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Appendix A
STANDING FINANCIAL INSTRUCTIONS
STANDING FINANCIAL INSTRUCTIONS
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1. INTRODUCTION General Terminology Responsibilities and Delegation 2. AUDIT Audit Committee Fraud, Bribery and Corruption Executive Director of Finance Role of Internal Audit External Audit 3. BUSINESS PLANNING, BUDGETS, BUDGETARY CONTROL AND MONITORING Preparation and approval of Business Plans and Budgets Budgetary Delegation Budgetary Control and Reporting Capital Expenditure Monitoring Returns 4. ANNUAL ACCOUNTS AND REPORTS 5. BANK ACCOUNTS General Bank Accounts Banking Procedures Tendering and Review 6. INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE INSTRUMENTS Income Systems Fees and Charges Debt Recovery Security of Cash, Cheques and other Negotiable Instruments 7. CONTRACTING FOR PROVISION OF SERVICES NHS Service Agreements NHS Non Commercial Agreements 8. TERMS OF SERVICE AND PAYMENTS OF DIRECTORS AND EMPLOYEES Remuneration and Terms of Service Funded Establishment Staff Appointments Payroll Contracts of Employment 9. NON PAY EXPENDITURE Delegation of Authority Choice, Requisitioning, Ordering, Receipt & Payment for Goods and
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Services 10. EXTERNAL BORROWING AND INVESTMENT Public Dividend Capital Commercial Borrowing and Investment Investment of Temporary Cash Surplus 11. CAPITAL INVESTMENT, PRIVATE FINANCING, FIXED ASSET REGISTERS AND SECURITY OF ASSETS Capital Investment Private Finance Asset Registers Protected Property Security of Assets 12. STORES AND RECEIPT OF GOODS 13. DISPOSALS & CONDEMNATIONS, LOSSES AND SPECIAL PAYMENTS Disposals and Condemnations Losses and Special Payments Insurance 14. INFORMATION TECHNOLOGY 15. PATIENTS’ PROPERTY 16. ACCEPTANCE OF GIFTS BY STAFF 17. RETENTION OF DOCUMENTS 18. RISK MANAGEMENT AND INSURANCE
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1. INTRODUCTION 1.1 General
1.1.1 These Standing Financial Instructions (SFIs) are issued in accordance with the
Financial Directions issued by the Secretary of State under the provisions of
Sections 99(3), 97(A)(4) and (7) of the National Health Service Act 1977 for the
regulation of the conduct of the Trust in relation to all financial matters. the Financial
Directions issued by the Secretary of State – under the provisions of the NHS Act
2006 (as amended by the Health and Social Care Act 2012) – for the regulation of
the conduct of the Trust in relation to all financial matters. They shall have effect as if
incorporated in the Standing Orders (SOs) of the Trust. 1.1.2 These SFIs detail the financial responsibilities, policies and procedures to be
adopted by the Trust. They are designed to ensure that its financial transactions are carried out in accordance with the law and Government policy in order to achieve probity, accuracy, economy, efficiency and effectiveness. They should be used in conjunction with the Reservations of Powers to the Board and the Scheme of Delegation to Group Committees in Common.
1.1.3 These SFIs identify the financial responsibilities that apply to everyone working for
the Trust and its constituent organisations including Trading Units These SFI’s also apply to the Services “Hosted” by the Trust as if they are a part of the core business. They do not provide detailed procedural advice. These statements should therefore be read in conjunction with the detailed departmental and financial procedure notes. All financial procedures in place within the Trust, both inside the Finance Department and in other Departments of the Trust, must be approved by the Chief Financial Officer.
1.1.4 Should any difficulties arise regarding the interpretation or application of any of the
SFIs then the advice of the Executive Director of Finance MUST BE SOUGHT BEFORE ACTING. The user of these SFIs should also be familiar with and comply with the provisions of the Trust's Standing Orders (SOs).
1.1.5 FAILURE TO COMPLY WITH SFIs AND SOs IS A DISCIPLINARY MATTER
WHICH COULD RESULT IN DISMISSAL. 1.1.6 Overriding Standing Financial Instructions – If for any reason these Standing
Financial Instructions are not complied with full details of the non-compliance and any justification for non-compliance and the circumstances around the non- compliance shall be reported to the next formal meeting of the Audit Committee for referring action or ratification. All members of the Board of Directors and staff have a duty to disclose any non-compliance with these Standing Financial Instructions to the Executive Director of Finance as soon as possible.
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1.2 Terminology 1.2.1 Any expression to which a meaning is given in Health Service Acts, or in the Financial
Directions made under the Acts, shall have the same meaning in these instructions. The following terms apply equally to the SFI and the SORD:
a) “Principal Accounting Officer” means the Officer responsible and accountable
for funds entrusted to the Trust in accordance with the role of Accounting Officer
for Salford Royal NHS Foundation Trust role of Accountable Officer for The
Pennine Acute Hospitals NHS Trust . He shall be responsible for ensuring the
proper stewardship of public funds and assets. This shall be the Chief Executive.
b) "Board " means the Board of Directors of the Salford Royal NHS Foundation
Trust the Trust Board of The Pennine Acute Hospitals NHS Trust
c) "Budget" means a resource, expressed in financial terms, proposed by the Board
for the purpose of carrying out, for a specific period, any or all of the functions of the Trust;
d) "Budget Holder" means the director or employee with delegated authority to
manage finances for a specific area of the organisation;
e) "Care Organisation Management Board" means the most senior decision making committee of the Care Organisation;
f) "Chief Financial Officer" means the Chief Financial Officer of the Group
Committees in Common;
g) “Chief Executive" means the Chief Executive Officer of the Trust;
h) "Director of Finance" means the most senior financial officer of the Care Organisation;
i) "Executive Director of Finance" means the most senior financial officer of the
Trust;
j) “Funds held on trust” shall mean those funds which the Trust holds on the date of incorporation, receives on distribution by statutory instrument or chooses subsequently to accept under powers derived under S.90 of the NHS Act 1977, as amended. Such funds may or may not be charitable.
k) “Group CiC” – means Group Committees in Common l) “Hosted Services” means services that the Trust provides the full range of
support services to but which is not part of Trust core healthcare activity. m) “Independent Regulator” means NHS Improvement, Monitor and the Trust
Development Authority.
n) "Legal Adviser" means the properly qualified person appointed by the Trust to provide legal advice.
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o) “SFIs” – means Standing Financial Instructions.
p) "Trust" means the Salford Royal NHS Foundation Trust The Pennine Acute
Hospitals NHS Trust
1.2.2 Wherever the title Chief Executive, Chief Financial Officer, Executive Director of
Finance, or other nominated officer is used in these instructions, it shall be deemed to include such other Director or employee who have been duly authorised to represent them.
1.2.3 Wherever the term "employee" is used and where the context permits it shall be
deemed to include employees of third parties contracted to the Trust when acting on behalf of the Trust.
