Scheme of Delegation
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Schedule of Matters
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CONTENTS
Page No
Introduction ……………………………………………………………………………………………………..
3
Decisions Reserved to the Council of Members ……………………………………………………………
4
Decisions Reserved to the Board of Directors jointly with the Council of Members…………………
6
Decisions Reserved to the Board of Directors ………………………………………………………………… 7
Decisions/Duties Delegated to Committees of the Board of Directors ….……………………………...... 12
Duties delegated to the Chairman……………………………………………………………………………….. 22
Duties delegated jointly to the Chairman and Chief Executive …………………………………………… 23
Responsibilities of the Accounting Officer ……………………………………………………………………. 24
Duties delegated to the Chief Executive ……………………………………………………………………….. 28
Duties delegated to the Finance Director ………………………………………………………………………. 31
Duties delegated to other named staff …………………………………………………………………………. 35
Duties required of all staff ………………………………………………………………………………………… 37
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Schedule of Matters
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INTRODUCTION
Delegation of Powers
The Foundation Trust has powers to delegate and make arrangements for delegation. The Standing Orders for the Practice and Procedure of the
Board of Directors set out the detail of these arrangements.
The power which the Board of Directors has retained to itself within the Standing Orders may in emergency be exercised by the Chief Executive and
the Chair after having consulted at least two non-executive Directors. The exercise of such powers by the Chief Executive and Chair shall be reported
to the next formal meeting of the Board of Directors.
This document details the decisions and responsibilities reserved to the Council of Members, the Board of Directors and those delegated to the agreed
committees of the Board of Directors. This document has effect as if incorporated into the Trust’s Standing Orders.
In the event of any unresolved dispute between the Council of Members and the Board of Directors, the Chair shall seek to resolve the dispute and
failing this the matter will be referred to a special joint committee of the Board of Directors and Council of Members. (para 10.3 of the SOs).
Established committees of the Trust Board are as follows:
The Audit Committee
The Business and Finance Committee
The Quality and Performance Committee
The Charitable Trust Board
The Nomination Committee
The Remuneration Committee
The Investment Committee
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Decisions Reserved to the Council of Members
DECISIONS RESERVED TO THE COUNCIL OF MEMBERS
General Enabling Provision
The Trust is to have a Council of Members. The Council of Members links the Foundation Trust to its members and community to ensure
engagement and involvement of the public in relation to the services provided by the Trust.
The Council of Members will hold the Board to account for performance of the Trust including ensuring the Board acts so that the Trust does not
breach its terms of authorisation
Strategy, Plans and Budget
1. Provide its views to the Board of Directors when preparing the document containing information about the Foundation Trust’s forward
planning.(Con12.3.2)
2. Support the Board in developing its longer term vision for the Trust (Con 12.4.1)
Regulation and Control
1. Respond as appropriate when consulted by the Board of Directors(Con 12.3.3).
2. Undertake such functions as the Board of Directors shall from time to time request.(Con12.4.5)
3. Adoption and suspension of Standing Orders for Council of Members
4. Approve and individually comply with the Code of Conduct including the Nolan Principles for Governors.
Appointments/ Dismissal and HR Matters
1. Appoint or remove the Chair and other Non-executive Directors.( Con 12.2.1)
2. Appoint Deputy Chair (Con27)
3. Approve the appointment (by the non-executive Directors) of the Chief Executive.( Con 12.3.1)
4. Appoint or remove the Foundation Trust’s External Auditor in consultation with the Audit Committee (Con 12.2.3)
5. Decide the remuneration and allowances and the other terms and conditions of office of the Non-executive Directors.(Con12.2.2)
6. Appoint Lead Governor (Con22.5)
7. Removal of Governors Con12.2.5)
Annual Reports and Accounts
1. Be presented with the annual accounts, any report of the appointed external auditor on them and the annual report.(Con18.6)
2. Review annually how the Trust is meeting its objectives (Con 12.4.3)
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Audit
1. Receive the ISA 260 Audit Highlights Memorandum from the appointed External Auditor.
Structure
1. Approve membership and Chairmanship of sub-committees of the Council of Members.
Corporate Governance Matters
1. Develop and promote relationships between the Council of Members and the Board of Directors.
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Decisions Reserved to the Board of Directors jointly with the Council of Members
DECISIONS RESERVED TO THE BOARD OF DIRECTORS AND THE COUNCIL OF MEMBERS
Corporate Governance Matters
1. Review and submit proposed changes to the Trust Constitution, as appropriate, to the Council of Members, the Board of Directors and Monitor.
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Decisions Reserved to the Board of Directors
DECISIONS RESERVED TO THE BOARD OF DIRECTORS
General Enabling Provision
The Trust may do anything which appears to it to be necessary or desirable for the purposes of or in connection with its function. Board of Director
members share corporate responsibility and accountability for all decisions of the Board of Directors.
The business of the Trust is to be managed by the Board of Directors, who, subject to the Trust’s Constitution shall exercise all the powers of the
Trust. The Board of Directors has key functions for which it is held accountable by the Independent Regulator of NHS Foundation Trusts
(Monitor) to:
1. The Board of directors’ role is to provide active leadership of the NHS Foundation Trust within a framework of prudent and effective
controls which enables risk to be assessed and managed.
2. The Board of directors is responsible for ensuring compliance by the NHS Foundation Trust with its terms of authorisation, its constitution,
mandatory guidance issued by Monitor, relevant statutory requirements and contractual obligations.
3. The Board of directors should set the NHS Foundation Trust’s strategic aims, taking into consideration the views of the Council of
Members, ensuring that the necessary financial and human resources are in place for the NHS Foundation Trust to meet its objectives
and review management performance.
4. The Board of Directors as a whole is responsible for ensuring the quality and safety of healthcare services, education, training and
research delivered by the NHS Foundation Trust and applying the principles and standards of clinical governance set out by the
Department of Health, the CQC, and other relevant NHS bodies.
5. The Board of Directors should also ensure that the NHS Foundation Trust exercises its functions effectively, efficiently and economically.
6. The Board of Directors should set the NHS Foundation Trust’s values and standards of conduct and ensure that its obligations to its
members, patients and other stakeholders are understood and met.
7. All directors have joint responsibility for every decision of the Board.
8. This does not impact upon the particular responsibilities of the Chief Executive as the accounting officer. The Chief Executive should refer
to guidance from Monitor on the responsibilities and obligations of the accounting officer (NHS Foundation Trust Accounting Officer
Memorandum, April 2008).
9. All directors, Executive and Non-Executive, have responsibility to constructively challenge the decisions of the board and help develop
proposals on strategy.
10. NEDs are responsible for determining appropriate levels of remuneration of Executive Directors and have a prime role in appointing, and
where necessary removing, Executive Directors, and in succession planning.
11. The Board as a whole is responsible for safeguarding the Trust’s assets.
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DECISIONS RESERVED TO THE BOARD OF DIRECTORS
It is the Board of Directors duty to:
1.
2.
3.
4.
5.
6.
Act within all applicable statutes.
Have regard to the NHS Constitution
Ensure that management arrangements are in place to enable responsibility to be clearly delegated to Executives for the main programmes
