Reservation of Powers to the Board and Delegation of Powers. (Scheme of Delegation)

Reservation of Powers to the Board and Delegation of Powers (Scheme of Delegation) Date of Issue: May 2017 Review Date: May 2020 Lead Director: Director of Finance and Performance POL-FIN/1154/14 V2.0.0

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CONTENTS INTRODUCTION... 3 SECTION 1 DECISIONS RESERVED TO THE BOARD... 4 SECTION 2 DECISIONS / DUTIES DELEGATED BY THE BOARD TO COMMITTEES... 8 SECTION 3 DECISIONS RESERVED TO THE COUNCIL OF GOVERNORS... 11 SECTION 4 DELEGATIONS DERIVED FROM THE ACCOUNTABLE OFFICER MEMORANDUM... 12 SECTION 5 DELEGATIONS DERIVED FROM THE CODES OF CONDUCT AND ACCOUNTABILITY... 14 SECTION 6 DELEGATIONS FROM STANDING ORDERS... 17 SECTION 7 DELEGATION FROM STANDING FINANCIAL INSTRUCTIONS... 18 SECTION 8 DETAILED SCHEME OF DELEGATION... 21 SECTION 9 OTHER MATTERS... 42 Appendix One... 43 DEFINITIONS... 43 Appendix Two... 45 GLOSSARY OF TERMS... 45 2

INTRODUCTION Within the terms of Authorisation issued by the Independent Regulator, NHS Foundation Trust's are required to demonstrate the existence of comprehensive governance arrangements for the practice and procedure of the Board of Directors SO 4.1 of the Standing Orders provide that: The Board may make arrangements for the exercise, on behalf of the Trust, of any of its functions by committee or sub-committee Or by a director or an officer of the Trust, in each case subject to such restrictions and conditions as the Board thinks fit". The NHS Code of Governance, also requires that there should be a formal schedule of matters specifically reserved to the Board of Directors The purpose of this document is to define those powers which are reserved to the Board while at the same time delegating to the appropriate level the detailed application of Trust policy and procedures. However, the Board remains accountable for all of its functions, including those delegated to the Chairman, individual Directors or officers, and would therefore expect to receive information about the exercise of delegated functions to enable it to maintain a monitoring role. A Role of the Chief Executive All powers of the Trust which have not been retained as reserved by the Board or delegated to a committee or sub-committee shall be exercised on behalf of the Board by the Chief Executive. The Chief Executive shall prepare a Detailed Scheme of Delegation proposing which functions he/she shall perform personally and which functions have been delegated to other Directors and officers, for consideration and approval by the Board as appropriate. The Chief Executive will also define those roles and tasks which are discharged through the Management Executive Committee B Caution over the Use of Delegated Powers Powers are delegated to Directors and officers on the understanding that they would not exercise delegated powers in a matter that in their judgment was likely to be a cause for public concern. C Absence of Director or Officer to whom Powers have been Delegated In the absence of a Director or officer to whom powers have been delegated those powers shall be exercised by that Director or officer's superior unless alternative arrangements have been approved by Board. If the Chief Executive is absent powers delegated to him/her may be exercised by the Chair after taking appropriate advice from the Director of Finance. 3

D Directors' Ability to Delegate their own Delegated Powers The Scheme of Delegation shows only the "top level" of delegation within the Trust. The Scheme is to be used in conjunction with the system of budgetary control and other established procedures within the Trust. This Scheme of Delegation should be read in conjunction with Standing Orders and Standing Financial Instructions. In addition all staff members, including Directors should be aware of the Trust s various policies and procedures which underpin its operations. A list of definitions is included as Appendix 1 and a Glossary of Terms at Appendix 2. 4

SECTION 1 DECISIONS RESERVED TO THE BOARD REF FT CODE OF GOVERNANCE (COG) A.1 THE BOARD BOARD General enabling provision 1. DECISIONS RESERVED TO THE BOARD The Board may determine any matter, for which it has delegated or statutory authority, in full session. 5 BOARD Regulations and Control 1. Approve Standing Orders (SOs), a schedule of decisions reserved to the Board and Standing Financial Instructions. 2. Suspend Standing Orders. (SO 3.31) 3. Vary or amend the Standing Orders. (SO 3.36) 4. Ratify any urgent decisions taken by the Chair and Chief Executive in public / private session in accordance with SO 4.2 5. Approve a scheme of delegation of powers from the Board to committees. (SO 4.1) 6. Receive any declaration of Board members' and Council of Governors interests which may conflict with those of the Trust and determine the extent to which that member may remain involved when the matter is under consideration. 7. Receive any declaration of officers' interests which may conflict with those of the Trust. 8. Approve arrangements for dealing with complaints. 9. Adopt the Executive Directors organisation structure and monitor the processes and procedures employed by Executive Directors to require and facilitate the discharge of business by the Trust and agree modification there to. 10. Receive reports from committees including those which the Trust is required by regulation to establish and to take appropriate action thereon. 11. Confirm the recommendations of the Trust's committees where the committees do not have executive powers. 12. Approve arrangements relating to the discharge of the Trust's responsibilities as a corporate trustee for funds held on trust. 13. Establish and remove committees and sub committees of the Board and approve terms of reference and reporting arrangements for those committees and sub-committees. 14. Approve arrangements relating to the discharge of the Trust's responsibilities as a bailee for patients' property.