1.3 Responsibilities and Delegation 1.3.1 The Board exercises financial supervision and control by: (a) formulating the financial strategy, which is articulated through the Annual Plan, (b) setting the Standing Orders and Standing Financial instructions for the
regulation of its financial proceedings and business, and (c) defining specific responsibilities placed on directors and employees as
indicated in the Detailed Scheme of Delegation document. 1.3.2 The Board has resolved that certain powers and decisions may only be exercised by
the Board in formal session. These are set out in the “Reservations of Powers to the Board”.
1.3.3 The Board will delegate responsibility for the performance of its functions in
accordance with the Scheme of Delegation. 1.3.4 Within the SFIs, it is acknowledged that the Chief Executive is ultimately accountable
to the Board and as accountable office to the Secretary of State, for ensuring that the Board meets its obligations to perform its functions with the available financial resources. The Chief Executive has overall executive responsibility for the Trust's activities, is responsible to the Board for ensuring that its financial obligations and targets are met and has overall responsibility for the Trust’s system of internal control.
1.3.5 The Chief Executive and Executive Director of Finance will, as far as possible,
delegate their detailed responsibilities but they remain accountable for financial control and the powers vested in them by the Board or the Independent Regulator.
1.3.6 It is a duty of the Chief Executive to ensure that existing directors and employees
and all new appointees are notified of and understand their responsibilities within these Instructions.
1.3.7 The Executive Director of Finance is responsible for:
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(a) implementing the Trust financial policies and for co-ordinating any corrective
action necessary to further these policies,
(b) maintaining an effective system of internal financial control including ensuring that detailed financial procedures and systems incorporating the principles of separation of duties and internal checks are prepared, documented and maintained to supplement these instructions,
(c) ensuring that sufficient records are maintained to show and explain the Trust
transactions, in order to disclose, with reasonable accuracy, the financial position of the Trust at any time,
and, without prejudice to any other functions of directors and employees to the
Trust, the duties of the Executive Director of Finance include:
(d) the provision of financial advice to the Trust and its directors, employees and
governors.
(e) the design, implementation and supervision of systems of internal financial
control, and (f) the preparation and maintenance of such accounts, certificates, estimates,
records and reports as the Trust may require for the purpose of carrying out its statutory duties.
1.3.8 All directors and employees, severally and collectively, are responsible for: (a) the security of the property of the Trust, (b) avoiding loss, (c) exercising economy and efficiency in the use of resources, and (d) conforming with the requirements of Standing Orders, Standing Financial
Instructions, Financial Procedures and the Scheme of Delegation. 1.3.9 Any contractor or employee of a contractor who is empowered by the Trust to
commit the Trust to expenditure or who is authorised to obtain income shall be covered by these instructions. It is the responsibility of the Chief Executive to ensure that such persons are made aware of this.
1.3.10 For any and all directors and employees who carry out a financial function, the form
in which financial records are kept and the manner in which directors and employees discharge their duties must be to the satisfaction of the Executive Director of Finance.
SECTION 2 AUDIT
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2.1 Audit Committee 2.1.1 In accordance with Standing Orders, the Board shall formally establish an Audit
Committee, with clearly defined terms of reference, which will provide an independent and objective view of internal control by:
(a) overseeing Internal and External Audit services
(b) receiving the annual management letter received from the external auditor and agree proposed action,
(c) receiving an annual report from the Internal Auditor and agree action on recommendations where appropriate
(d) reviewing financial systems and monitoring the integrity of the financial statements and reviewing significant financial reporting judgments;
(e) reviewing the establishment and maintenance of an effective system of integrated governance, risk management and internal control, across the whole of the organisation’s activities (both clinical and non-clinical), that supports the achievement of the organisation’s objective.
(f) monitoring compliance with Standing Orders and Standing Financial Instructions,
(g) reviewing schedules of losses and compensations and making
recommendations to the Group CIC.
(h) reviewing schedules of debtors/creditors balances over 6 months old and £10k and explanations/action plans.
(i) reviewing and approving accounting policies
(j) review and approving write-off of non-NHS debtors
(k) reviewing the arrangements in place to support the Assurance Framework process prepared on behalf of the Group CiC and advising the Group CiC accordingly.
(l) reviewing the arrangements in place for Counter Fraud, Bribery and Corruption by receiving the annual work plan and report and by receiving information regarding on-going cases.
(m) reviewing the effective implementation of corporate governance measures to
enable the Trust to implement best practice as set out in appropriate guidance. This will include the Assurance Framework and control related disclosure statements, for example the Annual Governance Statement and supporting assurance process; together with any accompanying audit statements, prior to endorsement by the Board of Directors.
2.1.2 Where the Audit Committee feels there is evidence of ultra vires transactions,
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evidence of improper acts, or if there are other important matters that the committee wishes to raise, the Chairman of the Audit Committee should raise the matter at a full meeting of the Group CiC.
2.1.3 It is the responsibility of the Executive Director of Finance to ensure adequate
internal and external audit services are provided and the Audit Committee shall be
involved in the selection process when an audit service provider is changed, with the
selection process for External Auditors being the responsibility of the Council of
Governors, guided by the Executive Director of Finance and Audit Committee.
2.2 Fraud, Bribery and Corruption 2.2.1 The Trust shall take all necessary steps to ensure that NHS funds and resources are
protected and safeguarded against those minded to commit fraud, bribery and corruption and that appropriate measures to combat fraud, bribery and corruption are put in place in accordance with its requirement to comply with all the Standards for Providers for Fraud Conditions 24 of the NHS Standard Contract in accordance with;
a) the NHS Anti-Fraud Manual published by the NHS Protect; b) the policy statement “Applying appropriate sanctions consistently
published by NHS Protect;
c) any other reasonable guidance or advice issued by NHS Protect that affects efficiency, systemic and/or procedural matters.
The Chief Executive and Executive Director of Finance shall monitor and ensure compliance with the above.
2.2.2 In line with their responsibilities, the Chief Executive and Executive Director of Finance is responsible for overseeing and providing strategic management and support for all anti-fraud, bribery and corruption work..
2.2.3 The Trust shall contract in an accredited, nominated person (or persons) to undertake the full range of anti-fraud, bribery and corruption work as detailed in four key sections that follow NHS Protect’s strategy and shall report to the Executive Director of Finance regarding all aspects of anti-fraud, bribery and corruption wok carried out.
2.2.4 The Anti-Fraud Specialist will develop an Annual Workplan that details the activities to be undertaken across the four key areas and shall provide a written report, at least annually, detailing progress on anti-fraud, bribery and corruption work carried out.
