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APPENDIX 1: DETAILED SCHEME OF DELEGATION 1 BUDGETARY CONTROL 1.1 Schedule of Budgetary Responsibility Each Divisional Clinical Director and Divisional General Manager is responsible for maintaining a Schedule of Budgetary Responsibility to be approved by the Chief Financial Officer. The Schedule indicates who within each Directorate fulfils the roles identified throughout the Scheme of Delegation. The Divisional General Manager is also responsible for ensuring that the Finance Department is kept informed of any amendments to the Schedule, within his/her delegated limits. The Procurement Department will maintain a record of any ordering limits for users of the electronic ordering system that are set lower than the overall budgetary responsibility limits. The Schedule and any subsequent amendments must be approved by the Chief Financial Officer and notified to the Trust Board. 1.2 Business Case Approval A business case is required for all service and capital developments and must be completed using the Trust’s business case template. The template is reviewed annually by the Finance Department and is located on the intranet. The business case approval process is applicable for business cases requiring capital investment, revenue funding, a combination of capital and revenue funding or business cases that are self- funding/income generating. All business cases will for consideration/approval be signed-off by the Divisional General Manager or Executive Director responsible for the Directorate. Business cases requiring capital investment must receive approval from the relevant Executive Director (refer to table below) before then following the same approval process as revenue business cases. Depending on the specifics of the business case, this approval by the relevant Executive Director may be sufficient to secure the capital funding. If not then the next stage, ie approval by the Chief Executive Officer, Capital Executive Group, Finance, Investment and Estates Committee and Trust Board, will be followed as appropriate. A Business Case register will be maintained by the Chief Financial Officer. A full description of the process to secure capital investment is detailed in the table below as expressed in SFI 24: Equipment business cases up to £200,000 within an overall capital programme approved by the Trust Board IM&T equipment or systems business cases up to £200,000 within an overall capital programme approved by the Trust Board Approved by Chair of Equipment Sub Group within delegated budget and reported to the Capital Executive Group. Approved by IMT Strategy Chair within delegated budget and reported to the Capital Executive Group. Page 1 of 20 Any urgent capital business cases less than £200,000 outside the capital programme approved by the Trust Board. Approved by Chief Financial Officer and reported to Capital Executive Group. All capital business cases over £200,000 within a capital budget allocation approved by the Trust Board. Approved by relevant Executive Director, and then submitted to the Capital Executive Group. All capital business cases up to £4,000,000 where no capital budget allocation has previously been approved by the Trust Board and none of the above categories applies. To Chief Executive Officer, then Capital Executive Group Capital Executive Group and the Finance, Investment and Estates Committee. Any urgent capital business cases in this category (i.e. greater than £200,000 and with no capital budget) must be approved by the Chief Financial Officer for Chairman’s action. To Chief Executive Officer, then Capital Executive Group Capital Executive Group and the Trust Board. Any urgent capital business cases in this category (i.e. greater than £4,000,000 and with no capital budget) must be approved by the Chief Financial Officer for Chairman’s action. All capital business cases over £4,000,000 where no capital budget allocation has previously been approved by the Trust Board and none of the above categories applies. Capital business cases are defined as urgent where they are so deemed by the Chief Executive Officer and Chief Financial Officer. Reference should also be made to the section on Single Tender Waivers in the Standing Orders - see SFI 17.5.3. However, it should be noted that urgency of requirement may not obviate the need to follow the required procurement process, especially where the procurement is in excess of the EU thresholds. The approval process for Revenue only or Revenue and Capital business cases is outlined in the table below: Divisional funded business cases revenue expenditure up to £50,000. of Divisional approval by Divisional General Manager up to an annual limit of £50,000. Divisional funded business cases of revenue expenditure up to £50,000 and requiring capital investment. Divisional approval by Divisional General Manager for revenue costs up to an annual limit of £50,000 and then follow the capital process as described in the table above. If the aggregate is exceeded then the Chief Executive Officer or Chief Financial Officer must approve the business case. Business cases requiring up to £200,000 revenue funding. Approved by relevant Chair of Capital Project Group (if case contains a capital element), then Chief Financial Officer or Chief Executive Officer for approval, within relevant capital and revenue budgets approved by Trust Board. Reported to the Capital Executive Group Capital Executive Group if case contains capital investment. Business cases up to £4,000,000 revenue funding. Approved by relevant Chair