

).

Ch

ief

Exe

cu

tive

, E

xe

cu

tive

Dire

cto

r o

r o

the

r off

ice

r a

s d

uly

auth

orise

d b

y t

he

G

rou

p C

iC.

SO

(B

oa

rd)

Pa

ra

10

.1

b)

Wave

rin

g o

f qu

ota

tio

ns &

ten

de

rs s

ub

ject to

SF

Is

U

p t

o th

e v

alu

e E

U p

rocu

rem

en

t th

resho

ld £

16

4,1

76

(€

20

9,0

00

)

Ch

ief

Fin

an

cia

l O

ffic

er

- A

ll w

aiv

ers

to

be

re

po

rted

to A

ud

it C

om

mitte

e

SF

Is 9

.2.1

c)

Op

en

ing T

en

de

rs a

nd

Qu

ota

tio

ns

He

ad

of

Pro

cu

rem

en

t a

nd

De

pu

ty D

oF

o

r A

ssis

tant

Do

F p

lus o

ne

oth

er

Sen

ior

Ma

na

ge

r

3.3

Te

nde

r V

aria

tion

s

Ap

pro

vin

g T

en

de

r V

aria

tio

ns:

up

to

10

%

up

to

£1

5k

wh

ich

eve

r is

th

e lo

we

r (w

ith

in a

va

ilab

le b

ud

ge

t)

In a

cco

rda

nce

with

th

e a

gre

ed

a

uth

orisa

tio

n le

ve

ls w

ith

in e

ach

spe

cia

lty

/ d

ep

art

me

nt

Ap

pro

vin

g T

en

de

r V

aria

tio

ns >

10

% o

r £

15

k u

p to

a m

axim

um

of

£2

5k (

with

in b

ud

ge

t a

va

ilab

le).

Exe

cu

tive

Dire

cto

r, M

an

agin

g D

ire

cto

r o

r e

qu

iva

len

t, D

ep

uty

Ma

na

gin

g D

ire

cto

r,

Ch

air o

f D

ivis

ion

or

equ

iva

len

t

of 62

45

Ap

pro

vin

g T

en

de

r V

aria

tio

ns >

10

% o

r £

15

k u

p to

a m

axim

um

of

£2

5k (

ou

tsid

e b

ud

ge

t ava

ilab

le).

Exe

cu

tive

Dire

cto

r, M

an

agin

g D

ire

cto

r,

Ch

air o

f D

ivis

ion

or

equ

iva

len

t D

ep

uty

D

oF

Ap

pro

vin

g T

en

de

r V

aria

tio

ns >

th

an

10%

an

d o

ve

r £

25

k

C

hie

f F

inan

cia

l O

ffic

er

– r

ep

ort

ed

to

A

ud

it c

om

mitte

e

SF

Is 9

.2.1

4.

Ca

pita

l P

rogra

mm

e /

Sch

em

es

SF

Is S

ectio

n 1

1

Sta

nd

ing O

rde

rs

Se

c.9

S

tand

ing O

rde

rs –

A

nn

ex A

Au

tho

risa

tio

n o

f C

ap

ital P

roje

cts

/ C

ap

ita

l P

rogra

mm

e.

Gro

up

CiC

with

da

y t

o d

ay e

xp

en

ditu

re

co

mm

itte

d in

lin

e w

ith

1.2

ab

ove

with

th

e

exce

ptio

n o

f th

e E

U P

rocu

rem

ent

Th

resh

old

wh

ich

fo

r cap

ita

l (w

ork

s)

sch

em

es is £

4,1

04

,394

(€

5,2

25,0

00

)

Waiv

ing o

f fo

rma

l te

nde

rin

g p

roce

du

res /

re

qu

ire

men

t fo

r w

ritt

en

qu

ota

tio

n /

acce

pta

nce o

f lo

we

st

qu

ota

tio

n o

the

r th

an

th

e lo

we

st

qu

ota

tio

n.

Au

tho

risa

tio

n to

exce

ed

sch

em

e a

pp

rove

d b

ud

ge

t.

Gro

up

CF

O / D

ire

cto

r of

Fin

an

ce

(C

O)

su

bje

ct to

ap

pro

va

l le

ve

ls in

se

ction

1

Gro

up

CiC

Se

lection

of

arc

hite

cts

, qu

an

tity

su

rve

yo

rs,

co

nsu

ltan

t en

gin

ee

r a

nd

oth

er

pro

fessio

na

l a

dvis

ors

with

in E

U r

egu

latio

ns

Exe

cu

tive

Dire

cto

r, M

an

agin

g D

ire

cto

r o

r e

qu

iva

len

t

F

ina

ncia

l m

on

ito

rin

g a

nd

re

po

rtin

g o

n a

ll ca

pita

l sch

em

e

exp

en

ditu

re

Assis

tan

t D

ire

cto

r of

Fin

an

ce

, D

epu

ty

Dire

cto

r of

Fin

an

ce

Item

14

of 62

46

Gra

ntin

g a

nd

te

rmin

atio

n o

f le

ase

s o

f >

£1

00

,00

0

G

rou

p C

iC

5.

Se

ttin

g o

f F

ee

s a

nd

Cha

rge

s

SF

Is S

ectio

ns 6

& 7

a)

Priva

te P

atie

nt,

Ove

rse

as V

isito

rs, In

co

me

Ge

ne

ratio

n

an

d o

the

r p

atie

nt re

late

d s

erv

ice

s.

