Reservation of powers to the board of directors and scheme of delegation

Contents

1 Regulation and control

1.1 Board of directors

• Approval of the standing orders of the board of directors (SOs), a schedule of matters reserved to the board of directors and standing financial instructions for the regulation of its proceedings and business instructions for the regulation of its proceedings and business.
• Suspension, variation or amendment of the standing orders.
• Approval of a scheme of delegation of powers from the board of directors to officers.
• Requiring and receiving the declaration of directors’ interests which may conflict with those of the trust and determining the extent to which that director may remain involved with the matter under consideration.
• Requiring and receiving the declaration of interests from officers which may conflict with those of the trust.
• Ensuring that the SID, chair and chief executive have in place specific arrangements for oversight of the conduct of directors who may be in breach of requirements (for example, Kark or FPPT)
• Approval of the disciplinary procedure.
• Annual review of the adequacy of arrangements for dealing with complaints and FTSU concerns.
• Adoption of the organisational structures, processes and procedures to facilitate the discharge of business by the trust and to agree modifications on the advice of the chief executive and with their agreement.
• To receive reports from committees including those which the trust is required to establish and to take appropriate action thereon.
• To confirm the recommendations of the trust’s committees where the committees do not have delegated powers.
• To establish terms of reference and reporting arrangements of all sub-committees (and other committees if required).
• Ratification of any urgent decisions taken by the chairman in accordance with SO 4.2 (emergency powers).
• Approval of arrangements relating to the discharge of the trust’s responsibilities as a corporate trustee for funds held on trust.
• Approval of arrangements relating to the discharge of the trust’s responsibilities as a bailee for patients’ property.

2 Appointments

2.1 Board of directors

• The appointment and dismissal of committees.
• The appointment to any committee of the board of directors or the appointment of representatives on outside bodies.
• The appointment of the vice chairman of the board of directors.

3 Policy determination

3.1 Board of directors

• The approval of the organisation wide policy for the development and management of procedural documents.

4 Strategy and business plans and budgets

4.1 Board of directors

• Definition of the mission, vision, strategic goals and values.
• Approval of the strategic and annual plans including the annual financial budget and capital budget, having regard to any related guidance issued by NHS improvement.
• Approval and monitoring of the trust’s policies and procedures for the management of risk.

5 Direct operational decisions

5.1 Board of directors

• Acquisition, disposal or change of use of land and, or buildings.
• The introduction or discontinuance of any significant activity or operation. An activity or operation shall be regarded as significant if it has a gross annual income or expenditure (that is before any set off) in excess of £1.25m.
• Approval of individual contracts (other than NHS or local authority contracts) of a capital or revenue nature amounting to, or likely to amount to over £1.25m over a 3-year period or the period of the contract if longer.
• Approve outline and final business cases for capital investment. (over £1.25m).
• Approval of individual compensation (civil) payments over £50,000 prior to submission to NHS England or treasury.
• To ensure scrutiny and oversight of significant litigation against or on behalf of the trust entered into on authority of the chief executive (including when necessary, the appointment of a NED to offer peer scrutiny).

5.2 FDE committee

6 Financial and performance reporting arrangements

6.1 Board of directors

• Approval of the opening or closing of any bank or investment account.
• Receipt and approval of a schedule of NHS contracts signed in accordance with arrangements approved by the chief executive.
• Consideration and approval of the trust’s annual report including the annual accounts.
• Receipt and approval of the annual report(s) for funds held on trust.

7 Audit arrangements

7.1 Board of directors

• To receive reports of the audit committee meetings and take appropriate action.

8 Acceptance of gifts by staff

8.1 All staff

• Receiving gifts or hospitality, applies to both individual and collective gifts or hospitality receipt items.

9 Agreements for the provision of services

9.1 Chief executive officer

• Negotiating contracts for provision of patient services.

9.2 Director of finance

• Regular reports of actual and forecast contract income.
• Negotiating contracts.
• Arrangements for payment of contracts and payments for non-contracted activity.

10 Annual accounts and reports

10.1 Director of finance

• Annual accounts and reports.

11 Asset registers

11.1 Director of finance

• Maintenance of asset registers
• Calculate and pay capital charges

11.2 Chief executive officer

• Overall responsibility for fixed assets.

11.3 Staff

• Responsibility for security of trust assets including notifying discrepancies to the director of finance and reporting losses in accordance with trust procedure.

12 Audit Committee

12.1 Audit Committee

• Ensure cost-effective external audit.
• Clinical audit annual programme.

12.2 Chief executive officer

• Implementation of internal and external audit recommendations.

13 Banking procedures

13.1 Director of finance

• Maintenance or operation of bank accounts.
• Banking arrangements.