REF THE BOARD 15 Authorise use of the Common Seal of the Trust. DECISIONS RESERVED TO THE BOARD 16. To consider instances of failure to comply with Standing Orders brought to the Chief Executive's attention in accordance with SO 4.9. 17. To ensure appropriate disciplinary action is taken where Board members or employees have breached statutory requirements of the Trust s Standing Orders. 18. Approve amendments to the Trust Constitution prior to submission to the Council of Governors and NHSI. BOARD Appointments/Dismissal 1. Appointment of the Vice Chair of the Board 2. Appoint and dismiss members of committees of the Board. 3. Appoint, discipline and dismiss the Chief Executive and Executive Directors (subject to SO 2.6) 4. Confirm appointment of Directors of the Trust as representatives on outside bodies if Board endorsement is required. 5. Appoint and dismiss the Chief Executive, Directors and Senior employees on the basis of proposals presented by the Remuneration Committee. 6. Appoint and dismiss the Senior Independent Non-Executive Director (SID), in consultation with Council of Governors. A.1/F BOARD Strategy, Business Plans and Budgets 1. Define the strategic aims and objectives of the Trust. 2. Approve proposals for ensuring quality and developing clinical governance in services provided by the Trust, having regard to any guidance issued by the Secretary of State, NICE, NHSI and the Care Quality Commission. 3. Approve the Trust's policies and procedures for the management of risk. 4. Approve Strategic Outline Cases, Outline Business Cases and Final Business Cases for Capital and or revenue Investment where the value is over 1.5m after review by the Finance and Investment Committee 5. Approve the Trust s Annual Revenue Budget. 6. Approve the Trust's organisational development plan on an annual basis. 6

REF THE BOARD DECISIONS RESERVED TO THE BOARD 7. Approve proposals for acquisition, disposal or change of use of land and/or buildings. 8. Approve PFI proposals. 9. Approve the opening of bank accounts. 10. Approve individual contracts (other than NHS contracts) of a capital or revenue nature amounting to, or likely to amount to a value that exceeds the limits in section 5/6 of the Detailed Scheme of Delegation. 11. Approve individual cases of write off of losses or special payments above the limits in section 12 of the Detailed Scheme of Delegation. 12. Approve the use the NHS risk pooling schemes or the use of commercial insurance arrangements. 13. Approve Workforce strategy. 14 Approve the individual NHS Contracts with the Commissioners. FT COG D BOARD Policy determination 1. Approve management policies including Workforce policies incorporating the arrangements for the appointment, removal and remuneration of staff. FT COG F3 BOARD Audit 1. Review the annual management letter received from the external auditor, taking account of the advice, where appropriate, of the Audit Committee. 2. Receive an annual report from the Internal Auditor and agree action on recommendations, where appropriate, taking account of the advice of the Audit Committee. FT COG F1 BOARD Annual Report and Accounts 7

REF THE BOARD DECISIONS RESERVED TO THE BOARD 1. Approve the Trust's Annual Report and Annual Accounts as prepared by the Executive Management Team in accordance with NHSI guidelines for presentation to the Council of Governors, and the Members at the Annual Members Meeting 2. Approve the Annual Report and Accounts for funds held on trust, prepared in accordance with the Charity Commissions guidelines. FT COG D BOARD Monitoring 1. Request and consider any reports in respect of powers delegated to committees. 2. Receive reports to enable continuous appraisal of the affairs of the Trust from Directors, committees and officers of the Trust as the Board sees fit. All monitoring returns required by the Independent Regulator and the Charity Commission shall be reported, at least in summary, to the Board. 3. Receive reports from the Director of Finance on financial performance against budget and business plans. 4. Receive reports from the Director of Finance on actual and forecast income. 5. Receive reports from the Finance and Investment Committee 6. Receive reports from the Quality Committee 7. Receive reports from the People Committee. 8. Receive reports from the Audit Committee 9. Receive reports from the Nomination and Remuneration Committee. 8

SECTION 2 DECISIONS / DUTIES DELEGATED BY THE BOARD TO COMMITTEES REF COMMITTEE DECISION/DUTIES DELEGATED BY THE BOARD TO COMMITTEES FT CODE OF Governance Section F.3 SFI 2.1.1 AUDIT COMMITTEE The Committee will: Oversee the maintenance of an effective system of internal financial control and management reporting. Maintain an overview of the Risk Management arrangements of the Trust including financial and non - financial aspects: - Relevant risk management strategies are in place to identify and manage risk. - Actions plans are being implemented. - The work of Internal Audit is validated and supervised by the committee in respect of controls assurance. Receive the report from the head of Internal Audit relating to the Trust's overall Controls Assurance position. Oversee the effective operation of Internal Audit and compliance with mandatory audit standards. Review of the Internal Audit programme. Appoint the Internal Auditors of the Trust. Consider the appointment of the External Auditor. Discuss and agree the nature and scope of the External Audit. Review External Audit Reports Review External Audit performance. Review and make recommendations for approval of the annual financial statements. Review Internal Audit performance. Review Counter Fraud performance. 9 FT Code of governance Section E SFI 9.1.1 NOMINATION AND REMUNERATION COMMITTEE The Committee will: Consider and agree the remuneration and terms of service of Executive Directors, other Directors and senior employees, as determined by the Board. Advise on and oversee contractual arrangements for Executive Directors, and other Directors as determined by the Board, including proper calculation and scrutiny of any termination payments. Monitor and evaluate the performance of individual Executive Directors.