of Capital Executive Group (if it contains a capital element), submitted to Chief Executive Page 2 of 20 Officer, then Capital Executive Group for approval (if it contains capital investment). Revenue element of case should be approved by Divisional General Manager, then Chief Financial Officer and the Finance, Investment and Estates Committee. Business cases over £4,000,000 revenue funding or costs. Board approval required. Business case applicants are required to demonstrate that they have involved Finance, HR and Procurement and Contracting where appropriate at the start of the activity for support and advice on costing and procurement strategy. Business case applicants are not permitted to talk directly with suppliers about costs and must instead obtain guide costs and quotations from the Procurement Department, IM&T Directorate or Estates Management Department, as appropriate, for inclusion in business cases. At all points of the business case or procurement process, business case applicants must not discuss commercial issues such as prices with suppliers unless a representative from the Procurement Department is present. In order to provide indicative costs to inform business cases the Estates Department and IT Department must comply with the Trust’s legal obligations and ask the required number of suppliers as outlined in the SO, to provide a quote against an independently drafted specification. Any third parties commissioned to undertake any part of the business planning or procurement process must comply with the Trust’s scheme of delegation and standing financial instructions. 1.3 Management of Budgets The budgets agreed annually by the Board are to be treated independently and should not be aggregated for the purposes of monitoring. With the exception of the Chairman, Chief Executive Officer and Chief Financial Officer no other officer of the Trust is empowered to incur expenditure beyond their budgeted limits. Budget Holders must confirm either in writing or via online confirmation that they have read the Trust’s Standing Orders, Standing Financial Instructions and Scheme of Delegation before they are approved as authorised signatories within the appropriate delegated limits. This confirmation must be renewed annually to take into account the annual revision to these documents. 2 REVENUE EXPENDITURE 2.1 Requisitions for Goods, Works & Services Authorisation limits for requisitioning goods, works & services (excluding Pharmacy) Up to £5,000 Up to £15,000 Up to £25,000 Up to £50,000 Between £50,000 and £150,000 Between £150,000 and £250,000 Over £250,000 Budget Manager or other Designated Signatory General Manager or equivalent Divisional Clinical Director or Divisional General Manager Executive Director Chief Financial Officer Chief Executive Officer Chief Executive Officer & Chairman or Vice Chairman after Board approval Page 3 of 20 All above values are exclusive of VAT Authorisation limits for the requisitioning of Pharmaceutical Drugs; Pharmacy Department Up to £10,000 Pharmacy Purchasing Co-ordinator Pharmacy Payments Administrator Pharmacy Invoicing Manager Pharmacy Buying Office & Stores Manager Homecare Administrator (For Healthcare at Home only) Principal Purchasing Technician Up to £50,000 Pharmacy Purchasing & Distribution Manager Principal Pharmacist Patient Service Up to £300,000 Deputy Chief Pharmacist Head of Pharmacy / Chief Pharmacist Up to £500,000 Chief Executive Officer &Chief Financial Officer Over £500,000 Trust Board All above values are exclusive of VAT The delegated limits shown above for all departments including Pharmacy do not confer any rights to avoid the duty to comply with EU directives governing public procurement, formal tendering or competitive quotations requirements as instructed in section 17 of the SFIs. The Procurement Department should initially be consulted for guidance and support to ensure Trust compliance. 2.2 Confirmation of Goods Received All Orders Appropriate staff member as nominated by Budget Manager and receipt and delivery staff on their behalf 2.3 Contracts for Goods and Services The following are the authorisation levels for entering into contracts for Goods & Services: The Procurement Department should initially be consulted for guidance and support to ensure Trust compliance prior to any new purchase as per the below threshold levels: Contract Value Up to £ 10,000 Contract Value Up to £ 50,000 Contract Value Up to £ 100,000 Contract Value Up to £300,000 Contract Value Up to £750,000 Contract Value Up to £4,000,000 Contract Value over £4,000,000 Budget Holder General Manager Non-Board Director, Divisional Clinical Director Executive Director Chief Executive Officer &Chief Financial Officer Finance & Investment Committee Trust Board Budget holders are reminded that only Procurement Department members of staff have the delegated authority to enter into contracts negotiations with suppliers however agreement of the contract remains subject to a budget holder’s approval in line with the limits above. 