Gro

up

CF

O a

nd

Dire

cto

r of

Fin

an

ce

(CO

) in

agre

em

en

t

b)

Price

of

NH

S S

erv

ice

Le

ve

l A

gre

em

ents

Dire

cto

r of

Fin

an

ce

(C

O)/

De

pu

ty

Dire

cto

r of

Fin

an

ce

(C

O)

an

d M

an

agin

g

Dire

cto

rs

c)

Sig

nin

g o

f S

erv

ice

Le

ve

l a

gre

em

en

ts w

ith

Com

mis

sio

ne

rs

SL

A v

alu

es u

p to

£1

0 m

illio

n

SL

A v

alu

es o

ve

r £

10 m

illio

n

CO

De

pu

ty D

ire

cto

r of

Fin

an

ce

CO

Acco

un

tab

le o

ffic

er

/ D

ire

cto

r of

Fin

an

ce

(C

O)

6

. E

nga

ge

men

t of

Ma

na

ge

men

t C

on

su

lta

ncy S

taff

SF

Is S

ectio

n 9

a)

No

n M

ed

ica

l C

on

su

ltan

cy S

taff

(sub

ject

to p

rocu

rem

ent

rou

tes in 1

ab

ove

an

d a

ny e

xta

nt

regu

lato

ry r

equ

ire

me

nts

e

.g.

the M

on

ito

r co

nsu

lta

ncy c

ap

).

Ma

na

gin

g D

ire

cto

r o

r equ

iva

len

t, C

ha

ir

of

Div

isio

n.

or

equ

iva

len

t/ D

ire

cto

r of

Fin

an

ce

b)

Where

aggre

ga

te c

om

mitm

en

t in

an

y o

ne

yea

r (o

r to

tal

co

mm

itm

en

t) is le

ss t

ha

n £

25

,00

0

Ma

na

gin

g D

ire

cto

r, C

ha

ir o

f D

ivis

ion

or

equ

iva

len

t /

Re

leva

nt D

ire

cto

r

c)

Where

aggre

ga

te c

om

mitm

en

t in

an

y o

ne

yea

r is

mo

re

tha

n £

25

,00

0

Ch

ief

Exe

cu

tive

or

Exe

cu

tive

Dire

cto

r of

Fin

an

ce

of 62

47

d)

En

ga

ge

men

t of T

rust's S

olic

ito

rs

C

hie

f E

xe

cu

tive

/ E

xe

cu

tive

Dire

cto

r of

Fin

an

ce

/ R

ele

va

nt

Dire

cto

r / A

uth

orise

d

Ma

na

ge

rs

7.

Exp

en

ditu

re o

n C

ha

rita

ble

an

d E

ndo

wm

en

t F

un

ds

Up

to

£5

,00

0

Up

to

£1

5,0

00

U

p t

o £

25,0

00

U

p t

o £

50,0

00

O

ve

r £

50

,00

0

Ch

arita

ble

Fu

nd

s C

om

mitte

e (

CF

C)

sh

ou

ld a

gre

e in

prin

cip

le e

xp

en

ditu

re o

n

ch

arita

ble

and

en

do

wm

ent fu

nd

s,

exp

en

ditu

re s

ign

ato

ries t

he

reaft

er

are

a

s f

ollo

ws:

Fu

nd

ho

lde

rs

Div

isio

na

l D

ire

cto

rs

CO

Dire

cto

rs

Ch

ief

Fin

an

cia

l O

ffic

er

CF

C

8.

Agre

em

en

ts/L

ice

nce

s/L

ea

se

s

S

FI

Se

ctio

n 7

a)

Pre

pa

ratio

n a

nd s

ign

atu

re o

f a

ll te

na

ncy

agre

em

en

ts/lic

en

ce

s fo

r a

ll sta

ff s

ub

ject

to T

rust

Po

licy o

n

acco

mm

od

atio

n fo

r sta

ff

Dire

cto

r of

Fin

an

ce

(F

ina

nce

will

wo

rk

with

CO

’s t

o d

efine

de

lega

tio

n

requ

ire

me

nts

)

b)

Exte

nsio

ns to

exis

tin

g le

ase

s

Exe

cu

tive

Dire

cto

r o

f F

ina

nce o

r D

ire

cto

r fo

r S

erv

ice

Str

ate

gy a

nd

De

ve

lop

me

nt

(or

no

min

ate

d d

epu

ty)

c)

Le

ttin

g o

f p

rem

ise

s to

ou

tsid

e o

rga

nis

ation

s

C

hie

f E

xe

cu

tive

& E

xecu

tive

Dire

cto

r of

Fin

an

ce

d)

Ap

pro

va

l of

ren

t b

ased o

n p

rofe

ssio

na

l a

sse

ssm

ent

E

xe

cu

tive

Dire

cto

r o

f F

ina

nce /

De

pu

ty

Do

F

Item

14

of 62

48

e)

Sig

nin

g o

f L

ea

se

Do

cum

enta

tion

Gro

up

CiC

9.