14 Brokers or advisors

14.1 Chief executive officer

• Ensure that the best cover and value is obtained for specific services.

14.2 Director of finance

• Ensure that the broker or advisor undertakes their role in the best interest of the trust.

15 Budgetary control and reporting

15.1 Budget manager

• Responsibility for keeping expenditure within budgets, at individual budget level (pay and non-pay), at service level.

15.2 Chief executive officer

• Responsibility for keeping expenditure within budgets, for the totality of services.
• Ensuring compliance with sector regulator for health services requirements.
• Temporarily or permanent adjustments to delegated limits under specific conditions.

15.3 Director of finance

• Overall responsibility for cash forecasting.
• Devise and maintain systems of budgetary control.
• Responsible for implementing the trust’s financial policies and coordinating corrective action and ensuring detailed financial procedures and systems are prepared and documented.
• Form and adequacy of financial records of all departments.
• To ensure, on appointment, all employees and directors, present and future, are notified of and understand standing financial instructions.
• Maintenance and update on trust financial procedures.

16 Capital investment

16.1 Board of directors

• Capital investment programme (capital plan).

16.2 Director of finance

• Monitoring the capital programme.
• Approve outline and final business cases for capital investment, up to £250,000.

16.3 Head of estates and facilities

• Selection of architects, quantity surveyors, consultant engineer and other professional advisors; within EU directives and statutes, taking full account of the quality of services to be provided.

16.4 Chief executive officer and director of finance

• Granting and termination of leases

16.5 Budget manager

• All contracts for goods and services and subsequent variations to
  contracts as per delegated limit.

16.6 Chief executive officer

• Approve outline and final business cases for capital investment, between £250,000 and £500,000.

17 Choice, requisitioning, ordering, receipt and payment for goods and services

17.1 Budget manager

• All single requisitions up to and including £2,000.
• Petty cash disbursements, expenditure up to £200 per item.
• Reimbursement of patients monies up to £200.
• Reimbursement of patients monies in excess of £200.

17.2 Senior managers

• All single requisitions up to and including £10,000, as per list of authorised nominated staff (subject to quotation rules).
• All single requisitions up to and including £25,000, as per list of authorised nominated staff (subject to quotation rules).

17.2 Care group directors

• All single requisitions up to and including £50,000 (subject to quotation rules).
• Foreign travel, less than £2000.

17.3 Directors

• All single requisitions up to and including £100,000 (subject to tender rules).

17.4 Director of finance

• All single requisitions up to £250,000 (subject to tender rules).

17.5 Chief executive officer

• All single requisitions from £250,000 to £500,000 (subject to tender rules).

17.6 Board of directors

• All single requisitions over £500,000 (subject to tender rules).
• All single requisitions over £1.25m (subject to tender rules).

17.7 FDC committee

• All single requisitions over £500,000 and up to £1.25m (subject to tender rules).

17.8 Care group director and directors

• Petty cash disbursements, expenditure above £100 per item (maximum £250).

17.9 Director of finance and director of people and organisational development

• Foreign travel, £2000 and above.

17.10 All staff

• Personal transactions, lease cars and mobile phones are the only areas for which personal recharges are acceptable.

18 Commissioning

18.1 Director of finance

• Ensure the effective accounting of expenditure under the adult eating disorder services (in patient) contract.

19 Counter fraud, corruption and security

• Ensure any suspected cases of fraud are investigated.
• Carry out all work to counter fraud and corruption and for security management.
• Reporting of incidents to the police, where a fraud is involved.

• Reporting of incidents to the police, where a criminal offence is suspected.

20 Disposals and condemnations

20.1 Director of finance

• Determining any items to be sold by auction or negotiation.

20.2 Budget manager and head of purchasing

• Condemning and disposal, Items obsolete, obsolescent, redundant, irreparable or cannot be repaired cost effectively.

20.3 Head of estates and facilities

• Condemning and disposal, disposal of mechanical and engineering plant.

20.4 Chief pharmacist

• Condemning and disposal, disposal of controlled drugs.

21 Engagement of staff not on the establishment

21.1 Budget manager

• Booking of bank, NHS professionals or agency staff (in accordance with establishment control procedures), medical locums, nursing, and clerical.

21.2 Board secretary

• Engagement of trust’s solicitors or legal representation and professional advice.

21.3 Director of health informatics and director of people and organisational development

• Medical consultancy staff.

21.4 Chief executive officer

• Management consultancy staff where aggregate commitment in any one year is more than £50,000.

21.4 Director of finance and chief executive officer

• Management consultancy staff where aggregate commitment in any one year (or total commitment) is less than £50,000.