2.4 Variations to Revenue Contracts Note – for all construction projects, authorisation is the responsibility of the relevant Project Board or Executive Director. Contract Value Up to £100,000 Contract Value Up to £200,000 Contract Value Up to £750,000 Non-Board Director, Clinical Director Executive Director Chief Executive Officer &Chief Financial Officer Page 4 of 20 Contract Value Up to £4,000,000 Contract Value over £4,000,000 Finance & Investment Committee Trust Board 2.5 Call-off Orders Against Existing Contracts including Pharmacy The following are the authorisation levels for signing call-off orders against existing contracts: Up to £ 10,000 Up to £ 50,000 Up to £100,000 Up to £300,000 Up to £750,000 Over £750,000 Budget Holder General Manager Non-Board Director, Divisional Clinical Director Executive Director Chief Executive Officer &Chief Financial Officer Trust Board 2.6 Invoices Against Existing Service Contracts (All departments excluding Pharmacy) The following are the authorisation levels for signing off invoices against existing service contracts: Up to £ 10,000 Up to £ 50,000 Up to £100,000 Up to £300,000 Up to £750,000 Over £750,000 Budget Holder / Manager General Manager Non-Board Director, Clinical Director Executive Director Chief Executive Officer &Chief Financial Officer Trust Board 2.7 Invoices Against Existing Service Contracts – Pharmacy The following are the authorisation levels for signing off invoices against existing service contracts specific to the Pharmacy Department: Up to £ 7,500 Pharmacy Invoicing Manager Pharmacy Buying Office Manager Pharmacy Payments Administrator Pharmacy Operational Dispensary Manager Lead Clinical Dispensary Pharmacist Chief Technician Technical Services Up to £ 50,000 Pharmacy Purchasing & Distribution Manager Lead Directorate Pharmacist Medicine Lead Directorate Pharmacist W&C Lead Directorate Pharmacist HIV/GUM Up to £300,000 Deputy Chief Pharmacist, Head of Pharmacy, Chief Pharmacist, Non-Board Director Over £300,000 Chief Executive Officer &Chief Financial Officer Over £500,000 Trust Board 2.8 Non-Budgeted Non-Pay Expenditure Non pay expenditure for which no specific budget has been set up and which is not subject to funding under delegated powers of virement (as specified in the budget manual) may only be authorised by the Chief Executive Officer or the Chief Financial Officer. The Chief Financial Officer is responsible for maintaining a register of occasions when the power above is used. Page 5 of 20 3 QUOTATION, EXPENDITURE TENDERING AND CONTRACT PROCEDURES – REVENUE The following procedures relate to all revenue expenditure and should be followed in conjunction with the authorisation limits stated in Section 2. All tendering activity is to be processed through the Trust’s e-tendering system. Paper tenders will not be accepted, and will be deemed to be noncompliant. 3.1 Expenditure Under £10,000 excluding VAT There is no formal quotation or tendering procedure relating to expenditure below £10,000. There is, however, a duty upon those responsible for the expenditure to achieve the best value for money – this means the optimisation of both cost and quality. A minimum of one written quotation must be obtained from the supplier. 1.2 Expenditure Between £10,000 and £50,000 excluding VAT There is a requirement to request a minimum of 3 written quotations, of which a minimum of two must be returned. Proposed purchases must first be verified by authorised staff from the Procurement Department prior to the order being placed. 3.3 Acceptance of Quotation The best value for money quotation should be accepted, that is the bid, which in the opinion of the independent evaluators, represents the most economically advantageous outcome and which under this condition is therefore deemed to be the offer that represents the best combination of quality and price. This may not, therefore, be the lowest priced quotation. 3.4 Waiving of Quotations The requirement to obtain quotations may be waived with the approval of the Chief Executive Officer or the Chief Financial Officer on a formal Single Tender Waiver document, and clear reasons for such being provided. All such instances must be recorded and reported to the Audit, Governance and Risk Committee in line with 5.3.7 3.5 Expenditure over £50,000 excluding VAT 3.5.1 The Formal Tendering Process The formal tendering process applies to all revenue expenditure over £50,000 excluding VAT and must be adhered to unless the expenditure fits the criteria under which formal tendering may be waived in line with the procedures in 5.3.7. Standing Orders state “The Board shall ensure that invitations to tender are sent to a sufficient number of firms/individuals to provide fair and adequate competition as appropriate and in no case less than three firms/individuals, having regard to their capacity to supply the goods or materials or to undertake the services or works required.” At least 6 tenders must be requested, of which at least 3 must be returned. If the proposed expenditure for the whole term of the contract is likely to exceed the prevailing OJEU threshold then the Procurement Department must be consulted. The process from the opening of tenders onwards applies to both capital and revenue expenditure and is detailed in section 5.2.2. 4 CAPITAL PROJECTS/EXPENDITURE AND PRIVATE FINANCE SCHEMES Page 6 of 20 4.1 Management All capital expenditure must be within the agreed capital programme approved by the Board. A business case submission must be completed for every capital project. The financial monitoring and reporting of all capital scheme expenditure is the responsibility of the Chief Financial Officer. Capital expenditure should be reported monthly to the Capital Executive Group, to the relevant Capital Project Board, Finance, Investment and Estates Committee and the Trust Board. 