REF COMMITTEE DECISION/DUTIES DELEGATED BY THE BOARD TO COMMITTEES HSC 1999/65 QUALITY COMMITTEE Ensure the fit and proper persons test is completed annually The Committee will: Ensure there is continuous improvement in care consistent with overall policies and priorities of the Government, the NHS, Care Quality Commission, NHSI, Trust strategies for Quality, Risk Management, Professional Development and the Royal Colleges, GMC and UKCC etc. Initiate the development and approval of Trust wide Clinical Policies, Procedures and Guidelines. Oversee the development and delivery of the Quality and Risk strategies and monitor performance against objectives and ensure corrective action is taken where necessary. Ensure effective systems and processes are in place to ensure the effective monitoring and management of performance against agreed standards. Agree clear lines of accountability and responsibility to ensure effective delivery of the strategy. Monitor progress and developments relating to the action plan arising from the Trust s Assurance Framework where these are not considered by other Board Committees e.g. F&IC. Report to the Board on Clinical Governance activities. Ensure there is effective involvement and communication with patients and other relevant parties. Respond to and liaise with NICE, Care Quality Commission, NHSI and successor bodies. Ensure effective management of clinical risk. Produce an annual report on clinical governance. Produce a monthly report on the Trust compliance with CQUIN targets 10

REF COMMITTEE DECISION/DUTIES DELEGATED BY THE BOARD TO COMMITTEES FT Code of governance section A FINANCE AND INVESTMENT COMMITTEE APPOINTMENTS AND REMUNERATION COMMITTEE for Non-Executive Directors TRUST DELIVERY GROUP The Committee will: Provide support and assurance to the Trust Board that key financial issues are properly scrutinised Provide that robust measures exist to review financial performance and to give oversight to the development of appropriate financial strategy. Report to the Trust Board in the form of a Summary Report, drawing specific detailed attention to any areas of concern, with recommendations on what remedial action should be taken. Scrutiny of the Performance Management Framework from a financial and contractual perspective. Establish and maintain a system of financial reporting to the Trust Board which is clear, concise, relevant, timely and NHSI compliant. To consider all business cases, clinical and or commercial with a whole life cost of: more than 0.5m To consider business cases for capital and / or revenue investment where the value is over 0.5m after review by Trust Management Group, and to approve as appropriate those cases in accordance with the delegated limits of > 500K < 1.5m The Council of Governors will establish an Appointments and Remuneration Committee. The committee will include the 5, nominated members of the Council of Governors, comprising 1 Staff Member, 3 Public Members and 1 Appointed Member and if necessary, external assessor (to provide advice only). The Trust Chair may attend for specific items in an advisory capacity. The Committee will recommend the appointment of Non-Executive Directors (including the Chair) to the Council of Governors together with the remuneration for the Trust Chair and Non-Executive Directors A Trust Delivery Group will be established to be responsible for the day to day operational activity of the organisation. The Committee will comprise, the Executive Members of the Trust Board, the Divisional Directors, Medical Directors, Heads of Nursing, the Head of Midwifery and the Trust Secretary/Director of Corporate Affairs. 11

REF COMMITTEE DECISION/DUTIES DELEGATED BY THE BOARD TO COMMITTEES PEOPLE COMMITTEE The People Committee is constituted as a Standing Committee of the Trust Board. The purpose of the Committee is to oversee the development and delivery of the Developing our People enabling strategy and associated frameworks. ovide assurance to the Trust Board that key workforce and workforce related performance issues are properly scrutinised and managed, ensuring that robust measures exist to monitor and review the workforce and organisational development activity. To provide the Board with assurance concerning all aspects of workforce relating to the provision of care and services in support of getting the best clinical outcomes and experience for patients and staff; working as appropriate with partner health and care organisations. To assure the Board that the structures, systems and processes are in place to support the workforce in the provision and delivery of high quality, safe patient care and to promote equality, diversity and inclusion. To assure the Board that, where there are workforce or organisational development risks (that may jeopardise the Trust s ability to deliver its strategic objectives), that these are being managed appropriately. 12

SECTION 3 DECISIONS RESERVED TO THE COUNCIL OF GOVERNORS REF N/A N/A N/A N/A N/A N/A N/A 13 Council of Governors COUNCIL OF GOVERNORS COUNCIL OF GOVERNORS COUNCIL OF GOVERNORS COUNCIL OF GOVERNORS COUNCIL OF GOVERNORS COUNCIL OF GOVERNORS COUNCIL OF GOVERNORS DECISIONS RESERVED TO THE COUNCIL OF GOVERNORS General enabling provision under Health and Social Care Act 2012 Regulations and Control Appointments/Dismissal 1. Subject to annex 5 section 1.1 to 1.7 and section 2.1 to 2.3 of the Constitution to appoint or remove respectively the Chair and the other Non-Executive Directors. Removal of the Chair and Non-Executive Directors requires a three-quarters majority of the Council of Governors as detailed in section 2.3 of annex 5. 2. To appoint or remove the Trust's external auditor on the recommendation of the Audit Committee 3. To approve an appointment (by the Non-Executive Directors) of the Chief Executive. Strategy, Business Plans and Budgets 1. 2 To decide the remuneration and other terms and conditions of office, of the Chair and other Non- Executive Directors. To approve: amendments to the constitution the Trust to entering into a significant transaction decisions on Non NHS income Policy determination 1. Preparation and review of the Trust's Membership Development Strategy and the role and composition of the Council of Governors. To receive audit reports and recommendations as referred to them by the Audit Committee To receive the Annual Report and Accounts approved by the Board prior to the presentation at the Annual Members Meeting.