2.3 Executive Director of Finance 2.3.1 The Executive Director of Finance is responsible for: (a) ensuring there are arrangements to review, evaluate and report on the
effectiveness of internal financial control including the establishment of an effective internal audit function,
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(b) ensuring that the internal audit is adequate and meets the NHS mandatory audit standards,
(c) ensuring that there are arrangements in place to involve the police, as
necessary, in cases of fraud, bribery, misappropriation, and other irregularities,
(d) ensuring that annual internal audit reports are prepared (which include the
Head of Internal Audit Opinion, Annual Report and Internal Audit Plans) for the consideration of the Audit Committee and the Board of Directors. These reports must cover:
(i) a clear statement on the overall adequacy and effectiveness of the
organisation’s framework of governance, risk management and internal control;
(ii) major internal [financial] control weaknesses discovered, (iii) progress on the implementation of internal audit
recommendations, (iv) progress against plan over the previous year, (v) strategic audit plan covering the coming three years, (vi) a detailed plan for the coming year. 2.3.2 The Executive Director of Finance and/or designated internal auditors are entitled
without necessarily giving prior notice to require and receive: (a) access to all records, documents and correspondence relating to any financial
or other relevant transactions, including documents of a confidential nature, (b) access at all reasonable times to any land, premises or employee of the Trust, (c) the production of any cash, stores or other property of the Trust under an
employee's control, and (d) explanations concerning any matter under investigation. 2.4 Role of Internal Audit 2.4.1 Internal Audit will review, appraise and report upon: (a) the extent of compliance with, and the financial effect of, relevant established
policies, plans and procedures, (b) the adequacy and application of financial and other related management
controls, (c) the suitability of financial and other related management data,
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(d) the extent to which the Trust’s assets and interests are accounted for and safeguarded from loss of any kind, arising from:
(i) fraud, bribery, corruption and other offences,
(ii) waste, extravagance, inefficient administration,
(ii) poor value for money or other causes.
2.4.2 Whenever any matter arises which involves, or is thought to involve, irregularities
concerning cash, stores, or other property or any suspected irregularity in the exercise of any function of a pecuniary nature, the Executive Director of Finance must be notified immediately.
2.4.3 The Head of Internal Audit will normally attend Audit Committee meetings and has a
right of access to all Audit Committee members, the Chairman and Chief Executive of the Trust.
2.4.4 The Head of Internal Audit shall be accountable to the Executive Director of
Finance. The reporting system for internal audit shall be agreed between the Executive Director of Finance, the Audit Committee and the Head of Internal Audit. The agreement shall be in writing and shall comply with the guidance on reporting contained in the Public Sector Internal Audit Standards. The reporting system shall be reviewed at least every 3 years.
2.4.5 Where, in exceptional circumstances, the use of normal reporting channels is
thought to limit the objectivity of the audit, the Head of Internal Audit shall have access to report direct to the Chairman or a non-executive member of the Trust’s Audit Committee.
2.4.5 Managers in receipt of audit reports referred to them have a duty to take appropriate
remedial action within the agreed time-scales specified within the reports. The Executive Director of Finance shall identify a formal review process to monitor the extent of compliance with the audit recommendations. Where appropriate remedial action has failed to take place within a reasonable time period the matter shall be reported to the Executive Director of Finance.
2.5 External Audit
2.5.1 The external auditor is appointed by the Council of Governors the Trust Board
and paid for by the Trust. 2.5.2 The Code of Audit Practice (“The Audit Code”) contains directions of the
Comptroller and Auditor General under Schedule 13(3)(1) and Schedule 6 of the
Local Audit and Accountability Act 2014 with respect to the standards, procedures and techniques to be adopted by the auditor.
2.5.3 The Trust shall comply with Schedule 10 of the NHS Act 2006 (Audit of Accounts
of NHS Foundation Trusts) and the specific provisions within Monitor’s NHS
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Foundation Trust Code of Governance C3. Audit Committee and Auditors.
2.5.4 The Auditor shall comply with the Audit Code. 2.5.5 References 2.4.3 and 2.4.5. relate equally to internal and external audit. 2.5.6 In the event of the Auditor issuing a Public Interest report the Auditor shall send
the report as soon as reasonably practical after it is made to the Trust and the
Secretary of State immediately or within 14 days of the conclusion of the audit
where not an immediate report to the Council of Governors of the Trust, the Board
of Directors of the Trust and NHS Improvement.
2.6 Security Management 2.6.1 In line with their responsibilities, the Trust Chief Executive will monitor and ensure
compliance with Directions issued by the Secretary of State for Health on NHS security management.
2.6.2 The Trust shall nominate a suitable person to carry out the duties of the Local
Security Management Specialist (LSMS) as specified by the Secretary of State for Health guidance on NHS security management.
2.6.3 The Trust shall nominate a Non-Executive Director to be responsible to the Board for NHS security management.
2.6.4 The Chief Executive has overall responsibility for controlling and coordinating security. However, key tasks are delegated to the Director of Estates and Facilities and the Areas Security Management Specialist (ASMS) together with the appointed Local Security Management Specialist (LSMS).
SECTION 3 SERVICE PLANNING, BUDGETS, BUDGETARY CONTROL, AND MONITORING 3.1 Preparation and approval of Business Plans and Budgets 3.1.1 The Chief Executive will compile and submit to the Board of Directors an Annual
Plan document which encompasses an annual business plan and takes into account financial targets and forecast limits of available resources. The annual business plan will contain:
(a) a statement of the significant assumptions on which the plan is based;
(b) details of major changes in workload, delivery of services or resources required to achieve the plan.
3.1.2 Prior to the start of the financial year, the Executive Director of Finance will, on
behalf of the Chief Executive, prepare and submit budgets for approval by the Board. Such budgets will:
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(a) be in accordance with the aims and objectives set out in the Trust’s annual business plan, and the local commissioning intentions (or equivalent documents).
(b) accord with workload and manpower plans, (c) be produced following discussion with appropriate budget holders,
(d) be prepared within the limits of available funds, and
(e) identify potential risks
(f) be based on reasonable and realistic assumptions. (g) enable the Trust to comply with the requirements set out by the independent
regulator. 3.1.3 The Chief Financial Officer shall monitor financial performance against budget and
business plan, periodically review them, and report to the Group CiC. Any significant variances should be reported by the Chief Financial Officer to the Group CiC as soon as they come to light and the Group CiC shall be advised of actions to be taken in respect of such variances.
3.1.4 All budget holders must provide information as required by the Executive Director of
Finance to enable budgets to be compiled. On completion of the budget setting all budget holders will be asked to confirm in writing their acceptance of their allocated budgets at the start of the financial year.
3.1.5 The Executive Director of Finance has a responsibility to ensure that adequate
training is delivered on an on-going basis to budget holders to help them manage successfully.
3.2 Budgetary Delegation 3.2.1 The Chief Executive may delegate the management of a budget to permit the
performance of a defined range of activities, including pooled budget arrangements under Section 75 of the 2006 Act. This delegation must be in writing and be accompanied by a clear definition of:
(a) the amount of the budget,
(b) the purpose(s) of each budget heading, (c) individual and group responsibilities, (d) authority to exercise virement, (e) achievement of planned levels of service, and (f) the provision of regular reports.
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3.2.2 The Chief Executive and delegated budget holders must not exceed the budgetary total or virement limits set by the Board.