4.2 Capital Schemes SOD no.9 and no.4 Selection of architects, quantity surveyors, consultant engineer and other professional advisors within EU regulations Chief Executive Officer or Chief Financial Officer or Director of Estates & Facilities Financial monitoring and reporting on all capital scheme expenditure Chief Financial Officer or Nominated Deputy or Director of Estates & Facilities Granting and termination of leases with an annual rental less than £100,000 Chief Executive Officer or Chief Financial Officer Granting and termination of leases with an annual rental greater than £100,000 Chief Executive Officer and Chief Financial Officer 5 QUOTATION, TENDERING & CONTRACT PROCEDURES - CAPITAL 5.1 Expenditure Under £10,000 excluding VAT There is no formal quotation or tendering procedure relating to expenditure below £10,000 excluding VAT. There is, however, a duty to achieve the best value for money, therefore the capital must be procured through the Procurement Department and a quotation must be obtained and approved before the order is placed. The nominated Capital Project Manager can authorise expenditure up to £10,000. 1.2 Expenditure Between £10,000 and £50,000 excluding VAT The nominated Capital Project budget holder is responsible for the authorisation of all expenditure up to £50,000 excluding VAT. There is a requirement to request a minimum of 3 written quotations, of which a minimum of 2 must be returned. All formal communication to initiate the procurement process should be undertaken by the Procurement Department. 5.2.1 Acceptance of Quotation SOD no.5 Best Value for Money quote: If quote does not vary from pre-quote estimate by more than 20% and there is sufficient funding Executive Director If quote does vary from pre-quote estimate by more than 20% Chief Executive Officer or Chief Financial Officer A quote other than the best value for money Chief Executive Officer or Chief Financial Officer 5.2.2 Waiving Of Quotations The requirement to obtain quotations may only be waived with the approval of the Procurement Department in conjunction with either the Chief Executive Officer or the Chief Financial Officer. 5.3 Expenditure Over £50,000 excluding VAT 5.3.1 Formal Tendering Process Page 7 of 20 The formal tendering process applies to all capital expenditure over £50,000 excluding VAT and must be adhered to, unless the expenditure fits the criteria under which formal tendering may be waived. In addition, the OJEU process must be complied with; refer to the Procurement department for the prevailing OJEU thresholds and the application of such to the whole life of the contract. In line with the provisions of SFI 17.5.4, it is a requirement to ensure that invitations to tender are sent to a sufficient number of firms or individuals to provide fair and adequate competition. In no case should fewer than three firms or individuals be requested to provide tenders. A minimum of 3 tenders should be requested and 2 should be returned. All tendering activity must be conducted through the electronic tendering system; paper submissions will not be accepted and may be deemed non-compliant. THE FOLLOWING SECTION IS APPLICABLE TO BOTH CAPITAL AND REVENUE TENDERS: 5.3.2 Opening Tenders Tenders will not be accepted in paper format. Where tenders are received via the Trust’s online Tender Management system: These need only be verified by representatives from the Legal Department and Procurement, as the system has built in security and is fully compliant with all relevant legal obligations. 5.3.3 Insufficient Tenders SFI 17.6.6 If insufficient tenders returned, decision whether to re-tender or to continue. Chief Executive Officer/Chief Financial Officer reporting to the Board. 5.3.4 Receipt of Late Tenders SFI 17.6.5 In the event that a tender is received by the Trust beyond the official deadline, only the Chief Executive Officer or his nominated officer is authorised to decide if the tender can still be included for consideration. Valid reasons for inclusion would include evidenced delivery to the Trust before the deadline where the Trust’s internal postal system caused the delay in receipt. 5.3.5 Acceptance of Tender Tenders should be evaluated in accordance with the guidance contained in the Purchasing Handbook (see the Trust intranet). The best value tender should be accepted. In the case of variations from the pre-tender estimate, the following rules apply: If the tender does not vary from the pre-tender estimate by more than 20% and there is sufficient funding – Executive Director is authorised to accept it. If the tender does vary from the pre-tender estimate by more than 20% - it may only be accepted with the agreement of the Chief Executive Officer or Chief Financial Officer. Where a tender other than the best value is accepted, the following should apply; Tender value under £500,000 Chief Executive Officer must approve & report reasons to the Trust Board. Tender value over £500,000 This power is reserved to the Trust Board. The Chief Executive Officer should make a recommendation as appropriate. Page 8 of 20 5.3.6 Reporting Of Tenders Reporting of all tenders including companies invited to tender, dates and values of tenders received. Over £50,000 Chief Financial Officer 5.3.7 Waiving Of Formal Tendering Process Formal tendering procedures for expenditure over £50,000 may be waived under SFI 17.5.3 (d) to (m) under the circumstances set out below. The SFI specifically prohibit the use of these waivers for the purpose of avoiding competition or for administrative convenience. Single Tender Waivers must be sought and approved PRIOR to any procurement taking place. All waivers must be reported to the Audit, Governance and Risk Committee. Supply under special arrangements negotiated by Dept. of Health which must therefore be complied with. Chief Financial Officer or Chief Executive Officer & reported to the Board Timescale precludes competitive tendering Chief Financial Officer or Chief Executive Officer & reported to the Board Specialist expertise is required and is available from only one source. Chief Financial Officer or Chief Executive Officer & reported to the Board Task is essential to complete project AND arises as a consequence of a recently completed assignment and engaging different consultants for the new task would be inappropriate. Chief Financial Officer or Chief Executive Officer & reported to the Board There is a clear benefit from continuity with an earlier project. Chief Financial Officer or Chief Executive Officer & reported to the Board 5.3.8 Recording Of Tender & Quotation Waiving The Chief Financial Officer is responsible for maintaining a record of the occasions when the requirement for tenders and quotations has been waived. 6 SIGNING OF CONTRACTS The following are the authorisation levels for the signing of contracts for both revenue and capital expenditure: Contract Value Up to £ 10,000 Contract Value Up to £ 50,000 Contract Value Up to £ 100,000 Contract Value Up to £300,000 Contract Value Up to £750,000 Contract Value Over £750,000 Budget Holder / Manager General Manager Non-Board Director Executive Director Chief Executive Officer & Chief Financial Officer Trust Board In addition to the budget holder’s signature on a contract, all contracts with a value of up to £100,000 must be countersigned by the following people: Associate Director of Procurement – in order to review all of the legal aspects of the contract Page 9 of 20 Assistant Director of Finance (Financial Control) – in order to review the financial aspects of the contract and ensure that budget exists for the related expenditure. Chief Information Officer (for ICT related contracts). Healthcare Contracts All healthcare contracts and contracts for private or new business ventures regardless of value must be approved by the Chief Financial Officer and Associate Director of Contracting. Grants All grant applications should be reviewed and signed off by the relevant Finance Managers in the first instance. All applications for grants exceeding £50,000 should also be counter signed by the Chief Financial Officer and the above rules on the signing of contracts would apply. 7 FINANCIAL CONTROL 7.1 Bank Accounts SFI 15 Maintenance & operation of bank accounts and Government Banking Service Chief Financial Officer Approval of cheque signatories Chief Executive Officer and Chief Financial Officer Signing cheques or approval of direct electronic payments up to £50,000 Two approved signatories Signing cheques or approval of direct electronic payments over £50,000 Two approved signatories including at least one Executive Director Electronic authoriser of direct electronic approved as above by two approved signatories Assistant Director of Finance (Financial Controller) or Senior Financial Accountant The only exception to the limits for approval of direct electronic payments over £50,000 is in the case of the transmission of funds to the National Loans Fund for short term (7 days) deposits. In this case ONLY, the transmission of funds can be approved by two approved signatories and this does not have to include at least one Executive Director. 7.2 BACS Payments Transmission BACS payments transmission of approved invoices is authorised by the Accounts Payable Manager or Deputy Accounts Payable Manager and Assistant Director of Finance (Financial Control) or Senior Financial Accountant. BACS payments transmission of salaries is authorised by the Payroll Manager or Deputy Payroll Manager and Assistant Director of Finance (Financial Control) or Senior Financial Accountant. 7.3 Fees and Charges SFI 16 SOD 6 The responsibility for setting fees and charges lies with the Chief Financial Officer, however in some cases the value may be set externally, e.g. by the Department of Health or legislation. Price of NHS Service Agreements Chief Financial Officer and Associate Director of Contracting Charges for all NHS Service Agreements Chief Financial Officer and Associate Director of Contracting Page 10 of 20 Price of Non-NHS activities: Income generation including Private Patients, Overseas Visitors Income Generation and other patient related services. Chief Financial Officer or Nominated Deputy 7.4 Losses, Write-Offs & Compensation SOD 11 SFI 26 Authorisation Limits 7.4.1 Losses and cash due to theft, fraud, overpayment and others up to £50,000 Over £50,000 Chief Executive Officer and Chief Financial Officer Audit, Governance and Risk Committee 7.4.2 Fruitless Payments (including abandoned Capital Schemes) up to £50,000 per case Over £50,000 per case Chief Executive Officer and Chief Financial Officer Audit, Governance and Risk Committee 7.4.3 Bad Debts and Claims Abandoned. Private Patients, Overseas Visitors and other Up to £1,000 per case Assistant Director of Finance (Financial Control) Up to £5,000 per case Director of Financial Operations Up to £10,000 per case Chief Financial Officer Up to £50,000 per case Chief Executive Officer Over £50,000 Audit, Governance and Risk Committee 7.4.4 Damage to buildings, fittings, furniture & equipment and loss of equipment & property in stores and in use due to Culpable causes (eg fraud, theft, arson) or other. Up to £50,000 Chief Executive Officer and Chief Financial Officer Over £50,000 Audit, Governance and Risk Committee 7.4.5 Compensation payments made under legal obligation. Up to £50,000 Over £50,000 Chief Executive Officer and Chief Financial Officer Audit Governance and Risk Committee 7.4.6 Ex-gratia Payments to Patients and Staff for loss of personal effects Up to £1,000 Up to £5,000 Up to £10,000 Up to £50,000 Over £50,000 Assistant Director of Finance (Financial Control) Director of Financial Operations Chief Financial Officer Chief Executive Officer Audit, Governance and Risk Committee 7.4.7 For clinical negligence all cases are referred to the NHS Litigation Authority Trust agreement to settle Medical Director and Chief Financial Officer 7.4.8 For personal injury claims all cases are referred to the NHS Litigation Authority 7.4.9 Other, all cases are referred to the Page 11 of 20 NHS Litigation Authority 7.5 Petty Cash Disbursements (not applicable to central Cashiers Office) SOD 13 The overall responsibility for Petty Cash Floats held within a Department lies with the General Manager. 