SECTION 4 DELEGATIONS DERIVED FROM THE ACCOUNTABLE OFFICER MEMORANDUM REF DELEGATED TO DUTIES DELEGATED FT COG A.2 FT COG A & F FT COG D FT COG A.2 FT COG A.2 Chief Executive (CE) CE and Director of Finance (DofF) CE CE CHAIR CE DofF CE CE Accountable through NHS Accounting Officer to Parliament for stewardship of Trust resources. Ensure the accounts of the trust are prepared under the principles and in a format directed by the Independent Regulator Accounts must show a true and fair view of the Trust's income and expenditure and its state of affairs and be prepared on a going concern basis. Ensure that the Trust operates within the Prudential Borrowing Code laid down by the Independent Regulator. Sign the accounts on behalf of the Board. Sign a statement in the accounts outlining responsibilities as the Accountable Officer. Ensure effective management systems that safeguard public funds and assist the Trust Chair to implement the requirements of corporate governance including ensuring that managers: 1. Have a clear view of their objectives and the means to assess achievements in relation to those objectives 2. Be assigned well defined responsibilities for making the best use of resources; and 3. Have the information, training and access to the expert advice they need to exercise their responsibilities effectively Implement requirements of corporate governance Achieve value for money from the resources available to the Trust and avoid waste and extravagance in the Trust's activities. Follow through the implementation of any recommendations affecting good practice as set out in reports from such bodies as the Audit Commission and the National Audit Office (NAO). Operational responsibility for effective and sound financial management and information. Primary duty to see that DofF discharges this function. Ensuring that expenditure by the Trust complies with Parliamentary requirements. 14

REF DELEGATED TO DUTIES DELEGATED FT COG F.1 FT COG F FT COG A CE and DofF CE CE Chief Executive, supported by Director of Finance, to ensure appropriate advice is given to the Board on all matters of probity, regularity, prudent and economical administration, efficiency and effectiveness. If the Chief Executive considers the Board or Chair is doing something which might infringe probity or regularity, he/she should set this out in writing to the Chair and the Board. If the matter is unresolved, he/she should ask the Audit Committee to enquire and if necessary inform the Independent Regulator. If the Board is contemplating a course of action which raises an issue not of formal propriety or regularity but affects the Chief Executive's responsibility for value for money, the Chief Executive should draw the relevant factors to the attention of the Board. If the outcome is that the Chief Executive is overruled it is normally sufficient to ensure that the advice and the overruling of it are clearly apparent from the papers. Exceptionally, the Chief Executive should inform the Independent Regulator. In such cases, and in those described in paragraph 24 of the Accountable Officer Memorandum, the Chief Executive should as a member of the Board vote against the course of action rather than merely abstaining from voting. 15

SECTION 5 DELEGATIONS DERIVED FROM THE CODES OF CONDUCT AND ACCOUNTABILITY REF DELEGATED TO AUTHORITIES/DUTIES DELEGATED FT COG A FT COG A&B FT COG A BOARD BOARD ALL BOARD MEMBERS, EXECUTIVE COMMITTEE MEMBERS AND COUNCIL OF GOVERNORS BOARD CHAIR AND NON EXECUTIVE DIRECTORS BOARD Approve procedure for declaration of hospitality and sponsorship - Audit Committee Ensure proper and widely publicised procedures for voicing complaints, concerns about maladministration, breaches of the Code of Conduct and other ethical concerns. Subscribe to the Code of Conduct. Board members share corporate responsibility for all decisions of the Board. Chair and Non-Executive Directors are responsible for monitoring the executive management of the Trust. The Board has six key functions: BOARD 1. To set the strategic direction of the Trust within the overall policies and procedures of the Government and the NHS, define its annual and longer term objectives and agree plans to achieve them. 2. To oversee the delivery of planned results by monitoring performance against objectives and ensuring corrective action is taken when necessary. 3. To ensure effective financial stewardship through value for money, financial control and financial planning and strategy. 4. To ensure that high standards of corporate governance and personal behaviour are maintained in the conduct of the business of the whole Trust. 5. To appoint, appraise and remunerate senior executives (Non-Executive Directors only) 6. To ensure that there is effective dialogue between the Trust and the local community on its plans and performance and that these are responsive to the needs of the community. It is the duty of the Board to: 16 1. Act within statutory financial and other constraints. 2. Be clear what decisions and information are appropriate to the Board and draw up Standing Orders, a schedule of decisions reserved to the Board and Standing Financial Instructions to reflect these. 3. Ensure that management arrangements are in place to enable responsibility to be clearly delegated to

REF DELEGATED TO AUTHORITIES/DUTIES DELEGATED Executive Directors for the main programmes of action and for performance against programmes to be monitored and Executives Directors held to account. 4. Establish performance and quality targets that maintain the effective use of resources and provide value for money. 5. Specify its requirements in organising and presenting financial and other information succinctly and efficiently to ensure the Board can fully undertake its responsibilities. 6. Establish audit and remuneration committees on the basis of formally agreed terms of reference which set out the membership of the sub committee, the limit to their powers, and the arrangements for reporting back to the Board. CHAIR It is the role of the Chair to : CHIEF EXECUTIVE 1. Provide leadership to the board. 2. Enable all Board members to make a full contribution to the Board's affairs and ensure that the Board acts as a team. 3. Ensure that key and appropriate issues are discussed by the Board in a timely manner. 4. Ensure the Board has adequate support and is provided efficiently with all the necessary data on which to base informed decisions. 5. Lead non-executive Directors through a formally appointed remuneration committee of the Board on the appointment, appraisal and remuneration of the Chief Executive and (with the latter) other executive Board members. 6. Advise the Independent Regulator on the performance of Non-Executive Directors. 7. Ensure Fit and Proper Persons test is presented to the Board The Chief Executive is accountable to the Chair and Non-Executive Directors. His / Her role is to ensure that the Boards decisions are implemented, that the Trust works effectively in accordance with Government policy and within the Trust's Constitution and also to ensure that public service values are maintained The Chief Executive is responsible for fulfilling the decisions of the Board, operating within the delegated powers, agreed by the Board The other duties of the Chief Executive as accountable officer are laid out in the Accountable Officer Memorandum. NON EXECUTIVE DIRECTORS Non-Executive Directors are appointed by the Council of Governors on the recommendation of the Governors Appointments and Remuneration Committee to bring independent judgement to bear on issues of strategy, performance, key appointments and accountability through Members to the local community. 17