Co

nd

em

nin

g &

Dis

po

sa

l

S

FIs

Se

ctio

n 1

3

It

em

s o

bso

lete

, ob

so

lesce

nt,

red

un

dan

t, irr

epa

rab

le o

r ca

nno

t be

re

pa

ire

d c

ost

eff

ective

ly

Exe

cu

tive

Dire

cto

r, M

an

agin

g D

ire

cto

r,

Ch

air o

f D

iv.

or

equ

iva

len

t /

Se

nio

r M

an

age

r In

vo

lve

d

Do

F o

r D

ep

uty

10

. Lo

sse

s, W

rite

-off

& C

om

pen

sa

tio

n

(all

ite

ms to

be

re

po

rted

to

th

e A

ud

it C

om

mitte

e b

i-a

nnu

ally

)

All

limits in

th

is s

ection a

pp

ly p

er

ca

se

.

Ma

nu

al fo

r A

ccou

nts

S

FI

Se

ctio

n 1

3

CN

ST

an

d R

PS

T

(NH

SL

A)

Me

mbe

rsh

ip R

ule

s.

a)

Lo

sse

s a

nd C

ash

due

to

theft

, fr

au

d,

ove

rpa

ym

ent

&

oth

ers

–

i.

Up

to

£5

0,0

00

ii.

Ove

r £

50

,00

0

i.

Dire

cto

r of

Fin

an

ce

(C

O)

ii.

CO

Ma

na

ge

me

nt B

oa

rd

b)

Fru

itle

ss P

aym

ents

(in

clu

din

g a

ban

do

ned

Cap

ita

l S

ch

em

es)

i.

Up

to

£2

50

,00

0

ii.

Ove

r

£2

50,0

00

i.

Dire

cto

r of

Fin

an

ce

(C

O)

ii.

CO

Ma

na

ge

me

nt B

oa

rd

c)

Ba

d D

eb

ts a

nd C

laim

s A

ba

nd

on

ed.

Priva

te P

atie

nts

, O

ve

rse

as V

isito

rs &

Oth

er

i.

Ind

ivid

ua

l d

eb

ts u

p to

£5

,00

0

ii.

Ind

ivid

ua

l d

eb

ts o

ve

r £

5,0

00

i.

Dire

cto

r of

Fin

an

ce

(C

O)

ii.

CO

Ma

na

ge

me

nt B

oa

rd

of 62

49

d)

Da

ma

ge

to

bu

ildin

gs, fitt

ings, fu

rnitu

re a

nd

equ

ipm

en

t a

nd

lo

ss o

f e

qu

ipm

en

t a

nd

pro

pe

rty in

sto

res a

nd

in

use d

ue

to

cu

lpa

ble

ca

use

s (

eg f

rau

d, th

eft

, a

rso

n)

or

oth

er

i.

Up

to

£5

0,0

00

ii.

Ove

r £

50

,00

0

i.

Dire

cto

r of

Fin

an

ce

(C

O)

ii.

CO

Ma

na

ge

me

nt B

oa

rd

e)

Co

mpe

nsatio

n p

aym

en

ts m

ade

un

de

r le

ga

l ob

liga

tio

n

Le

ad

HR

Off

ice

r fo

r th

e C

O

liste

d u

nd

er

Ca

tego

ry D

- f

or

sta

ff c

om

pe

nsa

tio

n

CO

Dire

cto

r of

Fin

an

ce -

fo

r n

on

-sta

ff

co

mpe

nsa

tio

n

f)

Extr

a C

on

tra

ctu

al p

aym

ents

to c

ontr

acto

rs

i.

Up

to

£5

0,0

00

ii.

Ove

r £

50

,00

0

i.

Dire

cto

r of

Fin

an

ce

(C

O)

ii.

CO

Ma

na

ge

me

nt B

oa

rd

E

x-G

ratia

Pa

ym

en

ts (

all

rep

ort

ed t

o A

ud

it C

om

mitte

e in

h

alf y

ea

rly lo

sse

s r

ep

ort

s).

g)

Pa

tie

nts

an

d s

taff

fo

r lo

ss o

f pe

rso

na

l eff

ects

: i.

Le

ss th

an

£2

,000

(pa

tie

nts

) ii.

L

ess th

an £

1,0

00

(sta

ff)

iii.

Ove

r £

1,0

00

i.

CO

Dire

cto

r of

Nu

rsin

g

ii.

Ma

na

gin

g D

ire

cto

r o

r equ

iva

len

t iii

. E

xe

cu

tive

Dire

cto

r

h)

Fo

r se

ttle

men

t of

insu

red

ris

ks:

C

linic

al

N

on

-Clin

ica

l –

Up

to

va

lue

of

Exce

ss

N.B

. a

bo

ve

exce

ss le

ve

l is

in

su

red r

isk a

nd t

he

refo

re n

o issue

fo

r th

e T

rust

Ma

na

gin

g D

ire

cto

r o

r equ

iva

len

t

Item

14

of 62

50

i)

Se

ttle

men

t of

no

n-in

sura

nce

cla

im r

isks:

U

p t

o £

10,0

00

(C

linic

al &

No

n-C

linic

al)

Ma

na

gin

g D

ire

cto

r o

r equ

iva

len

t

£2

0,0

01 -

£50

,00

0 (

Clin

ica

l &

Non

-Clin

ica

l)

C

O A

cco

un

tab

le O

ffic

er

or

Dire

cto

r of

Fin

an

ce

(C

O)

£

50

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an

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go

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ii.

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pu

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ii.

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k)

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to

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insta

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eport

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om

mitte

es

i.

De

pu

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O)

ii.