7.5.1 Expenditure up to £50 per item Petty Cash Holder 7.5.2 Reimbursement of patients’ monies up to £50 in cash Patient Affairs Officer 7.5.3 Reimbursement of patients’ monies in excess of £50 by cheque Patient Affairs Officer Approval for Petty Cash Float Assistant Director of Finance (Financial Control) or Senior Financial Accountant Costs incurred by staff in the ordinary course of business, e.g. travel costs, must be reclaimed through an expenses application form and paid to the employee in the salary to ensure the tax implications are correctly accounted for. 7.6 Purchasing Cards Overall responsibility for the security and use of a purchasing card is the named holder of the card. Each card must only be used for the purpose for which it is authorised, for example, travel and subsistence costs. Each cardholder must comply with the administrative requirements of the Trust’s Purchasing Cards User Manual. Approval for issue of new cards Chief Financial Officer or Chief Executive Officer. 7.7 Patients’ Monies and Valuables SFI 28 The General Manager/Divisional Clinical Director is responsible for the control and safe-handling of patients’ monies and valuables up to the point of receipt by the Cashiers Office after which the Chief Financial Officer is responsible for their safe-keeping and recording. Withdrawals of patients’ monies (Maximum £100 per day) Ward Manager Reimbursement of closing balance of Patients’ monies and valuables Ward Manager (These transactions must also be authorised by the Patient). In the event of a patient’s death where no next of kin is known then the claimant must provide evidence that he/she is the executor of the patient’s estate. If there is no such evidence available but the claimant can show the original death certificate, the monies and valuables will be given to the claimant. Probate see SFI 28. 7.8 External and Internal Audit Recommendations SOD 15 SFI 11 Implementation of recommendations Relevant Executive Director Follow up of recommendations to ensure effective implementation Audit, Governance and Risk Committee 7.9 Trust Financial Procedures SOD 16 Maintenance & update on Trust Chief Financial Officer Page 12 of 20 Financial Procedures 7.10 Investment of Funds SOD 17 Approval of organisations in which the Treasury Management department of the Trust may invest and of the types of investment permitted. Chief Financial Officer and approved by the Trust Board Authorisation of individuals responsible for making investments. Chief Financial Officer 7.11 External Borrowing SFI 22 The authority to sign loan draw-downs against approved loans is delegated to the Chief Financial Officer or the Chief Executive Officer. 1.12 Charitable Donations SOD 8 &17 SFI 15 & 29 The following criteria must be considered when making charitable donations from Trust funded budgets: Whether the donation is an appropriate use of NHS funds Whether the donation directly supports the department’s objectives Any donation for an amount greater than £5,000 must be countersigned by an Executive Director and donations may only be made to arm’s length charities, i.e. charities that are not controlled by the budget holder making the donation. 8 HUMAN RESOURCES SOD 18 SFI 20 8.1 Engagement of Staff on the Establishment Authority to fill funded post on the establishment with permanent staff Divisional General Manager or equivalent Authority to appoint staff to post not on the formal establishment Chief Executive Officer or Executive Director 8.2 Engagement of Staff Not On the Establishment SOD 7 This is bound by the rules governing revenue expenditure including the need for quotation and tender, and the Trust’s policy on the use of contract staff as owned by HR. Non Medical Consultancy Staff: Where aggregate commitment in any one year (or total commitment) is less than £25,000 Where aggregate commitment in any one year is more than £25,000 Director and Chief Financial Officer Engagement of Trust's Solicitors Chief Executive Officer or Executive Director Chief Executive Officer and Chief Financial Officer Booking of Bank or Agency Staff: Medical Locums Nursing and other Agency Staff Medical Director or approved deputy Budget Manager Page 13 of 20 8.3 Additional Staff to the Agreed Establishment With specifically allocated finance Chief Financial Officer or Nominated Deputy Without specifically allocated finance Chief Executive Officer and Director of Human Resources and Organisational Development 8.4 Fixed Term Contracts Authorisation or renewal of fixed term Contracts General Manager/Director of Human Resources and Organisational Development 8.5 Pay Increases/Decreases 8.5.1 Additional Increments The granting of one additional increment to staff within budget Assistant Director and Director of Human