REF DELEGATED TO AUTHORITIES/DUTIES DELEGATED SENIOR INDEPENDENT NON EXECUTIVE DIRECTOR The role of the Senior Independent Director (SID) is identified within the Combined Code of Governance, and more recently in the NHS Foundation Trust Code of Governance. The role has specific responsibilities which would come into effect should there be conflict within the Board of Directors, and where such conflict involves the Chair of the Board. The role has responsibilities for overseeing the procedures for appraising the Chair s performance, (in the case of the Trust in conjunction with the Council of Governors). The SID is appointed as a means for other directors, and/or governors to call upon to resolve a conflict involving the Chair. In such an instance, the SID has authority to suspend the Chair from office pending investigation, while the matter of conflict is considered and resolved. CHAIR AND DIRECTORS BOARD Declaration of conflicts of interest. NHS FT Boards must comply with legislation and Authorisation issued by the FT Regulator, respect agreements entered into by themselves or on their behalf and establish terms and conditions of service that are fair to the staff and represent good value for money. 18

SECTION 6 DELEGATIONS FROM STANDING ORDERS REF DELEGATED TO AUTHORITIES/DUTIES DELEGATED SO 1.1 CHAIR Final authority in interpretation of SOs. SO 3.4 CHAIR Calling meetings. SO 3.13 CHAIR Chairing all Board meetings and associated responsibilities. SO 6.8 Trust Secretary Register(s) of interests. SO 9.4 CE Authorise an officer to oversee and manage a contract on behalf of the Trust. SO 9.1 Trust Secretary Keeping Trust Seal in a safe place, maintaining a register of sealings and reporting use to the Trust Board. The Trust Secretary is also a signatory for sealings. SO 10.1 CE Approving and signing all documents which will be necessary in legal proceedings. SO 10.2 CE or DofF Signing on behalf of the Trust any agreement or document required to be executed as a deed. SO 11.1 CE Ensuring all Directors and employees, present and future, are notified of and understand the requirements of the Trust s Standing Orders. 19

SECTION 7 DELEGATION FROM STANDING FINANCIAL INSTRUCTIONS 20 SFI REF DELEGATED TO AUTHORITIES/DUTIES DELEGATED 1.3.6 CE Ensuring all Directors and employees, present and future, are notified of and understand the requirements of the Trust s Standing Financial Instructions. 1.3.9 DofF Implementing the Trust s financial policies and coordinating corrective action and ensuring detailed financial procedures and systems are prepared and documented. 1.3.10 All Directors & Employees Responsible for the security of the Trust s property, avoiding loss, exercising economy and efficiency in using resources and conforming to Standing Orders, Standing Financial Instructions, financial procedures and the Reservation of Powers to the Board and Detailed Scheme of Delegation. 1.3.9 DofF Form and adequacy of financial records of all departments. 2.1.1 AUDIT COMMITTEE Providing an independent and objective view on internal control and probity. 2.3 AUDIT COMMITTEE 2.4 AUDIT COMMITTEE Ensuring cost effective audit. Reviewing, appraising and reporting in accordance with the NHS Internal Audit Manual and best practice. 2.6 DofF Investigating any suspected cases of fraud or other irregularity, in conjunction with the Counter Fraud Officer. 2.7 CE Responsible for controlling and coordinating security. 3.1.2 DofF Submitting budgets, monitoring performance against budget, submitting financial estimates and forecasts to the Board. FINANCE AND INVESTMENT COMMITTEE The purpose of the Finance and Investment Committee is to provide support and assurance to the Trust Board that key financial issues are properly scrutinised and that robust measures exist to review financial performance and to give oversight to the development of appropriate financial strategy. 3.2.1 CE Delegating budgets to budget holders and submitting monitoring returns to the Independent Regulator. 3.3 DofF Devising and maintaining systems of budgetary control. 4 DofF Production of annual accounts and reports. 5 DofF Banking arrangements. 6 DofF Income systems. 6.5.5 DofF Maximum cash that can be accepted in respect of a single or related linked transaction is 10,000

SFI REF DELEGATED TO AUTHORITIES/DUTIES DELEGATED 7.1 DofF Negotiating contracts for the provision of patient services. 7.1 DofF Authorise officers with power to negotiate contracts with commissioners of healthcare and other authorities. 7.6 DofF Regular reports of actual and forecast contract income and expenditure. 8 CE Tendering and Contract Procedure. 8.13 CE Ensuring best value for money is demonstrated for all services provided under contract or in-house. 9 NOMINATION AND REMUNERATION COMMITTEE Making recommendations to the Board concerning remuneration and terms of service of Directors. 9.3 CE Executive Appointments within establishment 9.4 DofWF and DoF Payroll SFI 9.5 Trust Board Authorise officers to enter into contracts of employment, re-grading staff, agency staff or consultancy service contracts. 10.1 CE Delegate non-pay expenditure budgetary responsibilities for specific budgets to budget managers. 10.2.2 DofF Payment of accounts in line with Trust payment terms 11 DofF 12 CE/DofF Capital investment programme. 12.1 CE/DofF Monitoring the capital programme. 12.3 CE Maintenance of asset registers. 12.4.1 CE Overall responsibility for fixed assets. 12.4.4 EXECUTIVE DIRECTORS AND EMPLOYEES Advising the Board on borrowing and investment needs and preparing procedural instructions in relation to these areas. Responsibility for security of Trust assets including notifying discrepancies to DofF, and reporting losses in accordance with Trust procedures. 13.2 DofF Responsibility for systems of control over stores and receipt of goods. 13.8 CE Identifying persons authorised to requisition and accept goods from Supplies/Trust stores. SFI 14 DofF Determining any items to be disposed of by sale or negotiation. 14.1.1 DoF Procedure for asset disposal and condemnations. 21