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of 62

51

11

. Re

po

rtin

g o

f In

cid

en

ts to

the

Po

lice

SF

Is S

ectio

ns 2

&

11

Tru

st P

olic

y o

n

Vio

len

ce &

A

ggre

ssio

n

Ap

pen

dix

6

a)

Where

a c

rim

ina

l off

ence

is s

uspe

cte

d:

crim

ina

l off

en

ce

of

a v

iole

nt n

atu

re

oth

er

(exce

pt fr

aud

)

CO

Dire

cto

r o

r

Se

nio

r M

an

age

r o

n c

all

b)

Where

a f

rau

d is in

vo

lve

d th

e p

olic

e a

re n

otifie

d in

a

cco

rdan

ce

with

the

Tru

st’s F

rau

d R

esp

on

se

Pla

n

Dire

cto

r of

Fin

an

ce

(C

O)/

De

pu

ty

Dire

cto

r of

Fin

an

ce

12

. Pe

tty C

ash

Dis

bu

rsem

en

ts (

no

t ap

plic

ab

le to

ce

ntr

al C

ash

iers

Off

ice)

S

FIs

Se

ctio

ns 6

a)

Exp

en

ditu

re u

p to

£3

0 p

er

item

Pe

tty C

ash

Ho

lde

r

b)

Re

imb

urs

em

en

t of

pa

tie

nts

mon

ies u

p to

£1

00

c)

Re

imb

urs

em

en

t of

pa

tie

nts

mon

ies in

exce

ss o

f £1

00

All

pa

tien

t m

on

ies m

ust

be

lo

dge

d w

ith

th

e c

en

tra

l ca

sh

iers

dep

art

me

nt of

the

rele

va

nt

ho

sp

ita

l an

d r

ece

ipte

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Re

imb

urs

em

en

t m

ust b

e r

equ

este

d b

y

the

Se

rvic

e M

an

age

r.

13

. Re

ce

ivin

g /

Re

gis

terin

g H

osp

ita

lity

A

pp

lies to

bo

th in

div

idu

al an

d c

olle

ctive

ho

spita

lity ite

ms o

f a

ll va

lue.

SF

I S

ectio

n 1

7 &

C

od

e o

f C

ond

uct fo

r N

HS

Sta

ff (

pa

ge

13

se

ctio

n 1

.3.1

.6).

S

FI

Se

ctio

n

9.2

.6(d

)

Item

14

of 62

52

a)

De

cla

ratio

n r

equ

ire

d in T

rust’s H

osp

ita

lity R

egis

ter

he

ld b

y

the

Dire

cto

r of

Co

rpo

rate

Se

rvic

es

All

sta

ff

In s

itua

tion

s w

he

re indiv

idu

als

be

lieve

th

at

a s

up

plie

r h

as o

ffe

red

an

ina

pp

rop

ria

te i

nd

uce

men

t th

is s

ho

uld

be

re

po

rted

to t

he

lin

e

ma

na

ge

r w

ho

will

re

fer

it u

pw

ard

s a

s a

pp

rop

ria

te.

14

. Co

mp

lian

ce

with

Re

leva

nt L

aw

s

E

nsu

re c

om

plia

nce w

ith

re

leva

nt

law

s a

nd r

egu

latio

ns,

inte

rna

l p

olic

ies a

nd

pro

ce

du

res a

nd

th

at a

ll exp

en

ditu

re

is la

wfu

l.

All

Se

nio

r M

an

age

rs, G

en

era

l M

an

age

rs,

Lin

e, W

ard

an

d

De

pa

rtm

en

tal M

ana

ge

rs.

(Th

e D

ecla

ration

of

Inte

rests

do

cum

ent

sig

ne

d e

ach

ye

ar

will

pro

vid

e a

ssu

ran

ce

tha

t co

mp

lian

ce

with

this

pro

vis

ion

is

evid

en

ce

d.)

Co

rpo

rate

G

ove

rna

nce

F

ram

ew

ork

Ma

nu

al.

15

. Im

ple

me

nta

tio

n o

f In

tern

al an

d E

xte

rna

l A

ud

it

Re

co

mm

en

datio

ns

Re

leva

nt

Ma

na

ge

r p

lus E

xe

cu

tive

D

ire

cto

r of

Fin

an

ce

Se

ctio

n 1

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P.2

0)

plu

s s

ectio

n 2

.4

(p.4

3).

S

FI

Se

ctio

n 2

&

Ap

pen

dix

7A

of 62

53

16

. Ma

inte

na

nce &

Upd

ate

on

Tru

st F

ina

ncia

l P

roce

du

res

Gro

up

Ch

ief

Fin

an

ce

Off

ice

r

Se

ctio

n 1

.5 (

pa

ge

2

2)

17

. In

ve

stm

en

t of

Fun

ds

C

O C

hie

f O

ffic

er

S

FIs

Se

ctio

n 8

18

. Co

ntr

acte

d P

ers

onn

el &

Pa

y a

dd

itio

na

l item

s w

ith

in e

xis

tin

g T

erm

s a

nd

Con

ditio

ns o

f E

mp

loym

en

t. (

The

se

lim

its a

pp

ly t

o

ite

ms w

ith

in t

he

bu

dge

ts a

va

ilab

le)

NO

TE

: E

xp

end

itu

re r

ela

ted t

o n

on

co

ntr

acte

d p

ay is d

eta

iled

at

se

ction

3.1

a)

Ad

ditio

na

l In

cre

me

nts

T

he

gra

ntin

g o

f a

dd

itio

na

l in

cre

me

nts

to s

taff

with

in

b

ud

ge

t:

o

S

en

ior

Med

ica

l S

taff

o

Oth

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Sta

ff

HR

Le

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the

CO

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de

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ate

go

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b)

Up

gra

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gra

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All

requ

ests

fo

r u

pgra

din

g/r

egra

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ha

ll b

e d

ea

lt w

ith

in

a

cco

rdan

ce

with

app

rove

d P

roce

du

re (

va

lue

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late

s to

th

e

incre

ase

in p

ay).