Resources and Organisational Development The granting of more than one additional increment to staff within budget Chief Financial Officer 8.5.2 Upgrading and Regrading All requests for upgrading/re-grading will be dealt with in accordance with Trust procedure. Assistant Director of Human Resources and Organisational Development 8.6 Pay Processes Authority to complete standing data forms effecting pay, new starters, variations and leavers Directorate Human Resources and Organisational Development or Nominated Deputy Authority to complete and authorise positive reporting forms Budget Holder or nominated deputy Authority to authorise overtime Budget Holder or nominated deputy Authority to authorise waiting list payments Divisional General Manager Authority to authorise other additional payments Chief Financial Officer Authority to authorise travel & subsistence expenses Budget Holder Authority to authorise staff bank payments MAPS System Manager or Bank Payroll Manager Approval of Performance Related Pay Remuneration Committee Page 14 of 20 8.7 Leave 8.7.1 Approval of annual leave Line/General Manager Approval of carry forward of annual leave (up to a maximum of 5 days or in the case of Ancillary & Maintenance staff as defined in their initial conditions of service) Line/General Manager Annual leave - approval of carry over in excess of 5 days but less than 10 days Assistant Director Annual leave - approval to carry forward 10 days or more Director 8.7.2 Compassionate leave up to 3 days Line/General Manager Compassionate leave up to 6 days Director or Assistant Director 8.7.3 Special leave arrangements - paternity leave - carer’s leave - up to 3 days - up to 5 days Assistant Director of Human Resources and Organisational Development Director of Human Resources and Organisational Development 8.7.4 Leave without pay Director Medical Staff Leave of Absence - paid and unpaid leave - < 5 days - paid and unpaid leave - > 5 days Divisional Clinical Director Medical Director and Chief Executive Officer 8.7.5 Time off in lieu Line Manager/Assistant Director 8.7.6 Maternity Leave - paid and unpaid Automatic approval within guidance 8.7.7 Sick Leave Extension of sick leave on half pay up three months Development Executive Director in conjunction with Director of Human Resources and Organisational Return to work part-time on full pay to assist recovery from sick leave Director or Assistant Director Extension of sick leave on full pay Director of Human Resources and Organisational Development or Chief Executive Officer Page 15 of 20 8.7.8 Study Leave Line Manager Study leave outside the UK Chief Executive Officer Medical staff study leave (UK) Assistant Director or Executive Director Director or Assistant Director All other study leave (UK) 8.7.9 Removal Expenses, Excess Rent and House Purchase Loans Authorisation of payment of removal expenses incurred by officers taking up new appointments (providing consideration was promised at interview): Up to £8,000 Director of Human Resources and Organisational Development Chief Executive Officer Over £8,000 8.8 Grievance Procedure All grievances must be dealt with strictly in accordance with the Grievance Procedure and the advice of a Human Resources Officer must be sought when the grievance reached the level of Director. Director of Human Resources and Organisational Development 8.9 Authorised Car & Mobile Phone Users Requests for new posts to be authorised as car users Director of Human Resources and Organisational Development or Chief Financial Officer Requests for new posts to be authorised as mobile telephone users Director of Human Resources and Organisational Development or Chief Information Officer or approved deputy 8.10 Staff Retirement Policy Authorisation of extension of contract beyond normal retirement age. Director of Human Resources and Organisational Development 8.11 Redundancy Negotiation of a payment in full and final settlement supported by a COT3 or compromise agreement: Up to £20,000 Up to £100,000 Over £100,000 Director of Human Resources and Organisational Development or Chief Financial Officer Chief Executive Officer and Director of Human Resources and Organisational Development or Chief Financial Officer Director of Human Resources and Organisational Development and Remuneration Committee The Director of Human of Resources shall provide a written report to the Remuneration Committee in retrospect for cases up to £100,000. The Trust will take legal advice and the decision to settle must be assessed against the value for money for the Trust. Page 16 of 20 8.12 Ill Health Retirement Decision to pursue retirement on the grounds of ill health. Director of Human Resources and Organisational Development 8.13 Dismissal Dismissal Dismissing Officers 8.14 Facilities for staff not employed by the Trust to gain practical experience Professional Recognition, Honorary Contracts, Development & Insurance of Medical Staff Director of Human Resources and Organisational Work experience students Director of Human Resources and Organisational Development 8.15 Reporting of Incidents to the Police SOD 12 Where a criminal offence is suspected Of a violent nature Security Officer on duty/Site Practitioner/Local Security Management Specialist On Call Manager Other Executive Director on call Where a fraud is involved Chief Financial Officer or Local Counter Fraud Specialist 8.16 Fixed Term Contracts Authorisation or renewal of fixed term Contracts. General Manager/Director of Human Resources and Organisational Development 9 CHARITABLE FUNDS 9.1 Charitable Donations SOD 8 &17 SFI 15 & 29 The following criteria must be considered when making charitable donations from Trust funded budgets: Whether the donation is an appropriate use of NHS funds and the terms of the gift Whether the donation directly supports the department’s objectives Any donation for an amount greater than £5,000 must be countersigned by an Executive Director and donations may only be made to arm’s length charities, i.e. charities that are not controlled by the budget holder making the donation. 