3.2.3 Any budgeted funds not required for their designated purpose(s) revert to the
immediate control of the Chief Executive, subject to any authorised use of virement. 3.2.4 Non-recurring budgets should not be used to finance recurring expenditure without
the authority in writing of the Chief Executive. 3.3 Budgetary Control and Reporting 3.3.1 The Executive Director of Finance will devise and maintain systems of budgetary
control. These will include: (a) monthly financial reports to the Group CiC in a form approved by the Group
CiC containing: ‐ income and expenditure to date showing trends and forecast year-
end position ‐ movements in working capital ‐ movements in cash and capital ‐ capital project spend and projected outturn against plan ‐ expectations of any material variances from plan ‐ details of any corrective action where necessary and the Chief
Executives and/or Chief Financial Officer’s view of whether such actions are sufficient to correct the situation.
(b) the issue of timely, accurate and comprehensible advice and financial reports
to each budget holder, covering the areas for which they are responsible, (c) investigation and reporting of variances from financial, workload and
manpower budgets, (d) monitoring of management action to correct variances, and
(e) arrangements for the authorisation of budget transfers.
(n) advising the Chief Executive of the consequences of changes in policy, pay awards and other events and other trends affecting budgets and shall advise on the economic and financial impact of future plans and projects; and
(o) review of the bases and assumptions used to prepare the budgets.
In performance of these duties the Executive Director of Finance will have access to
all budget holders and budget managers on budgetary matters and shall be provided with such financial and statistical information as is necessary.
3.3.2 Each Budget Holder is responsible for ensuring that: (a) any likely overspending or reduction of income which cannot be met by
virement is not incurred without the prior consent of the Board of Directors,
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(b) the amount provided in the approved budget is not used in whole or in part for any purpose other than that specifically authorised subject to the rules of virement, and
(c) no permanent employees are appointed without the approval of the Chief
Executive other than those provided for in the budgeted establishment as approved by the Board of Directors.
(d) that any proposal to increase revenue spending has an appropriate funding
stream identified and that this has been agreed by the Chief Executive. Proposals to increase revenue spending should also be signed off by the Executive Director of Finance. This applies to all revenue developments whether part of the Commissioning Intentions [or other appropriate plans of commissioners] discussions or separate initiatives, however funded.
3.3.3 The Chief Executive is responsible for identifying and implementing cost
improvements and income generation initiatives in accordance with the requirements of the Annual Plan and in accordance with the financial plan.
3.4 Capital Expenditure 3.4.1 The general rules applying to delegation and reporting shall also apply to capital
expenditure. (The particular applications relating to capital are contained in Section 11.)
3.5 Monitoring Returns 3.5.1 The Chief Executive is responsible for ensuring that the requisite monitoring forms
are submitted to the appropriate monitoring organisation within the required time-scale.
SECTION 4 ANNUAL ACCOUNTS AND REPORTS 4.1 The Executive Director of Finance, on behalf of the Trust, will: (a) keep accounts, and in respect of each financial year must prepare annual
accounts, in such form as the Independent Regulator may, with the approval of the Treasury, direct.
(b) ensure that, in preparing the annual accounts, the Trust complies with any
directions given by the Independent Regulator Department of Health with the
approval of the Treasury as to;
the methods and principles according to which the accounts are to be prepared and
the information given in the accounts (c) ensure that a copy of the annual accounts and any report by the external
auditor on them, are laid before Parliament and that copies of these
documents are sent to the Independent Regulator Department of Health,
within the prescribed timetable.
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4.2 The Trust will prepare annual reports as required by the NHS Foundation Trust Annual
Reporting Manual Department of Health Group Accounting Manual. This will be
received by the Council of Governors at a public meeting. The Trust will publish an
annual report, in accordance with guidelines on local accountability, and present it at a
public meeting. A copy will be forwarded to the Independent Regulator Department of
Health.
SECTION 5 BANK ACCOUNTS 5.1 General 5.1.1 The Executive Director of Finance is responsible for managing the Trust’s banking
arrangements and for advising the Trust on the provision of banking services and operation of accounts. This advice will take into account guidance/ directions issued from time to time by the Independent Regulator.
5.1.2 The Group CiC shall approve the banking arrangements other than mandated
government banking service accounts where any proposed changes will be reported to the Audit Committee.
5.1.3 No employee may open or hold a bank account in the name of the Trust or of its
constituent hospitals/departments. Any employee aware of the existence of such an account shall report the matter to the Executive Director of Finance.
5.2 Bank Accounts 5.2.1 The Executive Director of Finance is responsible for: (a) bank accounts and Government Banking Services (GBS) [accounts and other
forms of working capital that may be available]. (b) establishing separate bank accounts for the Trust’s non-exchequer funds, (c) ensuring payments made from bank or GBS accounts do not exceed the
amount credited to the account except where arrangements have been made. The GBS accounts (one for payments and one for receipts) are treated as one account for the purposes of calculating the overall balance,
(d) reporting to the Group CiC of any external borrowing requirements
(e) ensuring that best value is obtained in securing loan finance and other sources of external funding, including Working Capital funding.
(f) monitoring compliance with DH guidance on the level of cleared funds. 5.3 Banking Procedures
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5.3.1 The Executive Director of Finance will prepare detailed instructions on the operation
of bank and GBS accounts, which must include: (a) the conditions under which each bank and GBS account is to be operated, (b) the limit to be applied to any overdraft, and
(c) those authorised to sign cheques or other orders drawn on the Trust’s accounts.
(d) the policy and terms of operation of any Working Capital facility or working
capital funding support in place
5.3.2 The Executive Director of Finance must advise the Trust’s bankers in writing of the conditions under which each account will be operated.
5.4 Tendering and Review of Banking Services 5.4.1 The Executive Director of Finance will review the banking arrangements of the Trust
at regular intervals to ensure they reflect best practice and represent best value for money by periodically seeking competitive tenders for the Trust’s banking business.
5.4.2 Competitive tenders should be sought at least every 5 years unless the Board
determines otherwise. The results of the tendering exercise should be reported to the Group CiC.
SECTION 6 INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND OTHER
NEGOTIABLE INSTRUMENTS
6.1 Income Systems 6.1.1 The Executive Director of Finance is responsible for designing, maintaining and
ensuring compliance with systems for the proper recording, invoicing, collection and coding of all monies due.
6.1.2 The Executive Director of Finance is also responsible for the prompt banking of all
monies received. 6.1.3 Self-funding private patients and overseas visitors (who are required to pay for their
treatment) will be required to make a pre-payment equal to the estimated cost of treatment prior to admission.
6.2 Fees and Charges 6.2.1 The Trust shall follow the Department of Health advice in the Payment by Results
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(PBR) guidelines and code of conduct in setting prices for NHS Service contracts. 6.2.2 The Executive Director of Finance is responsible for approving and regularly
reviewing the level of all fees and charges other than those determined by the Department of Health or by Statute. Independent professional advice on matters of valuation may be taken as necessary.
6.2.3 All employees must inform the Executive Director of Finance promptly of money due
arising from transactions which they initiate/deal with, including all contracts, leases, tenancy agreements, private patient undertakings and other transactions.