HR

Le

ad in

the

CO

lis

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un

de

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ate

go

ry D

c)

Pro

tecte

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age

/ S

ala

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aym

en

ts

The

pro

tection

of

wa

ge

s /

sa

lary

pa

ym

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in

acco

rda

nce

with

th

e a

pp

rove

d P

olic

y.

HR

Le

ad in

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CO

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Item

14

of 62

54

d)

Cre

atio

n o

f N

ew

Ma

nage

me

nt P

osts

(w

ith

in a

va

ilab

le

reso

urc

es a

nd

ma

na

gem

ent

co

sts

ta

rge

ts)

i.

Up

to

Tru

st G

rade

4 / u

p t

o A

FC

Ban

d 7

ii.

T

rust G

rad

e 3

to

1 /

AF

C B

an

d 7

an

d a

bo

ve

iii

. E

xe

cu

tive

Dire

cto

r

i.

Ch

air o

f D

ivis

ion

ii.

D

ire

cto

r of

OD

& C

orp

ora

te A

ffa

irs +

re

leva

nt

dire

cto

rs/C

ha

irs o

f D

ivis

ion

iii

. G

rou

p C

iC

e)

Au

tho

rity

to

co

mp

lete

sta

nd

ing d

ata

fo

rms e

ffectin

g p

ay,

ne

w s

tart

ers

, va

ria

tio

ns a

nd le

ave

rs.

Le

ad

HR

Off

ice

r fo

r th

e C

O lis

ted u

nd

er

Ca

tego

ry D

(H

R w

ill w

ork

with

CO

’s t

o

define

de

lega

tio

n r

equ

ire

men

ts)

f)

Au

tho

rity

to

co

mp

lete

an

d a

uth

orise

po

sitiv

e r

ep

ort

ing

form

s

Le

ad

HR

Off

ice

r fo

r th

e C

O lis

ted u

nd

er

Ca

tego

ry D

(H

R w

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with

CO

’s t

o

define

de

lega

tio

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equ

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men

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g)

Au

tho

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au

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rtim

e

L

ead

HR

Off

ice

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r th

e C

O lis

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nd

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Ca

tego

ry D

(H

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o

define

de

lega

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n r

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men

ts)

h)

Au

tho

rity

to

app

rove

wo

rkin

g in

a t

em

po

rary

gra

de

:

i.

Co

ve

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aca

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ii.

Tem

po

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Re

gra

din

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Le

ad

HR

Off

ice

r fo

r th

e C

O lis

ted u

nd

er

Ca

tego

ry D

(H

R w

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with

CO

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o

define

de

lega

tio

n r

equ

ire

men

ts)

i)

Va

ria

tio

n t

o O

ve

rtim

e P

aym

en

t R

ate

s

All

pa

ym

en

ts t

o b

e m

ad

e in

acco

rda

nce w

ith

Na

tio

na

l T

erm

s a

nd

Co

nd

itio

ns a

nd

ap

pro

ve

d T

erm

s a

nd

Con

ditio

ns a

s a

pp

rop

ria

te

Ch

ief

Str

ate

gy a

nd

Org

an

isa

tion

al

De

ve

lop

men

t O

ffic

er

k)

Au

tho

rity

to

au

tho

rise

ad

-ho

c p

aym

en

ts (

ou

tsid

e o

f n

orm

al

term

s a

nd c

ond

itio

ns)

su

bje

ct to

co

mp

lian

ce w

ith

an

y

Tru

st o

r n

atio

na

l re

qu

ire

men

ts a

bou

t ra

tes o

f p

ay.

Le

ad

HR

Off

ice

r fo

r th

e C

O lis

ted u

nd

er

Ca

tego

ry D

(H

R w

ill w

ork

with

CO

’s t

o

define

de

lega

tio

n r

equ

ire

men

ts)

of 62

55

l)

Sa

lary

/ w

age

pa

ym

en

ts f

rom

Ch

arita

ble

Fu

nds

F

un

d S

ign

ato

rie

s (

see

se

ctio

n 7

)

m)

R

ene

wa

l o

f F

ixe

d T

erm

Co

ntr

act

Ma

na

gin

g D

ire

cto

r, C

ha

ir o

f D

ivis

ion

of

Equ

iva

len

t

19

. Tra

ve

l a

nd

asso

cia

ted

Exp

en

se

s R

e-im

bu

rsem

ent

A

uth

ority

to

au

tho

rise

tra

ve

l a

nd

asso

cia

ted

exp

en

se

s:

Exe

cu

tive

Dire

cto

rs

Oth

er

Sta

ff

Ch

airm

an /

Ch

ief

Exe

cu

tive

Lin

e M

an

age

r o

r ap

pro

ve

d D

ep

uty

20

. Le

ave

C

on

ditio

ns o

f S

erv

ice

T

rust L

ea

ve

P

olic

y

a)

Ap

pro

va

l of

an

nu

al le

ave

Ward

/Lin

e/D

ep

art

men

tal M

an

age

r

b)

An

nua

l le

ave

- a

pp

rova

l of

ca

rry f

orw

ard

(u

p to

ma

xim

um

of

5 d

ays

Ward

/Lin

e/D

ep

art

men

tal M

an

age

r

c)

An

nua

l le

ave

- a

pp

rova

l of

ca

rry o

ve

r in

exce

ss o

f 5 d

ays

bu

t le

ss t

ha

n 1

0 d

ays.