SFI REF DELEGATED TO AUTHORITIES/DUTIES DELEGATED 14.2 DofF Preparing procedures for recording and accounting for losses and special payments, all frauds and informing the police in cases of suspected arson or theft, and where appropriate involving the Local Counter Fraud Office (LCFS). 15 DofF Responsibility for accuracy and security of computerised financial data. 16 CE Responsibility for ensuring patients and guardians are informed about patients' money and property procedures on admission. 18 CE Retention of document procedures. 19 CE Risk management programme. 19.3 Trust Board Insurance arrangements. See Standing Financial Instructions Section 19. 19.4 DofF Risk Pooling arrangements. 19.5 DofF Management of liabilities for taxation. 22

SECTION 8 DETAILED SCHEME OF DELEGATION Matters which have been delegated by the board are set out below together with the levels to which they have been delegated. Delegation to lower levels of authority may only be made with the approval of the Director of Finance. This delegation of authority will be enacted through the allocation of Budgets and Budget Responsibilities and Authorised Signatories Lists. Where decisions that may have far reaching effect have been taken at the delegated level they should nevertheless be reported to the Chief Executive. All decisions relating to finance matters should also have regard to the Trust's Standing Financial Instructions and Standing Orders. For the purposes of this Scheme of Delegation UK is defined as England, Wales, Scotland, Northern Ireland, Isle of Man, Channel Islands All monetary limits include Value Added Tax (VAT). Where more than one officer is listed, the use of the word and means that both individuals must authorise the action, whereas, if or is used, authorisation is required by only one of the individuals. 23

SECTION 8 DETAILED SCHEME OF DELEGATION 1. Management of Budgets DELEGATED MATTER All revenue budgets will be allocated to a cost centre and all cost centres will have a named individual specified as budget holder Responsibility for keeping expenditure within budget. DELEGATED TO REFERENCE DOCUMENTS SFIs section 3 a) At individual budget level (Pay/Non-pay/Income) Budget Holder b) At Service/Department level Manager or Department Head c) For the totality of services covered by Chief Operating Officer or Functional Executive Director Directors, Divisional Directors and Deputy Directors where applicable d) For any other areas Board Director or CE 1.1 Budget Virement a) Virement within Cost Centres and Directorates from within approved revenue budgets Recurrent and Non Recurrent. Up to 9,999 From 10,000 to 19,999 From 20,000 to 49,999 From 50,000 to 99,999 From 100,000 to 249,999 Over 250,000 b) Virement between Directorates from within approved revenue budgets Recurrent and Non Recurrent. Limits as above (1.1 a) [All parties agreement required if transferring outside the scope of a single parties delegated authority] Budget Managers General Managers Divisional Directors taking advice from Business Partner DofF CE Trust Board As above with agreement of both Directorates. SFIs section 3.2.6 SFIs section 3.2.6 2. Maintenance and operation of bank accounts and facilities Director of Finance SFIs Section 5 24

DELEGATED MATTER 3. Requisitioning - Non Pay expenditure / payment for goods and services. 3.1 Revenue goods and services Authorisation & Approval of Purchase Requisitions and Supplier Invoices as follows: Up to 9,999 From 10,000 to 19,999 From 20,000 to 49,999 These limits are aligned with the Authorised Signatories forms for each cost centre. From 50,000 to 99,999 Over 100,000 Note: Where the total expenditure of the requisition is to be ordered against a contract which has otherwise been formally approved in accordance with SFI s (and the requisition is therefore in effect a technical device to allow progression to order stage e.g. as within the electronic procurement system), then in addition to the above, requisition approval up to the limit of the formally approved contract may be delegated to Associate Directors or Operation Managers. DELEGATED TO [Always subject to sections 5 and 6, Quotations, tendering and contract procedures] Budget Managers General Managers & Corporate Equivalent Divisional Directors and Corporate Directors Authorised Signatory Forms may be used to delegate to specified officers below these levels. Any Executive Director Director of Finance REFERENCE DOCUMENTS SFIs Section 10 3.2 Capital Works Requisition Authorisation & Approval of Purchase Requisitions and Supplier Invoices as follows: 25 Up to 49,999 Scheme Manager

From 50,000 to 249,999 Over 250,000 DELEGATED MATTER All the above limits are subject to the scheme budget having been approved by a Capital Expenditure Committee (CAPEX) either; MDC Medical Devices Committee IT IT Committee EPSG Estates Prioratisation Schemes Group.and the expenditure being within this budget 3.3 Business Case Approval Where whole life cost is: Up to 499,999 From 500,000 to 1,499,999 Over 1,500,000 DELEGATED TO Capital Projects Manager Director of Finance and Capital Projects Manager Trust Delivery Group Finance and Investment Committee Trust Board REFERENCE DOCUMENTS 4. Capital Schemes SFIs Section 12 a) Selection of architects, quantity surveyors, consultant engineers and other professional advisors via tender evaluation form Where the fee estimate is up to 25,000 Where the fee estimate exceeds 25,000 b) Financial monitoring and reporting on all capital scheme expenditure c) Disposal of land and buildings Up to 149,999 From 150,000 d) Authorisation limits for capital expenditure (excluding works schemes (see 5.e) Capital Projects Manager and reported to CAPEX committee CAPEX DofF CAPEX and Reported to the Board Trust Board 26