of action and for performance against programmes to be monitored and Executives held to account.
Establish performance and quality measures that maintain the effective use of resources and provide value for money.
Specify its requirements in organising and presenting financial and other information succinctly and efficiently to ensure the Board of
Directors can fully undertake its responsibilities.
Establish Audit and Remuneration Committees on the basis of formally agreed terms of reference that set out the membership of the
committee, the limit to their powers, and the arrangements for reporting back to the Board of Directors.
The NHS Foundation Trust Board of Directors must comply with legislation and guidance issued by Monitor in respect of contracts entered into by
themselves or into on their behalf and establish terms and conditions of service that are fair to staff and represent good value for taxpayers'
money and are in accordance with the Constitution and Terms of Authorisation.
Strategy, Plans and Budgets
1. Define the values, strategic aims and objectives of the Trust.
2. Approve proposals for ensuring quality and developing governance in services provided by the Trust, having regard to any guidance issued by
the Secretary of State and Monitor.
3. Approve the Trust’s policies and strategies for the management of risk and strategic development.
4. Approve Business Cases for Capital Investment subject to the limits within the Scheme of Authority and Decisions.
5. Approve any proposal to use PFI
6. Approve annual plans including annual budgets.
7. Ratify proposals for acquisition, disposal or change of use of land and/or buildings subject to the Terms of Authorisation and the Scheme of
Delegation.
8. Approve proposals on individual contracts of a capital or revenue nature subject to the Scheme of Authority and Decisions.
9. Ensure the Trust does not dispose of any protected asset without the consent of the Regulator
10. Approve proposals in individual cases for the write off of losses or making of special payments above the limits of delegation to the Chief
Executive and Director of Finance (for losses and special payments).
11. Approve proposals for action on non-clinical litigation against or on behalf of the Trust as per the Scheme of Delegation.
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Regulation and Control
Approve the Trust’s registration with the CQC and licensing requirements of any appropriate regulator.
Ensure a sound system of internal control and risk management.
Ensure a sound system of quality governance
Approve Standing Orders (SOs), a schedule of matters reserved to the Board of Directors and Standing Financial Instructions for the
regulation of its proceedings and business.
5. Vary amend or suspend the Standing Orders.
6. Approve a Scheme of Reservation and Delegation of Powers from the Board of Directors.
7. Require and receive the declaration of Board of Directors interests that may conflict with those of the Trust.
9. Receive and review the Assurance Framework regularly.
10. Establish terms of reference and reporting arrangements of all committees that are established by the Board of Directors including those that
the Trust is required by the Secretary of State, Monitor or other regulation to establish
11. Receive reports from committees and to take appropriate action on.
12. Approve arrangements relating to the discharge of the Trust’s responsibilities as a corporate trustee for funds held on trust including
compliance with Charity Commission Guidance.
13. Regularly review the register of documents signed and sealed by Directors.
14. Be responsible for compliance with the Trust’s Terms of Authorisation.
15. Comply with any order issued by Monitor under Section 23 of the Act.
16. Approve a list of staff authorised to make short term borrowings/accessing facility on behalf of the Trust. (This must contain the CE and DoF.)
17. Approve long-term borrowing.
18. Comply with the Principles and Rules for Cooperation and Competition
19. Decide whether the Trust will use the risk pooling schemes administered by the NHS Litigation Authority or self-insure for some or all of the risks
(where discretion is allowed). Decisions to self-insure should be reviewed annually.
1.
2.
3.
4.
Appointments/ Dismissal and HR Matters
1. Appoint and dismiss Executive Directors in accordance with Trust policies and procedures and decide on their remuneration and expenses.
2. Appoint Senior Independent Director
Annual Reports and Accounts
1. Approve the Trust's Annual Report, Quality Accounts and Annual Accounts.
2. Approve the Annual Report and Accounts for funds held on trust.
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Audit
1. Receive the ISA 260 Audit Highlights Memorandum from the external auditor and agreement of proposed action, taking account of the advice,
where appropriate, of the Audit Committee.
2. Receive an annual report from the Audit Committee providing assurance to the Board of Directors on the system of Internal Control and the
effectiveness of the Assurance Framework.
Monitoring
1. Receive such reports and minutes as the Board of Directors sees fit from committees in respect of their exercise of powers delegated.
2. Continuous appraisal of the affairs of the Trust by means of the provision to the Board of Directors as they may require from directors,
committees, and officers of the Trust as set out in management policy statements. All monitoring returns required by Monitor and the Charity
Commission shall be reported, at least in summary, to the Board of Directors.
3. Receive reports from DoF on financial performance.
4. Receive reports from the Medical Director on clinical performance and quality.
5. Receive reports from the DIPC
6. Receive reports from the Chief Pharmacist
7. Oversight of Trust operations and compliance with statutory and regulatory obligations.
8. Receive reports and review the effectiveness of the risk and control processes to support its strategy and objectives from the Audit Committee;
 Undertaking an annual assessment of those processes;
 Approving an appropriate statement for inclusion in the Annual Report;
 Approving the declarations required.
Mental Health Act
Discharge its responsibilities under the Mental Health Act in respect of the exercise of the hospital managers’ power to discharge patients from
detention or SCT through the appointment of managers’ panels made up of people (sometimes called “associate hospital managers”) appointed
specifically for the purpose who are not officers or employees of the organisation concerned.
A detailed Mental Health Act 1983 Scheme of Delegation, held by the Trust Mental Health Act Manager, sets out the statutory and guidance
functions with the statutory reference, the guidance reference and the person or body delegated to exercise that function as determined by the
Trust. The Scheme of Delegation provides assurance that the Trust has appropriate governance arrangements in place in order to lawfully
exercise its powers under the Mental Health Act.
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Corporate Governance Matters
1. Undertake a formal and rigorous review (annually) of its own performance and that of its committees.
2. Maintain relationships between the Council of Members and the Board of Directors.
3. Trust shall nominate a Local Security Management Specialist, and shall nominate an Executive Director to be responsible to the Board for
security management.( the Security management Director and a Non-Executive Director as the designated NED to support and challenge
4. The Board shall appoint a Senior Information Risk officer ( SIRO) an Executive Director who is familiar with and takes ownership of the
organisation’s information risk policy and acts as an advocate for information risk on the Board.
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Decisions/Duties Delegated to Committees of the Board of Directors
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Decisions/Duties Delegated by the Board of Directors to Committees
COMMITTEE
AUDIT COMMITTEE
DECISIONS/DUTIES DELEGATED BY THE BOARD OF DIRECTORS TO COMMITTEES
Governance, Risk Management and Internal Control
The Committee shall review the establishment and maintenance of an effective system of integrated governance, risk
management and internal control, across the whole of the organisation’s activities (both clinical and non-clinical), that
supports the achievement of the organisation’s objectives.
In particular, the Committee will review the adequacy of:

All risk control related disclosure statements (in particular the Statement on Internal Control), together with any
accompanying Head of Internal Audit statement, external audit opinion or other appropriate independent assurances,
prior to endorsement by the Board

The underlying assurance processes that indicate the degree of the achievement of corporate objectives, the
effectiveness of the management of principal risks and the appropriateness of the above disclosure statements

The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements

The policies and procedures for all work related to fraud and corruption as set out in Secretary of State
Directions and as required by the Counter Fraud and Security Management Service.
In carrying out this work the Committee will primarily utilise the work of Internal Audit, External Audit and other
assurance functions, but will not be limited to these audit functions. It will also seek reports and assurances from
directors and managers as appropriate, concentrating on the over-arching systems of integrated governance, risk
management and internal control, together with indicators of their effectiveness.
The Committee shall rely upon the Quality and Performance Committee to give it assurance that appropriate clinical
risk management systems are in place and the Quality and Performance Committee shall alert the Audit Committee to
any significant unaddressed risks.
This will be evidenced through the Committee’s use of an effective Assurance Framework to guide its work and that of
the audit and assurance functions that report to it.
Internal Audit
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COMMITTEE
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DECISIONS/DUTIES DELEGATED BY THE BOARD OF DIRECTORS TO COMMITTEES
The Committee shall ensure that there is an effective internal audit function established by management, that meets
mandatory NHS Internal Audit Standards and provides appropriate independent assurance to the Audit Committee
Chief Executive and Board. This will be achieved by:

Consideration of the provision of the Internal Audit service, the cost of the audit and any questions of
resignation and dismissal.

Review and approval of the Internal Audit strategy, operational plan and more detailed programme of work,
ensuring that this is consistent with the audit needs of the organisation as identified in the Assurance Framework.

Consideration of the major findings of internal audit work (and management’s response), and ensure coordination between the Internal and External Auditors and Counter Fraud to optimise audit resources

Ensuring that the Internal Audit function is adequately resourced and has appropriate standing within the
organisation.

Annual review of the effectiveness of Internal audit.
External Audit
The Committee shall review the work and findings of the External Auditor appointed by the Audit Commission and
consider the implications and management’s responses to their work. This will be achieved by:

Consideration of the appointment and performance of the External Auditor, as far as the Audit Commission’s
rules permit

Discussion and agreement with the External Auditor, before the audit commences, of the nature and scope of
the audit as set out in the Annual Plan, and ensure coordination, as appropriate, with other External Auditors in the
local health economy

Discussion with the External Auditors of their local evaluation of audit risks and assessment of the Trust and
associated impact on the audit fee.

Review all External Audit reports, including agreement of the annual audit letter before submission to the
Board and any work carried outside the annual audit plan, together with the appropriateness of management
responses.
Local Counter Fraud & Security
The Committee shall ensure that there is an effective and appropriately LCFS function in place in the Trust. It should:
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COMMITTEE
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DECISIONS/DUTIES DELEGATED BY THE BOARD OF DIRECTORS TO COMMITTEES
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


Receive the annual work plan.
Ensure the independence of the LCFS
Ensure that the LCFS function is adequately resourced
Consider findings derived from both internal cases and any national initiatives
Other Assurance Functions
The Audit Committee shall review the findings of other significant assurance functions, both internal and external to the
organisation, and consider the implications to the governance of the organisation.
These will include, but not limited to, any reviews by Department of Health Arms Length Bodies or
Regulators/Inspectors (e.g CQC, NHS Litigation Authority, etc), professional bodies with responsibility for the
performance of staff or functions (e.g Royal Colleges, accreditation bodies etc).
Management
The Committee shall request and review reports and positive assurances from directors and managers on the overall
arrangements for governance, risk management and internal control.
They may also request specific reports from individual functions within the organisation as they may be appropriate to
the overall arrangements.
Financial Reporting
The Audit Committee shall review the Annual Report and Financial Statements before submission to the Board,
focusing particularly on:




The wording in the Annual Governance Statement and other disclosures relevant to the Terms of Reference of the
Committee
Changes in, and compliance with, accounting policies and practices
Unadjusted mis-statements in the financial statements
Major judgemental areas
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COMMITTEE
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DECISIONS/DUTIES DELEGATED BY THE BOARD OF DIRECTORS TO COMMITTEES

Significant adjustments resulting from the audit
The Committee should also ensure that the systems for financial reporting to the Board, including those of budgetary
control, are subject to review as to completeness and accuracy of the information provided to the Board.
BUSINESS &
FINANCE
A
Business
1
2
3
4
5
Develop and review the Annual Business Plan
Develop and review the Business development strategy
Develop and review the process for considering new business opportunities
Consider proposals for new business developments.
i.
Where the proposal is a value >£5M but <£10M the Committee shall take the final decision.
ii.
Where the proposal is >£10M the Committee shall make a recommendation to the Board.
iii.
Where the proposal is equal to or in excess of Monitor definitions for a material transaction as set
out in the REID guidance the proposal shall be considered by the Investment Committee.
In considering any proposal, the Committee shall adopt the principles as outlined in Monitor’s REID
Guidance and shall as appropriate
i.
Commission market analysis and testing of new business development proposals, including the
carrying out of SWOT and PEST analyses.
ii.
Review the findings of activity and financial modelling.
iii.
Review due diligence testing of new business proposals.
B
Finance
1. The Committee will review the financial position and provide up-to-date analysis to the Board.
2. The Committee is responsible for Financial Management and shall:
 ensure a comprehensive budgetary control framework that accords with guidance and legislation

assess the Monitor reports on behalf of the Board prior to submission
 recommend revenue budgets to the Board arising from the Business Planning Process
 monitor financial performance against plans
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COMMITTEE
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DECISIONS/DUTIES DELEGATED BY THE BOARD OF DIRECTORS TO COMMITTEES







monitor cash flow against plans and assess changes to plans
ensure appropriate financial control mechanisms are in place
ensure financial management resources are appropriate and of high quality
propose Treasury management policy to Board and monitor treasury process throughout year
monitor performance against major contracts
ensure effective debt management /provision
direct improvement activity as required
3. To review the content and format of financial information, focusing particularly on:




clarity and appropriateness of presentation
timeliness and accuracy
provision of sufficient and relevant detail to inform decision-making
requirements of different audiences
4. To develop Investment Strategy and recommend it to the Board
 To review the Strategy as appropriate
 To monitor the implementation of the Strategy
5. Capital programme
 Monitor capital spend on the estates and facilities programme
 Monitor capital spend on the IM&T programme