Se

rvic

e M

an

age

r /

SN

M

Item

14

of 62

56

d)

An

nua

l le

ave

- a

pp

rova

l to

ca

rry f

orw

ard

10

da

ys o

r m

ore

.

Ma

na

gin

g D

ire

cto

r, C

ha

ir o

f D

iv o

r e

qu

iva

len

t

e)

Co

mpa

ssio

na

te L

ea

ve

C

om

pas

Ward

/Lin

e/D

ep

art

men

tal M

an

age

r

f)

Specia

l le

ave a

rrange

ments

viiS

M

ate

rnity L

eave

P

ate

rnity L

ea

ve

A

doption L

eave

Au

tom

atic A

pp

rova

l w

ith

gu

ida

nce

Au

tom

atic A

pp

rova

l w

ith

gu

ida

nce

Au

tom

atic A

pp

rova

l w

ith

gu

ida

nce

C

are

rs lea

ve

D

om

estic

T

rade U

nio

n D

uties / A

ctivitie

s

Ward

/Lin

e/D

ep

art

men

tal M

an

age

r

Ward

/Lin

e/D

ep

art

men

tal M

an

age

r

Ward

/Lin

e/D

ep

art

men

tal M

an

age

r

viii

) g)

Leave w

ithout pay

W

ard

/Lin

e/D

ep

art

men

tal M

an

age

r

ix

) h)

Medic

al S

taff L

eave o

f A

bsence -

paid

and u

npaid

Me

dic

al D

ire

cto

r

i)

Tim

e o

ff in lie

u

Au

tom

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pp

rova

l w

ith

gu

ida

nce

j)

Sic

k L

ea

ve

Exte

nsio

n o

f sic

k le

ave o

n h

alf p

ay u

p to

th

ree

mo

nth

s

Ma

na

gin

g D

ire

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r o

r equ

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len

t, C

ha

ir o

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iv o

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qu

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t &

Sen

ior

HR

Ma

na

ge

r

Tru

st S

ickn

ess

Ha

nd

ling

Gu

ide

line

s

Ph

ased

re

turn

to

wo

rk o

n a

dju

ste

d p

ay t

o a

ssis

t re

co

ve

ry,

revie

wa

ble

on

a m

on

thly

ba

sis

in

a

cco

rdan

ce

with

sic

kne

ss g

uid

an

ce

.

Se

rvic

e M

an

age

r

of 62

57

Dis

cre

tio

na

ry e

xte

nsio

n o

f sic

k le

ave

on

fu

ll pa

y,

revie

wa

ble

mon

thly

.

HR

Le

ad in

the

CO

lis

ted

un

de

r C

ate

go

ry D

k)

Stu

dy L

ea

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T

rust P

olic

y

No

n M

ed

ica

l S

tud

y le

ave

Ma

na

gin

g D

ire

cto

r, C

ha

ir o

f D

ivis

ion

or

equ

iva

len

t

Me

dic

al sta

ff s

tud

y le

ave

Me

dic

al D

ire

cto

r

A

ll o

the

r stu

dy le

ave

Se

rvic

e M

an

age

r /

De

pa

rtm

en

tal M

an

age

r

21

. Re

mo

va

l E

xp

en

se

s,

Exce

ss R

en

t a

nd

Ho

use P

urc

ha

se

s

A

uth

orisa

tio

n o

f p

aym

en

t of

rem

ova

l e

xp

en

ses in

cu

rre

d b

y o

ffic

ers

ta

kin

g u

p n

ew

ap

po

intm

ents

(p

rovid

ing c

on

sid

era

tion

wa

s p

rom

ised

at in

terv

iew

)

Up

to

£8

,00

0

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Le

ad in

the

CO

lis

ted

un

de

r C

ate

go

ry D

Exp

en

se

s o

ve

r a

nd

abo

ve

th

e a

bo

ve

lim

it c

an o

nly

b

e a

wa

rde

d in

exce

ptio

na

l circum

sta

nce

s o

n a

ca

se

-by-c

ase

ba

sis

.