6.3 Debt Recovery 6.3.1 The Executive Director of Finance is responsible for the appropriate recovery action
on all outstanding debts. 6.3.2 Income not received should be dealt with in accordance with losses procedures. 6.3.3 Overpayments should be detected (or preferably prevented) and recovery initiated in
line with Trust policy. 6.4 Security of Cash, Cheques and other Negotiable Instruments 6.4.1 The Executive Director of Finance is responsible for: (a) approving the form of all receipt books, agreement forms, or other means of
officially acknowledging or recording monies received or receivable, (b) ordering and securely controlling any such stationery, (c) the provision of adequate facilities and systems for employees whose duties
include collecting and holding cash, including the provision of safes or lockable cash boxes, the procedures for keys, and for coin operated machines, and
(d) prescribing systems and procedures for handling cash and negotiable
securities on behalf of the Trust. 6.4.2 Official money shall not under any circumstances be used for the encashment of
private cheques. 6.4.3 All cheques, postal orders, cash etc., shall be banked intact. Disbursements shall
not be made from cash received, except under arrangements approved by the Executive Director of Finance. Organisations/Individuals owing monies to the Trust should be encouraged, wherever practical to make payment in the form of cheques rather than cash, such cheques should be crossed and made payable to the Trust.
6.4.4 The holders of safe keys shall not accept unofficial funds for depositing in their safes
unless such deposits are in special sealed envelopes or locked containers. It shall be made clear to the depositors that the Trust is not to be held liable for any loss,
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and written indemnities must be obtained from the organisation or individuals absolving the Trust from responsibility for any loss.
6.4.5 Any loss or shortfall of cash, cheques or other negotiable instruments, however
occasioned, shall be monitored and recorded within the Finance Department. Any significant trends should be reported to the Executive Director of Finance and Internal Audit. Where there is prima facie evidence of fraud or corruption this should be dealt with using the Trust’s Anti Fraud, Bribery and Corruption Policy and the guidance provided by the NHS Protect. Where there is no evidence of Fraud, Bribery or Corruption it should be dealt with under the Trust’s Losses and Compensations procedures.
SECTION 7 CONTRACTING FOR PROVISION OF SERVICES 7.1 NHS Service Agreements 7.1.1 The Chief Executive of the Trust shall regularly review and shall at all times maintain
and ensure the capacity and capability of the Trust to provide mandatory goods and
services referred to in the Trust’s Licence Establishment Order.
7.1.2 The Chief Executive, as the accounting officer, is responsible for ensuring the Trust
enters into suitable legally binding Service Level Agreements with CCGs, NHS England and other commissioners for the provision of NHS services. The Trust will follow the priorities contained within the schedules of the contract, and wherever possible, be based upon integrated care pathways to reflect expected patient experience. In discharging this responsibility, the Chief Executive should take into account:
(a) the standards of service quality expected; (b) the relevant national service framework and other national guidance (if any);
(c) the provision of reliable information on cost and volume of services;
(d) the Performance Assessment Framework contained within the Trust Service
Level Agreements
(e) that Trust Service Level Agreements builds where appropriate on existing partnership arrangements;
7.1.3 A good Trust Service Level Agreement will result from a dialogue with clinicians,
users, carers, public health professionals and managers. It will reflect knowledge of local needs and inequalities. This will require the Chief Executive to ensure that the Trust works with all partner agencies involved in both the delivery and the commissioning of the service required.
7.1.4 The Chief Executive, as the accounting officer, will need to ensure that regular
reports are provided to the Group CiC detailing actual and forecast income from the Trust Service Level Agreements. This will include appropriate payment by results performance information, and other such information as deemed appropriate by the
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Executive Director of Finance
7.1.5 The Chief Executive, will ensure that Trust has in place suitable Service Level Agreements with other NHS Providers for both the delivery and receipt of services (known locally as Provider to Provider agreements). These agreements should be based upon the actual levels of service provided (or received) at an appropriate price to ensure all costs are covered). The Executive Director of Finance will ensure that appropriate systems are in place to agree and monitor such SLA’s on a regular basis.
7.2.1 Non Commercial Contracts 7.2.1 Where the Trust enters into a relationship with another organisation for the supply or
receipt of other services – clinical or non-clinical, the responsible officer should ensure that an appropriate non-commercial contract is present and signed by both parties.
7.2.2 This should incorporate:
(a) indicative activity levels and a description of the service
(b) the term of the agreement
(c) the value of the agreement
(d) the lead officers
(e) performance and dispute resolution procedures
(f) risk management and clinical governance arrangements
7.2.3 Non-commercial contracts should be reviewed and agreed on an annual basis or as determined by the term of the agreement so as to ensure value for money and to minimise the potential loss of income.
SECTION 8 TERMS OF SERVICE AND PAYMENT OF DIRECTORS AND EMPLOYEES 8.1 Remuneration and Terms of Service 8.1.1 In accordance with Standing Orders the Board of Directors shall establish a
Nominations, Remuneration and Terms of Service Committee, with clearly defined terms of reference, specifying which posts fall within its area of responsibility, its composition, and the arrangements for reporting.
8.1.2 The Committee will:
(a) advise the Board on the appropriate remuneration options and terms of service for the Chief Executive and other Executive Directors (and any other
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employees specified within the Terms of Reference), including: (i) all aspects of salary (including any performance-related elements /
bonuses), (ii) provisions for other benefits, including pensions and cars,
(iii) arrangements for termination of employment and other contractual terms;
(b) determine on behalf of the Board, noting that the terms of reference for the Nominations, Remuneration and Terms of Service Committee provide for the Chairman and all Non-Executive Directors to participate, the remuneration and terms of service of Executive Directors and any other employees specified within the Terms of Reference to ensure they are fairly rewarded for their individual contribution to the Trust - having proper regard to the Trust’s circumstances and performance and to the provisions of any national arrangements for such staff where appropriate;
(c) monitor and evaluate the performance of individual Executive Directors (and
other senior employees); and (d) advise on and oversee appropriate contractual arrangements for such staff
including the proper calculation and scrutiny of termination payments taking account of such national guidance as is appropriate.
8.1.3 The Committee shall report in writing to the Group CiC the basis for its
recommendations. The Group CiC will report these to the Board of Directors who shall use the report as the basis for requirements for public disclosure in the Annual Report.
8.1.4 The Board of Directors is responsible for ensuring appropriate systems and
processes are in place for setting remuneration and conditions of service for those employees not covered by the Committee.
8.1.5 The Council of Governors at the General Meeting will decide the remuneration and
allowances and other terms and conditions of office of the Chairman and Non-
Executive Directors. The Trust will remunerate the Chairman and Non-Executive
Directors in accordance with instructions issued by the Secretary of State.
8.2 Funded Establishment 8.2.1 The workforce plans incorporated within the annual budget will form the funded
establishment. 8.2.2 The funded establishment of any department may not be varied without the approval
of the Chief Executive (subject to the limits set out in the Scheme of delegation). 8.3 Staff Appointments 8.3.1 No director or employee may engage, re-engage, or regrade employees, either on a
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permanent or temporary basis, or hire agency staff, or agree to changes in any aspect of remuneration unless:
(a) authorised to do so by the Chief Executive , or
(b) within the limit of the approved budget and funded establishment
8.3.2 The Board of Directors will approve procedures presented by the Chief Executive for the determination of commencing pay rates, conditions of service, etc, for employees.