22 External borrowing

22.1 Director of finance

• Advise board on borrowing and investment needs and prepare procedural instructions.

23 Fees and charges

23.1 Director of finance

• Private patient, overseas visitors, NHS trust communications trading agency, income generation and other patient related services.
• Price of NHS contracts, charges for all NHS contracts, be they block, cost per case, cost per volume, spare capacity.

24 Funded establishment

24.1 Chief executive officer and chief operating officer

• Variation to funded establishment of any department.

25 Funds held on trust

25.1 Funds manager

• Under £1,000 per request.

25.2 Director of finance

• £1,000 to £5,000 per request.
• Shall ensure each fund held on trust is managed appropriately (subject to the discretion and approval of the Charitable Funds Committee).

25.3 Chief executive officer

25.4 Charitable Funds Committee

• Over £10,000 per request.

26 Income

26.1 Director of finance

• Income systems.

27 Information technology

27.1 Director of finance

• Responsible for accuracy and security of computerised financial data.

27.2 Director of health informatics

• Responsible for Freedom of Information requirements and the Publication Scheme.
• Review of trust’s compliance with the Data Protection Act.
• Review the trust’s compliance with the Access to Records Act.
• Review of the trust’s compliance code of practice for handling confidential information in the contracting environment and the compliance with “safe haven” per EL 92/60.

28 Internal control and probity

28.1 Audit Committee

• Provide independent and objective view on internal control and probity.

29 Losses and special payments

29.1 Audit Committee

• To receive the report of losses and special payments.

29.2 Director of finance

• Losses of cash due to theft, fraud, overpayment and others, up to £10,000 inclusive.
• Fruitless payments (including abandoned capital schemes), up to £10,000 inclusive.
• Bad debts and claims abandoned, up to £10,000 inclusive.
• Private patients, overseas visitors and other, up to £10,000 inclusive.
• Damage to buildings, fittings, furniture and equipment and loss of equipment and property in stores and in use due to culpable causes (for example, fraud, theft, arson), up to £10,000 inclusive.
• Ex-gratia payment, up to £10,000 inclusive.
• Other, except cases of mal administration where there was no financial loss by claimant, up to £10,000.
• For personal injury claims involving negligence where legal advice has been obtained and guidance applied, up to £9,999.

29.2 Chief executive officer

• Losses of cash due to theft, fraud, overpayment and others, above £10,000.
• Fruitless payments (including abandoned capital schemes), above £10,000.
• Bad debts and claims abandoned, above £10,000.
• Private patients, overseas visitors and other, above £10,000.
• Damage to buildings, fittings, furniture and equipment and loss of equipment and property in stores and in use due to culpable causes (for example, fraud, theft, arson), above £10,000.
• Ex-gratia payment, above £10,000.
• For clinical negligence, £50,000 up to £1,000,000.
• For personal injury claims involving negligence where legal advice has been obtained and guidance applied, £50,000 up to £1,000,000.

29.3 Director of finance and chief executive officer

• Compensation payments made under legal obligation (subject to redundancy limits).
• Extra contractual payment to contractors.
• For personal injury claims involving negligence where legal advice has been obtained and guidance applied, £10,000 to £50,000 (including claimant’s costs).
• Other, except cases of mal administration where there was no financial loss by claimant, above £10,000.
• Write-off of NHS or non-NHS debtors (all losses shall be reported to the Audit Committee).

29.4 Medical director

• For clinical negligence, up to £50,000 (negotiated settlements).

29.5 Board of directors

• For clinical negligence, over £1,000,000.

30 NHS internal audit manual

30.1 Head of internal audit

• Review, appraise and report in accordance with NHS internal audit manual and best practice.

31 Non-pay expenditure

31.1 Director of finance

• Prompt payment of accounts.
• Determine, and set out, level of delegation of non-pay expenditure to budget managers.

31.2 Director of finance and chief executive officer

• Ensure that standing financial instructions are compatible with Health Building Note 00 to 08 and other relevant guidance requirements re building and engineering contracts.
• Material non-pay expenditure for which no specific budget has been set up and which is not subject to funding under delegated powers of virement.
• Orders exceeding 12-month period and £500,000 in value.

32 Patient services

32.1 Chief operating officer

• All proposed changes in bed allocation and use, temporary change.

32.2 Chief executive officer

• All proposed changes in bed allocation and use, permanent change.

33 Patient and relatives complaints

33.1 Chief executive officer

• Overall responsibility for ensuring that all complaints are dealt with effectively.

33.2 Chief executive officer or chief nurse officer

• Responsibility for ensuring complaints relating to a care group are investigated thoroughly.

33.2 Chief executive officer and medical director

• Medico, legal complaints.