General
Review financial plans and strategies to ensure they are consistent with overall Trust objectives and plans
and local delivery plans and identify where there are inconsistencies
Ensure value for money is assessed on a regular basis in financial decision making
Horizon scan and recommend action to the Board in respect of both opportunities and threats
Monitor the risk profile of the Trust and make recommendations to the Board as appropriate
Ensure that all relevant guidance is complied with
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COMMITTEE
DECISIONS/DUTIES DELEGATED BY THE BOARD OF DIRECTORS TO COMMITTEES
R
REMUNERATION
COMMITTEE
To determine the level of remuneration of the Chief Executive.
To consider recommendations of the Chief Executive in relation to remuneration of members of the Executive Board.
To monitor remuneration levels for al Senior Managers and Senior Nurses.
To determine the remuneration strategy for the Trust.
NOMINATION
COMMITTEE
To review the structure size and composition of the board of directors and make recommendations for change where
appropriate
In the event of a vacancy, to prepare a description of the role and capabilities required for a particular appointment
To agree with the Appointments Committee of the Council of Members a clear process for the nomination a new Chair
of non-executive director
To make recommendations to the board in respect of the appointment of executive directors .
QUALITY &
PERFORMANCE
COMMITTEE
To focus, on behalf of the Board, on areas of high risk where for whatever reason there are low levels of assurance.
To monitor compliance with all statutory and mandatory quality requirements
To ensure action is undertaken to ensure ‘significant lapses’ in compliance are addressed.
To review the evidence used to support the Trust’s compliance including ongoing registration with the CQC.
To review the robustness of data presented and the level of assurance it affords.
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COMMITTEE
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DECISIONS/DUTIES DELEGATED BY THE BOARD OF DIRECTORS TO COMMITTEES
To review the data Quality Strategy
To review the IM&T strategy to ensure it adequately provides for the collection of information and the provision of data
to support quality performance
To ensure that the Annual Plan reflects the Trust’s quality priorities
To monitor performance to ensure it is sufficient to meet agreed targets and thereby deliver the annual plan
To ensure that quality priorities align with the needs of the local community as expressed by stakeholder groups
To ensure the production of the Quality Account
To ensure that there is a comprehensive system of quality governance across the Trust and to receive feedback from
clinicians through the report of the Care Quality Management Group
To learn from good practice as evidenced in the Trust and externally.
To ensure the Trust has responded appropriately to clinical concerns raised locally by staff, patients or external
sources
To direct service improvement activity as required and to advise the Board on any actions that may be required to
safeguard standards of care and improve quality of service. To monitor progress against such actions
To ensure that appropriate clinical risk management systems are in place and that a robust schedule of clinical audit is
in place. The Committee shall alert the Audit Committee to any significant unaddressed risks.
To use benchmarking, internally and externally, to drive and challenge the effectiveness of the services we provide.
To champion the provision of regular feedback to staff on quality performance
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COMMITTEE
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DECISIONS/DUTIES DELEGATED BY THE BOARD OF DIRECTORS TO COMMITTEES
To review the findings of other significant assurance functions, both internal and external to the organisation, and
consider the implications to the clinical governance of the organisation
To direct and monitor organizational leaning on behalf of the Board
To annually review its terms of reference and performance
INVESTMENT
COMMITTEE
1. The Committee shall:
1.1. Approve the methodology, processes and controls which govern the investment decision making process
1.2. Confirm the appointment (including the terms of reference and scope of work) of appropriate independent
professional advisors with demonstrated expertise in advising on transactions of the size and nature being
proposed
1.3. Evaluate and validate the fit of the investment with the Trust’s overall investment strategy
1.4. Ensure each investment has been subject to rigorous evaluation using a thorough evaluation, execution and
monitoring process (as envisaged by appendix 1 of the REID guidance)
1.5. Receive and approve the business case in respect of each investment considered
1.6. Ensure confirmation has been received that the Trust has the legal power to make the proposed investment
1.7. Set criteria by which Business Cases should be tested and subsequently post merger developments tested
1.8. Review Letter of Authority from other bodies (eg CCP)
1.9. Report to the Board of Directors and where appropriate recommend a course of action including where
appropriate to recommend self certification to the Foundation Trust Board
2. The Committee can gain assurance through the work of other Trust Committees eg Business & Finance
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COMMITTEE
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DECISIONS/DUTIES DELEGATED BY THE BOARD OF DIRECTORS TO COMMITTEES
General
Monitor, DH and NHS London have published documents concerning the process regarding Provider Services. In
establishing a process within CNWL it should be mindful of these other organisations
The Investment Committee is established under the guidance published by Monitor, Risk Evaluation for Investment
Decisions.
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CENTRAL AND NORTH WEST LONDON NHS FOUNDATION TRUST
SCHEME OF DELEGATION
AUTHORITIES/DUTIES DELEGATED TO CHAIR
It is the Chair's role to:
1. Provide leadership to the Board and the Council of Members and to ensure that the two bodies work together effectively;
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; and
Ensure that constructive relations exist between Executive and Non-Executive Directors.
Final authority in interpretation of SOs.
Call meetings of the Board.
Chair all Board meetings, Council of Members meetings and associated responsibilities.
Give final ruling in questions of order, relevancy of members’ statements, regularity and any other matters under discussion at the time of the
meeting.
Having a second or casting vote.
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AUTHORITIES/DUTIES DELEGATED JOINTLY TO CHAIR AND CHIEF EXECUTIVE
The powers which the Board has retained to itself within these SOs (SO 4) may in emergency be exercised by the Chair and Chief Executive after
having consulted at least two Non-Executive Directors.
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RESPONSIBILITIES OF THE CHIEF EXECUTIVE AS ACCOUNTING OFFICER ( as set out in the NHS Foundation Trust Accounting Officer
Memorandum 2008 (amended 2010))
The general responsibilities of an NHS Foundation Trust Accounting Officer
The Accounting Officer has responsibility for the overall organisation, management and staffing of the NHS foundation trust and for its procedures in financial
and other matters. The Accounting Officer must ensure that:
• there is a high standard of financial management in the NHS foundation trust as a whole;
• financial systems and procedures promote the efficient and economical conduct of business and safeguard financial propriety and regularity
throughout the NHS foundation trust; and
• financial considerations are fully taken into account in decisions on NHS foundation trust policy proposals.
The specific responsibilities of an NHS foundation trust Accounting Officer
The essence of the Accounting Officer's role is a personal responsibility for:
• the propriety and regularity of the public finances for which he or she is answerable;
• the keeping of proper accounts;
• prudent and economical administration;
• the avoidance of waste and extravagance; and
• the efficient and effective use of all the resources in their charge.
. As Accounting Officer you must:
• personally sign the accounts and, in doing, so accept personal responsibility for ensuring their proper form and content as prescribed by Monitor in
accordance with the Act;
• comply with the financial requirements of the terms of authorisation;
• ensure that proper financial procedures are followed and that accounting records are maintained in a form suited to the requirements of
management, as well as in the form prescribed for published accounts (so that they disclose with reasonably accuracy, at any time, the financial
position of the NHS foundation trust);
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• ensure that the resources for which you are responsible as Accounting Officer are properly and well managed and safeguarded, with independent
and effective checks of cash balances in the hands of any official;
• ensure that assets for which you are responsible such as land, buildings or other property, including stores and equipment, are controlled and
safeguarded with similar care, and with checks as appropriate;
• ensure that any protected property (or interest in) is not disposed of without the consent of Monitor;
• ensure that conflicts of interest are avoided, whether in the proceedings of the Board of Directors, Board of Governors or in the actions or advice of
the NHS foundation trust’s staff, including yourself; and
• ensure that, in the consideration of policy proposals relating to the expenditure for which you are responsible as Accounting Officer, all relevant
financial considerations, including any issues of propriety, regularity or value for money, are taken into account, and brought to the attention of the
Board of Directors.
An Accounting Officer should ensure that effective management systems appropriate for the achievement of the NHS foundation trust’s objectives,
including financial monitoring and control systems, have been put in place. An Accounting Officer should also ensure that managers at all levels:
• have a clear view of their objectives, and the means to assess and, wherever possible, measure outputs or performance in relation to those
objectives;
• are assigned well-defined responsibilities for making the best use of resources (both those consumed by their own commands and any made
available to organisations or individuals outside the NHS foundation trust), including a critical scrutiny of output and value for money; and
• have the information (particularly about costs), training and access to the expert advice which they need to exercise their responsibilities effectively.
. Accounting Officers must make sure that their arrangements for delegation promote good management and that they are supported by the necessary
staff with an appropriate balance of skills. Arrangements for internal audit should accord with the objectives, standards and practices set out in the
Government Internal Audit Standards.
Advice to the board
An Accounting Officer has particular responsibility to see that appropriate advice is tendered to the Board of Directors and the Board of Governors on all
matters of financial propriety and regularity and, more broadly, as to all considerations of prudent and economical administration, efficiency and
effectiveness. Accounting Officers will need to determine how and in what terms such advice should be tendered, and whether in a particular case to
make specific reference to their own duty as Accounting Officer to justify, to the Public Accounts Committee, transactions for which they are accountable.
The Board of Directors and the Board of Governors of an NHS foundation trust should act in accordance with the requirements of propriety or regularity. If
the Board of Directors, Board of Governors or the Chairman is contemplating a course of action involving a transaction which you as Accounting Officer
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consider would infringe these requirements, however, you should set out in writing your objection to the proposal and the reasons for this objection. If the
Board of Directors, Board of Governors or Chairman decides to proceed, you should seek a written instruction to take the action in question. You should
also inform Monitor of the position, if possible before the decision is taken or in any event before the decision is implemented, so that Monitor, if it
considers it appropriate, can intervene in accordance with its responsibilities under the Act. If the outcome is that you are overruled, the instruction must
be complied with, but your objection and the instruction itself should be communicated without undue delay to the NHS foundation trust's external auditors
and to Monitor. Provided that this procedure has been followed, the PAC can be expected to recognise that the Accounting Officer bears no personal
responsibility for the transaction.
. If a course of action is contemplated which raises an issue not of formal propriety or regularity but relating to your wider responsibilities for economy,
efficiency and effectiveness, it is your duty to draw the relevant factors to the attention of the Board of Directors and the Board of Governors and to advise
them in whatever way you deem appropriate. If your advice is overruled, and the proposal is one which as Accounting Officer you would not feel able to
defend to the PAC as representing value for money, you should seek a written instruction before proceeding. Monitor should be informed of such an
instruction, if possible before the decision is implemented. It will then be for Monitor to consider the matter, and decide whether or not to intervene.
If, because of the extreme urgency of the situation, there is no time to submit advice in writing in either of the eventualities referred to in paragraphs 13
and 14 before the decision is taken, you must ensure that, if the advice is overruled, both the advice and the instructions are recorded in writing
immediately afterwards.
Appearance before the Committee of Public Accounts (PAC)
The C&AG may, under the National Audit Act 1983, carry out examinations into the economy, efficiency and effectiveness with which the NHS foundation
trust has used its resources in discharging its functions. An Accounting Officer may expect to be called upon to appear before the PAC from time to time to
give evidence on the reports arising from these examinations or reports following the annual certification audit, and to answer the PAC's questions
concerning expenditure and receipts for which he or she is Accounting Officer. An Accounting Officer may be supported by one or two other senior
officials who may, if necessary, assist in giving evidence.
An Accounting Officer will be expected to furnish the PAC with explanations of any indications of weakness in the matters covered by paragraphs 8 - 15
above, to which their attention has been drawn by the C&AG or about which they may wish to question the Accounting Officer.
In practice, an Accounting Officer will normally have delegated authority to others, but cannot on that account disclaim responsibility or dilute his or her
accountability. Nor, by convention, does the incumbent Accounting Officer decline to answer questions where the events took place before taking up
appointment: the PAC may be expected not to press the incumbent's personal responsibility in such circumstances.
The PAC has emphasised the importance it attaches to accuracy of evidence, and the responsibility of witnesses to ensure this, in order to ensure that
relevant lines of enquiry may be pursued at its hearings. The Accounting Officer should ensure that he or she is adequately and accurately briefed on
matters which are likely to arise at the hearing. The Accounting Officer may, however, ask the PAC for leave to supply information not within his or her
immediate knowledge by means of a later 4
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note. Should it be discovered subsequently that the evidence provided to the PAC has contained errors, these should be made known to the PAC at the
earliest possible moment.
In general, the rules and conventions governing appearances of officials before parliamentary committees apply to the PAC, including the general
convention that officials do not disclose the advice given to the board. Nevertheless, in a case where the procedure described in paragraph 13 was used
concerning a matter of propriety or regularity, the Accounting Officer's advice, and its overruling by the board, would be disclosed to the PAC. In a case