Ch

ief

Exe

cu

tive

22

. Grie

va

nce

Pro

ced

ure

All

grie

va

nce

s c

ase

s m

ust

be

de

alt w

ith

str

ictly in

a

cco

rdan

ce

with

the

Grie

va

nce

Pro

ce

du

re a

nd

the

ad

vic

e

of

a H

um

an

Re

so

urc

es O

ffic

er

mu

st b

e s

ou

ght

wh

en

the

grie

va

nce

re

ache

s th

e le

ve

l o

f G

ene

ral M

anage

r

Ward

/Lin

e/D

ep

art

men

tal M

an

age

r

Tru

st G

rie

va

nce

P

roce

du

re

Item

14

of 62

58

2

3. A

uth

orise

d C

ar

& M

ob

ile P

hon

e U

se

rs

a)

Re

qu

ests

fo

r n

ew

po

sts

to

be

au

tho

rise

d a

s c

ar

use

rs

W

ard

/Lin

e/D

ep

art

men

tal M

an

age

r

b)

Le

ase

Ca

r A

pp

rova

l

Ma

na

gin

g D

ire

cto

r o

r equ

iva

len

t

c)

Le

ase

Ca

r M

ilea

ge

Ra

tes

E

xe

cu

tive

Dire

cto

r o

f F

ina

nce

d)

Re

qu

ests

fo

r n

ew

po

sts

to

be

au

tho

rise

d a

s m

ob

ile

tele

ph

one

use

rs

Ma

na

gin

g D

ire

cto

r, C

ha

ir o

f D

iv o

r e

qu

iva

len

t

e)

Re

qu

ests

fo

r n

ew

po

sts

to

be

au

tho

rise

d a

s te

lep

ho

ne

use

rs

Ma

na

gin

g D

ire

cto

r, C

ha

ir o

f D

iv o

r e

qu

iva

len

t

24

. Re

du

nd

an

cy

Re

du

nd

an

cy

Ch

ief

Exe

cu

tive

/Ch

ief

Fin

an

cia

l O

ffic

er/

Ch

ief

Str

ate

gy a

nd

Org

an

isatio

na

l D

eve

lopm

en

t O

ffic

er

Vo

lun

tary

se

ve

ran

ce

arr

an

ge

me

nts

(a

s d

ete

rmin

ed

an

d a

gre

ed

fro

m t

ime t

o tim

e b

y t

he

N

om

inatio

ns, R

em

une

ratio

n a

nd T

erm

s o

f S

erv

ice

C

om

mitte

e)

Gro

up

CiC

25

. Ill

He

alth

Re

tire

men

t

D

ecis

ion

to

te

rmin

ate

on

the

gro

un

ds o

f ill

-health

S

en

ior

Man

age

r o

r E

qu

iva

len

t w

ith

HR

a

dvic

e.

26

. Dis

mis

sa

l

Ma

na

gin

g D

ire

cto

r, C

ha

ir o

f D

ivis

ion

or

equ

iva

len

t w

ith

HR

ad

vic

e.

Tru

st

Dis

cip

lina

ry

Pro

ce

du

res

of 62

59

27

. Au

tho

risa

tio

n o

f N

ew

Dru

gs

Me

dic

ine

s M

ana

ge

men

t G

roup

28

. Au

tho

risa

tio

n o

f S

pon

so

rsh

ip d

ea

ls

Gro

up

CE

O a

nd

Ch

ief F

ina

ncia

l O

ffic

er

29

. Au

tho

risa

tio

n o

f R

ese

arc

h P

roje

cts

Dire

cto

r of

R&

D p

lus D

ire

cto

r of

Fin

an

ce

(CO

) T

rusts

Re

se

arc

h

Po

licy

30

. Au

tho

risa

tio

n o

f C

linic

al T

ria

ls

Dire

cto

r of

R&

D p

lus D

ire

cto

r of

Fin

an

ce

(CO

) p

lus H

ea

d o

f P

harm

acy.

Tru

sts

Clin

ica

l T

ria

ls P

olic

y

31

. In

su

ran

ce

Po

licie

s a

nd R

isk M

an

age

me

nt

Gro

up

CiC

S

FIs

Se

ctio

n 1

9

32

. Pa

tie

nts

& R

ela

tive

s C

om

pla

ints

a)

Ove

rall

resp

on

sib

ility

fo

r e

nsu

rin

g t

ha

t a

ll com

pla

ints

are

d

ea

lt w

ith

eff

ective

ly

Ch

ief

Exe

cu

tive

/Ch

ief

Nu

rsin

g O

ffic

er

b)

Re

sp

on

sib

ility

fo

r e

nsurin

g c

om

pla

ints

re

lating t

o a

d

ire

cto

rate

are

in

ve

stig

ate

d t

ho

rou

gh

ly.

Ma

na

gin

g D

ire

cto

r, C

ha

ir o

f D

ivis

ion

or

equ

iva

len

t

c)

Me

dic

o -

Le

ga

l C

laim

s -

Co

ord

ina

tion

of

the

ir

ma

na

ge

me

nt.

C

laim

s M

an

age

r

33

. Re

latio

nsh

ips w

ith

Pre

ss

E

nqu

irie

s :

-

With

in H

ou

rs

Ou

tsid

e H

ou

rs

He

ad

of

Com

mu

nic

ation

s

Se

nio

r M

an

age

r o

n-c

all

34

. Infe

ctio

us D

ise

ase

s &

No

tifia

ble

Ou

tbre

aks

M

ed

ica

l D

ire

cto

r /

Head

of

Infe

ctio

n C

on

tro

l

Item

14

of 62

60

35

. Exte

nd

ed R

ole

Activitie

s

A

pp

rova

l of

Nu

rse

s t

o u

nde

rta

ke

du

tie

s /

pro

ce

du

res w

hic

h c

an

p

rop

erly b

e d

escrib

ed

as b

eyo

nd t

he

no

rma

l sco

pe

of

Nu

rsin

g

Pra

ctice

.