8.4 Payroll 8.4.1 The Executive Director of Finance (via the Shared Services Provider) is responsible
for: (a) specifying timetables for submission of properly authorised time records and
other notifications, (b) the final determination of pay, (c) making payment on agreed dates, and (d) agreeing method of payment. 8.4.2 The Executive Director of Finance (via the shared services provider) will issue
instructions regarding: (a) verification and documentation of data, (b) the timetable for receipt and preparation of payroll data and the payment of
employees, (c) maintenance of subsidiary records for superannuation, income tax, social
security and other authorised deductions from pay, (d) security and confidentiality of payroll information, (e) checks to be applied to completed payroll before and after payment, (f) authority to release payroll data under the provisions of the Data Protection
Act, (g) methods of payment available to various categories of employee, (h) procedures for payment by cheque, bank credit, or cash to employees, (i) procedures for the recall of cheques and bank credits, (j) pay advances and their recovery, (k) maintenance of regular and independent reconciliation of pay control
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accounts, (l) separation of duties of preparing records and handling cash, and (m) a system to ensure the recovery from leavers of sums of money and property
due by them to the Trust. 8.4.3 Appropriately nominated managers have delegated responsibility for: (a) submitting time records, and other notifications in accordance with agreed
timetables, (b) completing time records and other notifications in accordance with the
Executive Director of Finance's instructions and in the form prescribed by the Executive Director of Finance, and
(c) submitting termination forms in the prescribed form immediately upon knowing
the effective date of an employee's resignation, termination or retirement. Where an employee fails to report for duty in circumstances that suggest they have left without notice, the Executive Director of Finance must be informed immediately.
8.4.4 Regardless of the arrangements for providing the payroll service, the Executive
Director of Finance shall ensure that the chosen method is supported by appropriate (contracted) terms and conditions, adequate internal controls and audit review procedures, and that suitable arrangements are made for the collection of payroll deductions and payment of these to appropriate bodies.
8.5 Contracts of Employment 8.5.1 The Board of Directors shall delegate responsibility to the Chief of Organisational
Development and Strategy for: (a) ensuring that all employees are issued with a Contract of Employment in a
form approved by the Board and which complies with employment legislation,
(b) dealing with variations to, or termination of, contracts of employment. SECTION 9 NON-PAY EXPENDITURE 9.1 Delegation of Authority 9.1.1 The Board of Directors will approve the level of non-pay expenditure on an annual
basis and the Chief Executive will determine the level of delegation to budget managers (via the Scheme of Delegation).
9.1.2 The Chief Executive will set out:
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(a) the list of managers who are authorised to place requisitions for the supply of goods and services, and
(b) the maximum level of each requisition and the system for authorisation above
that level. 9.1.3 The Executive Director of Finance shall set out procedures on the seeking of
professional advice regarding the supply of goods and services. 9.2 Choice, Requisitioning, Ordering, Receipt and Payment for Goods and
Services 9.2.1 The requisitioner, in choosing the item to be supplied (or the service to be
performed) shall always obtain the best value for money for the Trust. In so doing, the advice of the Trust’s adviser on procurement shall be sought. Where this advice is not acceptable to the requisitioner, the Executive Director of Finance (and/or the Chief Executive) shall be consulted.
9.2.2 The Executive Director of Finance shall be responsible for the prompt payment of
accounts and claims. Payment of invoices shall be in accordance with contract terms, or otherwise, in accordance with national guidance.
9.2.3 The Executive Director of Finance will: (a) advise the Board of Directors regarding the setting of thresholds above which
quotations (competitive or otherwise) or formal tenders must be obtained; and, once approved, the thresholds should be incorporated in standing orders and regularly reviewed,
(b) ensure that procedural instructions on the obtaining of goods, works and
services (incorporating the thresholds) are prepared, distributed and regularly reviewed,
(c) be responsible for the prompt payment of all properly authorised accounts and
claims, (d) be responsible for designing and maintaining a system of verification,
recording and payment of all amounts payable. The system shall provide for: (i) a list of directors/employees (including safe procedures to accept
electronic authorisation) authorised to certify invoices, (ii) certification that: - goods have been duly received, examined and are in accordance
with specification and the prices are correct, - work done or services rendered have been satisfactorily carried
out in accordance with the order, and, where applicable, the materials used are of the requisite standard and the charges are correct,
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- in the case of contracts based on the measurement of time,
materials or expenses, the time charged is in accordance with the time sheets, the rates of labour are in accordance with the appropriate rates, the materials have been checked as regards quantity, quality, and price and the charges for the use of vehicles, plant and machinery have been examined,
- where appropriate, the expenditure is in accordance with
regulations and all necessary authorisations have been obtained, - the account is arithmetically correct, - the account is in order for payment. (iii) a timetable and system for submission to the Executive Director of
Finance of accounts for payment; provision shall be made for the early submission of accounts subject to cash discounts or otherwise requiring early payment.
(iv) instructions to employees regarding the handling and payment of
accounts within the Finance Department. (e) be responsible for ensuring that payment for goods and services is only made
once the goods and services are received (except as below). 9.2.4 Prepayments are only permitted where exceptional circumstances apply. In such
instances:
(a) Prepayments should demonstrate that the financial advantages outweigh the disadvantages
(b) the appropriate Executive Director must provide, in the form of a written report,
a case setting out all relevant circumstances of the purchase. The report must set out the effects on the Trust if the supplier is at some time during the course of the prepayment agreement unable to meet his commitments,
(c) the Executive Director of Finance will need to be satisfied with the proposed
scheme before contractual arrangements proceed (taking into account the EU public procurement rules where the contract is above the stipulated financial threshold) and
(d) the budget holder is responsible for ensuring that all items due under a
prepayment contract are received and he/she must immediately inform the appropriate Director or Chief Executive if problems are encountered.
9.2.5 Official Orders must: (a) be consecutively numbered, (b) be in a form approved by the Executive Director of Finance, and
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(c) state the Trust terms and conditions of trade 9.2.6 Managers must ensure that they comply fully with the guidance and limits specified
by the Executive Director of Finance and that: (a) all contracts other than for a simple purchase permitted within the Scheme of
Delegation or delegated budget, leases, tenancy agreements and other commitments which may result in a liability are notified to the Executive Director of Finance in advance of any commitment being made,
(b) contracts above specified thresholds are advertised and awarded in
accordance with EU rules on public procurement (c) where consultancy advice is being obtained, the procurement of such advice
must be in accordance with good practise, (d) no order shall be issued for any item or items to any company (or individual)
which has made an offer of gifts, reward or benefit to directors or employees, other than:
(i) isolated gifts of a trivial character or inexpensive seasonal gifts, such as
calendars,
(iv) conventional hospitality, such as lunches in the course of working visits, provided that any such gift / hospitality is in line with the guidance contained
within the Trust’s Standards of Business Conduct
(e) no requisition/order is placed for any item or items for which there is no budget
provision unless authorised by the Executive Director of Finance on behalf of the Chief Executive,
(f) all goods, services, or works are ordered on an official order except works and
services executed in accordance with an existing contract and purchases from petty cash,
(g) verbal orders must only be issued very exceptionally - by an employee
designated by the Chief Executive and only in cases of emergency or urgent necessity. These must be confirmed by an official order and clearly marked "Confirmation Order",
(h) orders are not split or otherwise placed in a manner devised so as to avoid the
financial thresholds, (i) goods are not taken on trial or loan in circumstances that could commit the
Trust to a future uncompetitive purchase. Any equipment on loan to the Trust and/or on Trust property must be notified to the Executive Director of Finance, together with any conditions attached to the loan of that equipment.