covered by paragraph 14, where the advice of an Accounting Officer has been overruled in a matter not of propriety or regularity but of prudent and
economical administration, efficiency or effectiveness, the C&AG will have made clear in the report to the PAC that the Accounting Officer was overruled.
The Accounting Officer should seek to avoid disclosing the advice given to the board, though subject to their agreement the Accounting Officer should be
ready to explain the reasons for their decision.
Absence of an Accounting Officer
An Accounting Officer should ensure that he or she is generally available for consultation, and that in any temporary period of unavailability due to illness
or other cause, or during the normal period of annual leave, there will be a senior officer in the NHS foundation trust who can act on his or her behalf if
required.
If it becomes clear to the Board of Directors that an Accounting Officer is so incapacitated that he or she will be unable to discharge these responsibilities
over a period of four weeks or more, the Board of Directors should appoint an acting Accounting Officer, usually the Director of Finance, pending the
Accounting Officer's return. The same applies if, exceptionally, the Accounting Officer plans an absence of more than four weeks during which he or she
cannot be contacted.
The PAC may be expected to postpone a hearing if the relevant Accounting Officer is temporarily indisposed. Where the Accounting Officer is unable by
reason of incapacity or absence to sign the accounts in time for submission, the NHS foundation trust may submit unsigned copies pending the
Accounting Officer's return. If the Accounting Officer is unable to sign the accounts in time for printing, the acting Accounting Officer should sign instead.
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AUTHORITIES/DUTIES DELEGATED TO THE CHIEF EXECUTIVE
Statutory/legal
Ensure that the Trust is compliant with its legal responsibilities
Approve and sign all documents, or formally delegate, as authorised by the Board and which will be necessary in legal proceedings.
Ensure the Trust enters into suitable Contracts with service commissioners and authorize appropriate employees to negotiate and agree such
contracts
Submit monitoring returns to regulators and statutory bodies as required.
Authorise who may use and be issued with official orders.
Ensure that the arrangements for financial control and financial audit of building and engineering contracts and property transactions comply with the
guidance from the Independent Regulator. The technical audit of these contracts shall be the responsibility of the relevant Executive Director.
Retention of document procedures in accordance with HSC 1999/053.
Ensure the Trust has a Risk Management policy.
Monitor and ensure compliance with Secretary of State Directions on fraud and corruption including the appointment of the Local Counter Fraud
Specialist.
Maintain a register of Governors
Ensure elections are carried out in a timely manner and in accordance with the election rules as set out in the constitution
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Annual plan
Compile and submit to the Board a Plan that takes into account financial targets and forecast limits of available resources. The Plan will contain a
statement of the significant assumptions on which the Plan is based and details of major changes in workload, delivery of services or resources
required to achieve the Plan.
Identify and implement cost improvements and income generation activities in line with the Plan.
Staffing
Ensure existing Board members, employees and contractors and all new appointees are notified of and understand their responsibilities within SOs
and SFIs.
Advise the Board on the remuneration and terms of service for staff not covered by the Remuneration Committee.
Finance
Delegate budget to budget holders and authority to requisition goods and services in accordance with the levels of authorization set out in the SFIs
and ensure that a system is in place to ensure compliance with those SFIs.
Be on an authorising panel comprising one other member for short term borrowing approval.
In relation to the capital investment programme:
a) Ensure that there is adequate appraisal and approval process for determining capital expenditure priorities and the effect that each has on
business plans;
b) Responsible for the management of capital schemes and for ensuring that they are delivered on time and within cost;
c) Ensure that capital investment is not undertaken without confirmation of purchaser(s) support or a risk assessment of demand where no single
purchaser can give sufficient reassurance and the availability of resources to finance all revenue consequences; and
Ensure that a business case is produced for each proposal.
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Overall responsibility for fixed assets and the maintenance of the asset register
Delegate overall responsibility for control of stores (subject to the Finance Director responsibility for systems of control).
Responsible for ensuring patients and guardians are informed about patients' money and property procedures on admission.
Ensure compliance with the tendering procedures as set out in SFIs including authorising waiving of these tendering procedures and reporting such
waivers to the Board
Approve acceptance of quotation committing Trust to expenditure over allocation limits.
Demonstrate that the use of private finance represents best value for money and transfers risk to the private sector.
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CENTRAL AND NORTH WEST LONDON NHS FOUNDATION TRUST
SCHEME OF DELEGATION – FROM STANDING FINANCIAL INSTRUCTIONS (SFIs)
[August] 2009
AUTHORITIES/DUTIES DELEGATED TO THE FINANCE DIRECTOR
Responsible for:
a) The SFIs and keeping them up to date.
b) Implementing the Trust's financial policies and co-ordinating corrective action;
c) Maintaining an effective system of financial control including ensuring detailed financial procedures and systems are prepared and documented;
d) Ensuring that sufficient records are maintained to explain Trust’s transactions and financial position;
e) Providing financial advice to members of Board and staff;
f)
The design, implementation and supervision of systems of internal financial control; and
Maintaining such accounts, certificates, estimates, records and reports, as are required for the Trust to carry out its statutory duties.
Approval of all financial procedures.
Advice on interpretation or application of SFIs.
Ensure an adequate Internal Audit service, is provided and involve the Audit Committee in the selection process when/if an Internal Audit service
provider is changed.
Assist the Council of Members in the appointment of External Audit
Submit budgets to the Board for approval.
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Monitor performance against budget and submit to the Board financial estimates and forecasts.
Ensure adequate training on financial management is delivered on an on-going basis.
Review allocations and prepare annual report and accounts.
Devise and maintain systems of budgetary control.
Managing banking arrangements, subject to Board approval, including provision of banking services, operation of accounts, preparation of
instructions and list of cheque signatories.
Ensure all covenants attached to borrowing are adhered to.
Managing income systems (including system design, prompt banking, review, and approval of fees and charges), debt recovery arrangements,
design and control of receipts, provision of adequate facilities, and systems for employees whose duties include collecting or holding cash.
With the Director of Human resources Ensure payroll function is adequate to make agreed payments by agreed dates and by agreed method of
payment and comply with HMRC requirements.
Advise the Board regarding the setting of thresholds for SFIs and scheme of delegation.
Ensure appropriate controls and arrangements relating to accounts payable
Approve proposed prepayment arrangements.
Ensure compliance with Prudential Borrowing Code and prepare instructions regarding applications for loans and overdrafts.
Advise the Board concerning the Trust's ability to pay dividend on, and repay Public Dividend Capital (PDC) and any proposed borrowing within the
limits set by its Terms of Authorisation. Responsible for reporting to the Board concerning the PDC debt and all loans and overdrafts.