DELEGATED MATTER Up to 149,999 From 150,000 to 499,999 From 499,999 to 1,499,999 From 1,500,000 5. Quotations, tendering and contract procedures (Capital Projects) a) Obtaining 2 minimum competitive verbal quotations for goods/services/advisers up to 9,999 b) Obtaining 2 written quotations for goods/services from 10,000 to 24,999 c) Obtaining at least 3 written competitive tenders for goods and services in excess of 25,000 d) Issuing formal EU tenders for goods/services in excess of the current EU limit DELEGATED TO Any 2 of DofF CE/ Exec Director CAPEX Committee or F&IC F&IC Trust Board Head of Procurement or Capital Projects manager or IT Projects Manager Head of Procurement or Capital Projects manager or IT Projects Manager Head of Procurement or Capital Projects Manager or Associate Director of IM&T Head of Procurement or Capital Projects Manager or Associate Director of IM&T REFERENCE DOCUMENTS SFIs Section 8 e) Procurement of Works Head of Procurement or Capital Projects Manager f) Approval of all contracts for goods/services via tender evaluation form / Trust Board report Up to 24,999 DofF or nominated deputies, independent of the Directorate involved From 25,000 to 249,999 Any 2 of CE / DofF /Head of Procurement From 250,000 to 499,999 Any 2 of CE / DofF / Exec Director From 500,000 Trust Board g) Waiving of quotations and tenders subject to SFIs Less than 9,999 DofF From 10,000 to 999,999 DofF and reported to the Finance and Investment Committee More than 1,000,000 Trust Board 27

DELEGATED MATTER DELEGATED TO h) Opening Tenders Officer designated by CE in accordance with Appendix A of the Trusts SFI s. i) Signing of detailed contract documents for Capital Projects on behalf of the Trust, provided due process followed (Excluding PFI) Up to 500,000 Head of Procurement or Capital Projects manager or IT Projects Manager Over 500,000 Any 2 of CE / DofF/ Exec Director and Sealed in accordance with SOs j) Contract Variation Up to 5% within Approved Sum From 5% to 10% Capital Projects Manager or Head of Procurement or Head of Facilities or IT Projects Manager 1 of CE / DofF REFERENCE DOCUMENTS SFI App A. Para. 2.3 28 Over 10% or outside Approved Sum 6. Quotations, tendering and contract procedures (Other expenditure, including non property lease and licences) a) Obtaining 2 minimum competitive quotations including verbal for goods/services from 2,000 up to 4,999, and maintaining audit evidence for a minimum of 18 months b) Obtaining 2 written quotations or tenders for goods/services from 5,000 to 49,999 c) Obtaining 2 or more, according to market conditions, written competitive tenders for goods and services in excess of 50,000 d) Issuing formal EU tenders for goods/services in excess of the current EU limit e) Approval of all contracts for goods/services From 5,000 up to 24,999 From 25,000 to 249,999 Return to Standard Approval Process Budget Manager and Head of Procurement Head of Procurement Head of Procurement Head of Procurement 1 of either DofF or Head of Procurement or nominated deputies, independent of the Directorate involved 2 of either CE or DofF or Head of SFIs Section 8

29 From 250,000 to 499,999 From 500,000 DELEGATED MATTER f) Waiving of quotations and tenders subject to SFIs (excluding capital projects) Less than 9,999 From 10,000 to 999,999 More than 1,000,000 g) Opening Quotes or Tenders Up to 49,999 From 50,000 Note: Where or when a quote or tender is issued via an electronic quote or tender system approved for use by the Trust, then the tender opening will be undertaken electronically. A full audit trail which provides the same evidence as a paper based system will be retained. h) Use of Nationally negotiated contracts / Procurement Hub contracts and PASA contracts in place of local tendering procedures Up to 249,999 From 250,000 to 499,999 From 500,000 i) Signing revenue contracts for goods and services on behalf of the Trust (Previously approved in accordance with 5f) Procurement DELEGATED TO Any 2 of CE / DofF / Exec Director Trust Board DofF DofF and reported to AC Trust Board Head of Procurement Officer designated by CE in accordance with Appendix A of the Trusts SFI s. Head of Procurement with agreement of budget holder or IT Projects Manager or Chief Pharmacist Any 1 of CE / DofF / Exec Director Trust Board REFERENCE DOCUMENTS SFI App A. Para. 2.3

Up to 499,999 From 500,000 DELEGATED MATTER j) Issue of Official Orders on behalf of the Trust, provided due process followed. Pharmaceutical items Capital Projects Facilities All other expenditure DELEGATED TO Head of Procurement with agreement of budget holder or IT Projects Manager or Chief Pharmacist Any 1 of CE / DofF/ Exec Director/ Trust Secretary assuming that approval has been obtained in accordance with 5f. [Responsibility delegated to following officers who may sub delegate the issuing but not responsibility.] Chief Pharmacist Capital Projects Manager or IT Projects Manager Head of Facilities Management or Head of Procurement Head of Procurement REFERENCE DOCUMENTS 7. Setting and annual review of fees and charges SFIs Section 6 a) Private patient, overseas visitors, income generation and other patient related services b) Negotiation and agreement of NHS income (including MPET and R & D) DofF DofF and DofWF or Medical Director or COO as appropriate 8. Engagement of Consultants/advisors (Excluding Construction Related Projects) a) Non medical consultancy staff. Where aggregate commitment on any one project in any one year (or total commitment) is Up to 49,999 Over 50,000 TDG member TDG member, Trust Board to be informed 30