(j) changes to the list of directors/employees authorised to certify invoices are
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notified to the Executive Director of Finance, (k) purchases from petty cash are restricted in value and by type of purchase in
accordance with instructions issued by the Executive Director of Finance, and (l) petty cash records are maintained in a form as determined by the Executive
Director of Finance. 9.2.7 The Executive Director of Finance shall ensure that the arrangements for financial
control and financial audit of building and engineering contracts and property transactions comply with current guidance. The technical audit of these contracts shall be the responsibility of the relevant Director.
9.2.8 Under no circumstances should goods or services be ordered through the Trust
for personal or private use. 9.3 Joint Finance Arrangements with Local Authorities and Voluntary Bodies 9.3.1 Payments to Local Authorities and voluntary organisations shall comply with
procedures laid down by the Executive Director of Finance which shall be in accordance with the relevant Acts.
SECTION 10 EXTERNAL BORROWING AND INVESTMENTS
10.1 Public Dividend Capital
10.2.1 On authorisation as a Foundation Trust the Public Dividend Capital held
immediately prior to authorisation continues to be held on the same conditions.
10.2.2 Additional Public Dividend Capital may be made available on such terms the
Secretary of State (with the consent of the Treasury) decides. 10.2.3 Draw down of Public Dividend Capital should be authorised in accordance with the
mandate held by the Department of Health Cash Funding Team, and is subject to approval by the Secretary of State.
10.2.4 The Trust shall be required to pay annually to the Department of Health a dividend
on its Public Dividend Capital at a rate to be determined from time to time, by the Secretary of State.
10.3 Commercial Borrowing and Investment
10.3.1 The Trust may borrow money from any commercial source for the purposes of or in
connection with its functions, subject to Board approval..
10.3.2 The Trust may invest money for the purposes of or in connection with its functions.
Such investment may include forming, or participating in forming, or otherwise
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acquiring membership of bodies corporate.
10.3.3 The Trust may also give financial assistance (whether by way of loan guarantee or
otherwise) to any person for the purposes of or in connection with its functions. This
must only be given under specific approval of the Executive Director of Finance on a
case by case basis.
10.4 Investment of Temporary Cash Surpluses 10.4.1 Temporary cash surpluses must be held only in such public and private sector
investments as set out in the approved Group policy. 10.4.2 The Care Organisations’ Finance and Information and Capital Committee is
responsible for monitoring compliance with the Group investment strategy and policy.
10.4.3 The Chief Financial Officer is responsible for advising on investments and shall
report periodically to the Group CiC concerning the performance of investments held.
10.4.4 The Chief Financial Officer will prepare detailed procedural instructions on
investment operations and on the records to be maintained. The Group’s Treasury Management Policy will incorporate guidance from the Independent Regulator as appropriate.
10.5 Working Capital Facility 10.5.1 The Trust may choose to have funds are available for short-term cash flow
management by negotiating an irrevocable Working Capital Facility with a lender.
SECTION 11
CAPITAL INVESTMENT, PRIVATE FINANCING, FIXED ASSET REGISTERS AND SECURITY OF ASSETS 11.1 Capital Investment 11.1.1 The Chief Executive:
(a) shall ensure that there is an adequate appraisal and approval process in place for determining capital expenditure priorities and the effect of each proposal upon business plans,
(b) shall ensure that management arrangements are in place in line with the
Capital Development Booklet Series (c) is responsible for the management of all stages of capital schemes and for
ensuring that schemes are delivered on time and to cost, and (d) shall ensure that the capital investment is not undertaken without confirmation
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of commissioners support and the availability of resources to finance all revenue consequences, including capital charges.
11.1.2 For every major capital expenditure proposal (as defined in the Scheme of
Delegation) the Chief Executive shall ensure: (a) that a business case is produced setting out: (i) an option appraisal of potential benefits compared with known costs to
determine the option with the highest ratio of benefits to costs, and (ii) appropriate project management and control arrangements, and (b) that the Executive Director of Finance has certified professionally the costs
and revenue consequences detailed in the business case. 11.1.3 For capital schemes where the contracts stipulate stage payments, the Chief
Executive will issue procedures for their management The Executive Director of Finance shall issue procedures for the regular reporting of
actual expenditure and commitment against authorised expenditure. 11.1.4 The Group CiC approves the capital programme. In year monitoring will be will be
undertaken by the relevant Group and Care Organisation capital committee on a monthly basis. Should a tender value be in excess of the value in the approved capital then this will be taken back to the Group CiC for Approval
The Chief Executive shall issue to the manager responsible for any scheme (within
the framework set out above): (a) specific authority to commit expenditure, (b) authority to proceed to tender, (c) approval to accept a successful tender. The Chief Executive will issue a scheme of delegation for capital investment
management in accordance with the Trust’s Standing Orders. 11.1.5 The Chief Financial Officer shall issue procedures governing the financial
management, including variations to contract, of capital investment projects and valuation for accounting purposes.
11.2 Private Finance 11.2.1 The Group CiC should normally test for PFI when considering capital procurement.
When the Group CiC proposes to use finance that is to be provided other than through its allocations, the following should apply:
(a) The Chief Financial Officer shall demonstrate that the use of private finance
represents value for money and genuinely transfers significant risk to the private sector.
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(b) The proposal must be specifically agreed by the Group Group CiC.
(c) Where the sum involved exceeds delegated limits, the business case must be
referred to the appropriate external reviewer. 11.3 Asset Registers 11.3.1 The Chief Executive is responsible for the maintenance of registers of assets, taking
account of the advice of the Chief Financial Officer concerning the form of any register and the method of updating, and arranging for a physical check of assets against the asset register to be conducted once a year.
11.3.2 The Trust will maintain an asset register recording fixed assets. The minimum data
set to be held within these registers shall be as specified in the Capital Charges Manual as issued by the Independent Regulator.
11.3.3 Additions to the fixed asset register must be clearly identified to an appropriate
budget holder and be validated by reference to: (a) properly authorised and approved agreements, architect's certificates,
supplier's invoices and other documentary evidence in respect of purchases from third parties,
(b) stores, requisitions and wages records for own materials and labour including
appropriate overheads, and (c) lease agreements in respect of assets held under a finance lease and
capitalised. 11.3.4 Where capital assets are sold, scrapped, lost or otherwise disposed of, their value
must be removed from the accounting records and each disposal must be validated by reference to authorisation documents and invoices (where appropriate).