CE

or

Dire

cto

r of

Nu

rsin

g /

De

puty

Dire

cto

r of

Nu

rsin

g

Nu

rse

/Mid

wiv

es/

He

alth

Vis

ito

rs

Act

Mid

wiv

es

Ru

les /

Co

de

of

Pra

ctice

UK

CC

C

od

e o

f P

rofe

ssio

na

l C

on

du

ct

36

. Pa

tie

nt

Se

rvic

es

a)

Va

ria

tio

n o

f o

pe

ratin

g a

nd

clin

ic s

essio

ns w

ith

in e

xis

tin

g

nu

mb

ers

:

Ou

tpa

tie

nts

The

atr

es

Oth

er

Ma

na

gin

g D

ire

cto

r, C

ha

ir o

f D

iv o

r e

qu

iva

len

t

b)

All

pro

po

se

d c

ha

nge

s in

bed

allo

ca

tio

n a

nd

use

Tem

po

rary

Ch

an

ge

Pe

rman

en

t C

ha

nge

Co

ntr

act m

on

ito

rin

g

Co

ntr

act

rep

ort

ing

Be

d M

an

age

r

Ma

na

gin

g D

ire

cto

r, C

ha

ir o

f D

iv o

r e

qu

iva

len

t

CO

Dire

cto

r of

Fin

an

ce

CO

Dire

cto

r of

Fin

an

ce

37

. Fa

cili

tie

s f

or

sta

ff n

ot em

plo

ye

d b

y t

he

Tru

st to

ga

in

pra

ctica

l e

xp

erie

nce

Tru

st P

olic

y o

n

Stu

de

nt W

ork

E

xp

erie

nce

of 62

61

a)

Pro

fessio

na

l R

eco

gn

itio

n,

Hon

ora

ry C

on

tra

cts

, &

In

su

ran

ce

of

Me

dic

al S

taff

.

R&

D D

ire

cto

r

b)

Work

exp

erie

nce

stu

den

ts e

tc.

A

ssis

tan

t H

R M

an

age

r

38

. Re

vie

w o

f fire

pre

cau

tio

ns

D

ire

cto

r of

Ca

pita

l

39

. Re

vie

w o

f com

plia

nce

with

all

sta

tuto

ry a

nd H

ea

lth

an

d

Safe

ty E

xe

cu

tive

re

qu

ire

men

ts (

inclu

din

g c

ontr

ol of

Su

bsta

nce

s H

aza

rdo

us t

o H

ea

lth

Re

gu

latio

ns)

CO

Ch

ief

Off

ice

rs

40

. Re

vie

w o

f M

ed

icin

es In

sp

ecto

rate

Re

gu

lation

s

C

O M

ed

ica

l D

ire

cto

r

41

. Re

vie

w o

f com

plia

nce

with

en

viro

nm

en

tal re

gu

latio

ns,

e.g

. th

ose r

ela

tin

g t

o c

lean

air a

nd

wa

ste

dis

po

sa

l C

O C

hie

f O

ffic

ers

42

. Re

vie

w o

f T

rust's c

om

plia

nce

with

the

Da

ta P

rote

ctio

n A

ct

Ch

ief

Info

rma

tio

n O

ffic

er

43

. Mo

nito

r p

rop

osa

ls fo

r co

ntr

actu

al a

rran

ge

ments

be

twe

en

th

e T

rust a

nd

ou

tsid

e b

od

ies

Gro

up

Ch

ief

Fin

an

cia

l O

ffic

er/

Dire

cto

r of

Fin

an

ce

(C

O)

44

. Re

vie

w t

he

Tru

st's

com

plia

nce

with

th

e A

ccess t

o H

ea

lth

R

eco

rds A

ct

CO

CIO

/ D

CIO

IG

45

. Re

vie

w o

f th

e T

rust's

co

mp

lian

ce

co

de

of

Pra

ctice

fo

r h

and

ling c

onfide

ntia

l in

form

atio

n in t

he

con

tractin

g

en

viro

nm

ent

an

d th

e c

om

plia

nce

with

"safe

ha

ve

n"

regu

latio

ns

CO

CIO

/ D

CIO

IG

46

. The

kee

pin

g o

f a

De

cla

ratio

n o

f In

tere

sts

Regis

ter.

D

ire

cto

r of

Co

rpo

rate

Se

rvic

es

SO

s S

ectio

n 6

47

. Att

esta

tio

n o

f S

ea

lings in

acco

rda

nce w

ith

Sta

nd

ing O

rde

rs

E

xe

cu

tive

Dire

cto

r o

f F

ina

nce a

nd

CE

O (

or

no

min

ate

d o

ffic

ers

, n

ot w

ith

in t

he

origin

atin

g

de

pa

rtm

en

t)

SO

s S

ectio

n 1

2

Item

14

of 62

62

48

. The

kee

pin

g o

f a

re

gis

ter

of

Se

alin

gs

Dire

cto

r of

Co

rpo

rate

Se

rvic

es

SO

s S

ectio

n 1

2

49

. The

kee

pin

g o

f th

e H

osp

ita

lity R

egis

ter

Dire

cto

r of

Co

rpo

rate

Se

rvic

es

50

. Re

ten

tio

n o

f R

eco

rds

Ch

ief

Exe

cu

tive

of 62