9.2 Charitable Expenditure Up to £1,000 per request Up to £5,000 per request Up to £10,000 per request £10,000 to £250,000 per request Over £250,000 per request Fundholder Fundholder and Chief Financial Officer Fundholder and Chief Executive Officer Charitable Funds Committee Charitable Funds Committee & Trust Board Page 17 of 20 10 ESTATE MANAGEMENT 10.1 Agreements / Licenses & Leases Preparation and signature of all tenancy agreements/licenses for all staff subject to Trust policy on accommodation for staff Director of Human Resources and Organisational Development or Chief Financial Officer Approval of rent based on professional assessment Chief Financial Officer Extension to existing leases Director of Estates & Facilities or Chief Executive Officer Director of Estates & Facilities or Chief Executive Officer Letting of premises to outside organisations 10.2 Condemning & Disposal SFI 26 Items obsolete, obsolete, redundant, irreparable or cannot be repaired cost effectively: with current purchase new price less than £5,000 Chief Financial Officer with current purchase new price greater than £5,000 Chief Financial Officer disposal of x-ray films (subject to estimated income of £1,000 per sale) Radiology Services Manager disposal of x-ray films (subject to estimated income exceeding £1,000 per sale) Radiology Services Manager and Assistant Director disposal of mechanical & engineering plant (subject to estimated sale proceeds of less than £5,000 per sale) Director of Estates and Facilities disposal of mechanical & engineering plant (subject to estimated sale proceeds not exceeding £5,000 per sale) Director of Estates and Facilities and Chief Financial Officer 10.3 Review of Fire Precautions Director of Estates and Facilities 10.4 Review of all statutory compliance Director of Estates and Facilities legislation and Health and Safety requirements including control of Substances Hazardous to Health Regulations 10.5 Review of compliance with environmental regulations, for example those relating to clean air and waste disposal Director of Estates and Facilities 10.6 Insurance policies & Risk Management Director of Estates and Facilities Page 18 of 20 11 CORPORATE AFFAIRS 11.1 The keeping of the Declaration of Interest Register Board Secretary 11.2 Attestation of sealing in accordance with Standing Orders Board Secretary 11.3 The keeping of the Register of Sealing Board Secretary 11.4 The keeping of the Hospitality Register Board Secretary 11.5 Receiving Hospitality Applies to both individual and collective hospitality receipt items. In excess of £25 per received. 11.6 Retention of Records Declaration required in Trust’s Hospitality Register Chief Executive Officer 11.7 Patients’ & Relatives’ Complaints 11.7.1 Overall responsibility for ensuring that all complaints are dealt with effectively Chief Executive Officer 11.7.2 Responsibility for ensuring complaints relating to a directorate are investigated thoroughly Executive Director or Assistant Director 11.8 Medico - Legal Complaints Co-ordination of their management Director of Nursing and Quality 11.9 Relationships with Press Non-Emergency General Enquiries Within Hours and Outside Hours Head of Communications Emergency Within Hours and Outside Hours Head of Communications 11.10 Review of Trust's compliance with the Data Protection Act Computer Records Patient Records Chief Information Officer Medical Director (as Caldicott Guardian) Staff Records Director of Human Resources and Organisational Other Corporate Records Development Chief Information Officer 11.11 Monitor proposals for contractual Healthcare services arrangements between the Trust and NHS bodies Associate Director of Contracting 11.12 Review the Trust's compliance with the Chief Information Officer Freedom of Information Act 11.13 Review the Trust's compliance code of Associate Director of Governance Practice for handling confidential information in the Healthcare contracting environment and the compliance with "safe haven" per Page 19 of 20 EL 92/60 12 CLINICAL AFFAIRS 12.1 Authorisation of New Drugs Drugs and Therapeutics Committee 12.2 Authorisation of Sponsorship Deals Chief Executive Officer, Medical Director, Ethics Committee Ethics Committee and Director of Research 12.3 Authorisation of Research Projects 12.4 Authorisation of Clinical Trials 12.5 Infectious Diseases & Notifiable Outbreaks Ethics Committee and Head of Clinical Risk and Legal Services or Research and Development Manager Duty Executive Director or Control of Infection Doctor 12.6 Extended Role Activities Director of Nursing and Quality or Medical Director Per Nurse/Midwives/ Health Visitors Act Midwives Rules / Code of Practice UKCC Code of Professional Conduct 12.7 Patient Services Variation of operating and clinic sessions within existing numbers. Chief Operating Officer or Head of Site Operations All proposed changes in bed allocation and use Chief Operating Officer or Head of Site Operations 12.8 Review of Medicines Inspectorate Regulations Medical Director 12.9 Clinical Governance Director of Nursing and Quality and Medical Director Page 20 of 20