DELEGATED MATTER b) Annual report on use of and projected use of non-medical consultants c) Engagement of Trust solicitors in accordance with the Trust legal framework 9. Engagement of Temporary Staffing a) Booking of Bank or Agency staff on framework (e.g. Medical locums, AHP s nursing, clerical) b) Booking of Agency staff (off framework) c) Change in approved number of nursing shifts to be filled by temporary staff DELEGATED TO DoF, presented to Finance and Investment Committee Any 2 members of Trust Delivery Group plus a NED - decision to be reported to Trust Board General Manager/Divisional Director (All temporary staff must be booked via the Flexible Staffing Office) Chief Executive or Executive Director On Call (All temporary staff must be booked via the Flexible Staffing Office) Safe Staffing Board REFERENCE DOCUMENTS 10. Property agreements, leases and licences a) Preparation and signature of all tenancy agreements or licences for all staff subject to Trust policy on accommodation for staff D of WF or DofF b) Entering into and termination of property leases or licences Annual rent up to 24,999 Any 1 of CE or DofF or Nominated Deputies Annual rent over 25,000 Any 2 of CE or DofF or Nominated Deputies c) Extension to existing leases DofF and CE or Nominated Deputies d) Approval of rent for all properties after professional assessment DofF and CE or Nominated Deputies 31

DELEGATED MATTER 11. Condemning and disposal Items obsolete, obsolescent, redundant, irreparable or that cannot be repaired cost effectively a) General Donation of all obsolete capital and revenue items for charitable or other non NHS purposes b) Revenue items originally costing Up to 999 From 1,000 to 9,999 From 10,000 to 49,999 Over 50,000 c) Items bearing a capital asset number with a book value Up to 9,999 From 10,000 to 49,999 Over 50,000 DELEGATED TO With approval to scrap from either Estates or Capital Projects or Medical Engineering or IT or pharmacy or Supplies as appropriate CE General/Budget Manager Divisional Director DofF Trust Board - minuted decision DofF CE and DofF Trust Board - minuted decision REFERENCE DOCUMENTS SFIs Section 14.1 12. Losses, write-offs and compensation SFIs Section 14.2 a) Cash and other losses due to theft, fraud, overpayments and other causes Up to 999 DofF reported to the Audit Committee From 1,000 to 4,999 Over 5,000 Audit Committee Trust Board - minuted decision b) Fruitless payments (including abandoned Capital Schemes) Up to 49,999 Audit Committee 32

Over 50,000 DELEGATED MATTER Trust Board DELEGATED TO REFERENCE DOCUMENTS c) Bad Debts, claims abandoned and write off of private patient, overseas visitor and other debts Individual debts up to 4,999 Individual debts from 5,000 to 49,999 Individual debts over 50,000 DofF Audit Committee, reported to the Board Trust Board - minuted decision Ex Gratia Payments (Excluding Staff) d) Damage to buildings, fittings, furniture and equipment and loss of equipment and property in stores and in use due to culpable causes (e.g. fraud, theft, arson) or other. Up to 4,999 From 5,000 to 49,999 Over 50,000 DofF Audit Committee Trust Board e) To patients for loss of or damage to personal effects Up to 999 From 1,000 to 9,999 Over 10,000 DofF CE Trust Board - minuted decision f) For clinical negligence (negotiated settlements) See legal framework g) For personal injury claims involving negligence where legal advice has been obtained and guidance applied. h) Other, except cases of maladministration, where there was no financial loss by claimant See legal framework CE and DofF - Reported to the Audit Committee i) Cancellation of NHS debtors 33

Up to 249,999 From 250,000 DELEGATED MATTER DofF Audit Committee DELEGATED TO REFERENCE DOCUMENTS 13. Reporting of incidents to the Police IR1 form also required a) In the event of an emergency Any member of staff, then complete IR1 and inform relevant Director b) Where a criminal offence is suspected TDG member Criminal offence of a violent nature TDG member Involving financial loss DofF IT security incidents DofF Other TDG member c) Where a fraud is involved DofF 14. Reporting Security incidents All members of staff 15. Petty cash disbursements SFIs Section 10.5 Expenditure up to 49 per claim In accordance with financial procedures petty cash holder or cashier s office Expenditure above 50 Cashiers offices approved by DoF, Director of Operational Finance, Deputy DoF or Head of Financial Services 16. Implementation of Internal and External Audit recommendations SFIs Section 2 Financial issues Other issues DofF and reported to AC Appropriate TDG member and reported to AC 34

DELEGATED MATTER DELEGATED TO REFERENCE DOCUMENTS 17. Maintenance and updating of Trust Financial Procedures DofF SFIs Section 1.3.9 18. Investment of funds a) Exchequer Funds DofF in accordance with Treasury Management Policy 19. Human Resources and pay (excluding staff covered by remuneration committee) a) Authority to fill funded post on the establishment with permanent General Manager unless vacancy control in staff place b) Retention and recruitment premium Divisional Director or Deputy Director in consultation with D of WF c) Approval to buy out annual leave D of WF in consultation with DofF d) Approval to withhold Agenda For Change (AfC) increments Appraiser in consultation with D of WF SFIs Section 11.2 SFIs Section 9 e) Approval to withhold increments from Consultant Medical staff COO in consultation with Medical Director f) Approval to pay more than 10 Programmed Activities to consultants (PA s) Divisional Director and Job Plans/Team Job Plans signed off by Divisional Medical Director g) All requests for upgrading and regrading D of WF on advice from re-grading panel and in accordance with the Trust s procedure. h) Establishments Additions to the agreed establishment with specifically identified recurrent finance General Manager taking advice from Business Partner and Directorate HR Mgr. Authority to appoint staff to posts not on the formal establishment, but for which non recurrent funding has been identified Divisional Director taking advice from Business Partner and Directorate HR Mgr Additional staff to the agreed establishment without specifically allocated finance over recruitment. COO/DofF 35