Advising the Board on investments, preparing instructions on operation of investment accounts, and authorise all investment transactions and ensure
compliance with investment policy.
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Certify professionally the costs and revenue consequences detailed in the business case for investment.
Assess the requirement for the operation of the construction industry taxation deduction scheme.
Issue procedures for the regular reporting of expenditure and commitment against authorised capital expenditure.
Issue procedures governing financial management, including variation to contract, of capital investment projects and valuation for accounting
purposes.
Demonstrate that the use of private finance represents value for money and genuinely transfers significant risk to the private sector.
Approve procedures for reconciling balances on fixed assets accounts in ledgers against balances on fixed asset registers.
Approval of fixed asset control procedures.
Set out procedures and systems to regulate the stores including disposals
Prepare procedures for recording and accounting for condemnations, losses and special payments and maintain a register of such payments.
In cases of fraud and corruption, or anomalies that may indicate fraud or corruption, then the Finance Director must inform the Local Counter Fraud
Specialist and should ensure that the External Auditor is notified of actual frauds.
Notify Board and External Auditor of losses caused by theft, arson, neglect of duty or gross carelessness (unless under £5,000).
Consider whether any insurance claim can be made.
Responsible for accuracy and security and efficacy of financial systems including the security of computerised financial data.
Provide detailed written instructions on the collection, custody, investment, recording, safekeeping, and disposal of patients' property (including
instructions on the disposal of the property of deceased patients and of patients transferred to other premises) for all staff whose duty is to administer,
in any way, the property of patients.
Agree arrangements to open and operate separate accounts for patients' monies, where required by the Independent Regulator.
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Agree arrangements to open and operate separate accounts for charitable funds, where required by the Independent Regulator.
Ensure compliance with the requirements of HMRC concerning any issue of taxation relevant to the Trust.
Notify Monitor of any financial matters which might cause or lead to a breach of authorisation
Ensure all staff are made aware of the Trust policy on the acceptance of gifts and other benefits in kind by staff.
Where the Board decides to use the risk pool schemes, the Finance Director shall ensure that the arrangements entered into are appropriate and
complementary to the Risk Management programme. The Finance Director shall ensure that documented procedures cover these arrangements.
Where the Board decides not to use the risk pooling schemes administered by the NHS Litigation Authority for any one or other of the risks covered
by the schemes, the Finance Director shall ensure that the Board is informed of the nature and extent of the risks that are self-insured as a result of
this decision. The Finance Director will draw up formal documented procedures for the management of any claims arising from third parties and
payments in respect of losses that will not be reimbursed.
For risk pooling schemes, ensure documented procedures cover management of claims and payments below the deductible
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AUTHORITIES/DUTIES DELEGATED TO OTHER STAFF
ALL DIRECTORS
Disclose to Chief Executive relationship between self and candidate for staff appointment. The
Chief Executive to report the disclosure to the Board.
ALL DIRECTORS
On appointment to the Board disclose if related to any other member of the Board or holder of
any office of the Trust.
ALL EXECUTIVE DIRECTORS
Notify Monitor, through the Trust Secretary of any matter that might cause or lead to a breach
of authorisation
Trust Secretary
Maintain Registers of Interests of the Board and the Council of Members.
Trust Secretary
Notify Monitor of any matter that might cause or lead to a breach of authorisation
Director of HR
Ensure that all employees are issued with a Contract of Employment in a form approved by the
Board and which complies with employment legislation and deal with variations to, or
termination of, contracts of employment.
Director of HR
Ensure all relevant staff have CRB checks
Medical Director
Ensure the development and production of an annual Quality Account
Medical Director
Ensure the revalidation of medical staff
Chief Pharmacist
Executive authority and responsibility for ensuring strategies are implemented for medicines
management at all levels in the organisation. The Chief Pharmacist will provide assurance to
the Board that systems are in place and correct policies and procedures are adhered to
across the organisation to ensure safe and effective management of medicines.
Accountable Officer for Controlled drugs
Currently the Chief Pharmacist. Statutory responsibility for ensuring effective management of
controlled drugs
Director Commercial Development
With the Director of Finance certify professionally the costs and revenue consequences
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detailed in the business case for investment.
Director Commercial Development
With the Director of Finance assess the requirement for the operation of the construction
industry taxation deduction scheme.
Director Commercial Development
Ensure delivery of the Trust’s sustainability strategy and compliance with
requirements in respect of environmental matters
Director Commercial Development
Ensure compliance with any legal requirements in respect of the Trust’s transport functions.
Associate Director Corporate Governance
Ensure procedures for informing the police in cases of suspected theft or arson.
DIPC
Director of Operations and Nursing
Director Operations and Nursing
Director Strategic Planning and Community Services
Director Strategic Planning and Community Services
any legal
Executive authority and responsibility for ensuring strategies are implemented to prevent
avoidable healthcare associated infections (HCAIs) at all levels in the organisation. The DIPC
will provide assurance to the Board that systems are in place and correct policies and
procedures are adhered to across the organisation to ensure safe and effective healthcare.
and to enable the organisation to continuously improve its performance in relation to HCAIs.
To be the Security Management Director and ensure that adequate security management
provision is made, as specified particularly in paragraphs 2 and 7 of the Secretary of State
Directions to NHS Bodies on Security Management Measures 2004 (amended 2006).
Ensure that serious incidents are reported appropriately to the relevant regulatory bodies.
To be the Senior Information Risk officer ( SIRO) and be familiar with and takes ownership of
the organisation’s information risk policy and act as an advocate for information risk on the
Board.
Ensure that procedure are in place to enable compliance with the Data Protection Act and
Freedom of Information Act
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AUTHORITIES/DUTIES OF ALL STAFF
Disclosure of non-compliance with SOs to the Chief Executive as soon as possible.
Comply with national guidance contained in HSG 1993/5 “Standards of Business Conduct for NHS Staff” the Code of Conduct for NHS
Managers and any other relevant guidance issued by the Independent Regulator or other relevant body.
Comply with requirements of conduct relating to gifts and hospitality and provisions of the Bribery Act.
Disclosure of non-compliance with SFIs as soon as possible to the Finance Director. The Finance Director to report to the Audit
Committee.
Responsible, severally and collectively, for: security of the Trust's property; avoiding loss; exercising economy and efficiency in using
resources; and conforming to SOs, SFIs and financial procedures.
Duty to inform Finance Director of money due arising from transactions which they initiate/deal with.
Duty to inform the Finance Director of any conflict of interest relating to any contracting process
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