34 Patients’ property

34.1 Chief operating officer

• Responsible for ensuring patients and guardians are informed about patients’ money and property procedures on admission.

35 Personnel and pay

35.1 Budget manager

• Authority to fill funded post on the establishment with permanent staff (after ECF).

35.2 Chief executive officer and director of people and organisational development

• Authority to appoint staff to post not on the formal establishment.
• Removal expenses, excess rent and house purchases, authorisation of payment of removal expenses incurred by officers taking up new appointments (providing consideration was promised at interview) up to £8,000.

• Additional increments, the granting of additional increments to staff within budget.

• Upgrading and re-grading, all requests for upgrading or re-grading shall be dealt with in accordance with trust policies and procedures with trust policies, for example, mandatory or statutory training or absence record.
• Sick leave, extension of sick leave on half pay up to 3 months.
• Sick leave, phased return over 4 weeks.
• Sick leave, extension of sick leave on half pay up to 3 months.
• Renewal of fixed term contract.
• Ill health retirement, decision to pursue retirement on the grounds of ill-health.

35.5 Care group directors or directors

• Establishments, additional staff to the agreed establishment with specifically allocated finance.

• Redundancy.

36 Processing payroll

36.1 Director of people and organisational development

• Payroll.

37 Retention of documents

37.1 Chief executive officer

• Retention of document procedures.

37.2 Board secretary

• Sign and seal documents in accordance with standing orders.
• The keeping of register of sealing’s.

38 Risk management

38.1 Director of finance and board secretary

• Insurance arrangements.

38.2 Chief executive officer

• Risk management programme.

38.3 Director of finance

• Review of fire precautions.
• Review of all statutory compliance legislation and health and safety
  requirements including control of substances hazardous to Health Regulation.

38.4 Head of estates and facilities

• Review of compliance with environmental regulations, for example, those relating to clean air and waste disposal.

38.5 Director of nursing and quality

• Infectious diseases and notifiable outbreak.

39 Staff appointments

39.1 Budget manager

• Staff, including agency staff, appointments.
• Work experience students.

39.2 Director of people and organisational development

• Honorary contracts.

40 Stores and receipts of goods

40.1 Director of finance

• Responsible for systems of control over stores and receipt of goods.

40.2 Chief executive officer

• Identify persons authorised to requisition and accept goods from supplies trust stores.

41 Tendering and contract procedures

• Obtaining 2 written quotations, for goods or services from £5,000 to £15,000.

41.2 Head of purchasing and director of finance

• Obtaining minimum of 3 written quotations for goods or services from £15,000 to £50,000.
• Obtaining tender returns for goods and services over £50,000.

41.3 Director of finance

• Waiver of quotations and tenders from £2,000 to £250,000.
• Designate an officer responsible for receipt and custody of tenders, e-tenders, e-auctions and electronic bids before opening.

41.4 Chief executive officer

• Waiver of quotations and tenders from £250,000 to £500,000.
• Nominate officers with power to negotiate commissioning contracts with providers of healthcare and other authorities.
• Best value for money is demonstrated for all services provided under contract or in-house.
• Nominate an officer to oversee and manage all contracts on behalf of the trust.
• Nominate officers to enter into contracts of employment, re-grading staff, agency staff or consultancy service contracts.

42 Property and estate

51 Roles and responsibilities of the council of governors

51.1 Council of governors

• Appoint and, if appropriate, remove the chair.
• Appoint and, if appropriate, remove the other non-executive directors.
• Decide the remuneration and allowances and other terms and conditions of office of the chair and the other non-executive directors.
• Approve (or not) any new appointment of a chief executive.
• Appoint and, if appropriate, remove the NHS Foundation trust’s auditor and agree the terms of engagement on recommendation of the Audit Committee.
• Receive the NHS Foundation trust’s annual accounts, any report of the auditor on them, and the annual report at a general meeting of the council of governors.
• Hold the non-executive directors, individually and collectively, to account for the performance of the board of directors.
• Represent the interests of the members of the trust as a whole and the interests of the public.
• Approve “significant transactions” (as defined in the trust’s constitution).
• Approve an application by the trust to enter into a merger, acquisition, separation or dissolution.
• Decide whether the trust’s non-NHS work would significantly interfere with its principal purpose, which is to provide goods and services for the health service in England, or performing its other functions.
• Agree annual priorities (areas of focus) in conjunction with the trust.

52 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

Document control

• Version: 7
• Unique reference number: 206.
• Date ratified: 23 November 2023.
• Name of originator or author: Director of corporate assurance and board secretary.
• Name of responsible individual or committee: Board of directors.
• Date issued: 26 January 2024.
• Review date: 31 January 2027.
• Target audience: All staff.