11.3.5 The Chief Financial Officer shall approve procedures for reconciling balances on
fixed assets accounts in ledgers against balances on fixed asset registers. 11.3.6 The value of each equipment asset shall be indexed to current values using
current Department of Health published indices. 11.3.7 The value of each asset shall be depreciated using methods and rates as specified
in the relevant Annual Reporting Manual issued by the Independent Regulator. 11.3.8 The Chief Financial Officer shall calculate and pay capital charges as specified by
the Department of Health and / or Independent Regulator
11.4 Property used to deliver Commissioner Requested Services
11.4.1 A register of property is maintained setting out property used to deliver commissioner
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requested services (“protected” property). 11.4.2 The Trust must have regard to Independent Regulator’s current guidance on
arrangements to dispose of protected property should it decide that such property is surplus to requirement
11.5 Security of Assets 11.5.1 The overall control of fixed assets is the responsibility of the Chief Executive. 11.5.2 Asset control procedures (including fixed assets, cash, cheques and negotiable
instruments, and also including donated assets) must be approved by the Chief Financial Officer. This procedure shall make provision for:
(a) recording managerial responsibility for each asset, (b) identification of additions and disposals, (c) identification of all repairs and maintenance expenses, (d) physical security of assets, (e) periodic verification of the existence of, condition of, and title to, assets
recorded, (f) identification and reporting of all costs associated with the retention of an
asset, and (g) reporting, recording and safekeeping of cash, cheques, and negotiable
instruments. 11.5.3 The up to date maintenance and annual checking of asset records is the
responsibility of the designated budget holder for all items for which the initial purchase or replacement is within their responsibility. All discrepancies revealed by verification of physical assets to fixed asset register shall be notified to the Executive Director of Finance.
11.5.4 Whilst each employee has a responsibility for the security of property of the Trust, it
is the responsibility of directors and senior employees in all disciplines to apply such appropriate routine security practices in relation to NHS property as may be determined by the Group CiC. Any breach of agreed security practices must be reported in accordance with instructions.
11.5.5 Any damage to the Trust’s premises, vehicles and equipment, or any loss of
equipment, stores or supplies must be reported by directors and employees in accordance with the procedure for reporting losses.
11.5.6 Where practical, assets should be marked as Trust property.
SECTION 12
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STORES AND RECEIPT OF GOODS 12.1 Stores, defined in terms of controlled stores and departmental stores (for immediate
use) should be:
(a) kept to a minimum, (b) subjected to annual stocktake, (c) valued at the lower of cost and net realisable value. 12.2 Subject to the responsibility of the Executive Director of Finance for the systems of
control, overall responsibility for the control of stores shall be delegated to an employee by the Chief Executive. The day-to-day responsibility may be delegated to departmental employees and stores managers/keepers, subject to such delegation being entered in a record available to the Executive Director of Finance. The control of Pharmaceutical stocks shall be the responsibility of a designated Head of Pharmacy; the control of fuel oil and coal of a designated Estates Manager.
12.3 The responsibility for security arrangements and the custody of keys for all stores
and locations shall be clearly defined in writing by the designated manager / Head of Pharmacy. Wherever practicable, stocks should be marked as health service property.
12.4 The Chief Financial Officer shall set out procedures and systems to regulate the
stores including records for receipt of goods, issues, and returns to stores, and losses.
12.5 Stocktaking arrangements shall be agreed with the Executive Director of Finance
and there shall be a physical check covering all items in store at least once a year. 12.6 Where a complete system of stores control is not justified, alternative arrangements
shall require the approval of the Executive Director of Finance. 12.7 The designated Manager / Head of Pharmacy shall be responsible for a system
approved by the Executive Director of Finance for a review of slow moving and obsolete items and for condemnation, disposal, and replacement of all unserviceable articles. The designated Officer shall report to the Executive Director of Finance any evidence of significant overstocking and of any negligence or malpractice (see also 13 Disposals and Condemnations, Losses and Special Payments). Procedures for the disposal of obsolete stock shall follow the procedures set out for disposal of all surplus and obsolete goods.
12.8 For goods supplied via the NHS Supply Chain, the Chief Executive shall identify
those authorised to requisition and accept goods from the store. The authorised person shall check receipt against the delivery note before forwarding this to the Executive Director of Finance who shall satisfy himself that the goods have been received before accepting the recharge.
SECTION 13
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DISPOSALS AND CONDEMNATIONS, LOSSES AND SPECIAL PAYMENTS 13.1 Disposals and Condemnations 13.1.1 The Executive Director of Finance must prepare detailed procedures for the disposal
of assets including condemnations, and ensure that these are notified to managers. 13.1.2 When it is decided to dispose of a Trust asset, the head of department or authorised
deputy will determine and advise the Executive Director of Finance of the estimated market value of the item, taking account of professional opinion including that of the Trust’s supply adviser where appropriate.
13.1.3 Where it is proposed to dispose or sell an asset that may impact on the delivery of a
protected service, then prior Authorisation is required from key stakeholders. 13.1.4 All unserviceable articles shall be: (a) condemned or otherwise disposed of by an employee authorised for that
purpose by the Executive Director of Finance, (b) recorded by the Condemning Officer in a form approved by the Executive
Director of Finance which will indicate whether the articles are to be converted, destroyed or otherwise disposed of. All entries shall be confirmed by the countersignature of a second employee authorised for the purpose by the Executive Director of Finance.
13.1.5 The Condemning Officer shall satisfy himself as to whether or not there is evidence
of negligence in use and shall report any such evidence to the Executive Director of Finance who will take the appropriate action.
13.2 Losses and Special Payments 13.2.1 The Chief Financial Officer must prepare procedural instructions on the recording of
and accounting for condemnations, losses, and special payments. The Executive Director of finance must also prepare a ‘fraud response plan’ that sets out the action to be taken both by persons detecting a suspected fraud and those persons responsible for investigating it.
13.2.2 Any employee discovering or suspecting a loss of any kind must either immediately
inform their head of department, who must immediately inform the Chief Executive. In the case of discovering or suspecting fraud, bribery or corruption, the employee mustcontact the Trust’s Anti- Fraud Specialist who will ensure that the Executive Director of Finance is informed in accordance with the Trust’s Anti-Fraud, Bribery and Corruption Policy and Response Plan. Where a criminal offence is suspected, the Executive Director of Finance must immediately inform the police if theft or arson is involved. In cases of fraud, bribery or corruption the Anti-Fraud Specialist will record the allegation on the NHS Protect’s Fraud Investigation and Reporting System Toolkit (FIRST) in accordance with the Standards for Providers for Fraud, Bribery and Corruption and conduct investigations in accordance with the NHS Anti-Fraud Manual in consultation with the Executive Director of Finance to ensure the
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most appropriate course of action is taken. 13.2.3 The Executive Director of Finance must notify NHS Protect and the External Auditor
of all frauds subject to the provisions of the Trust’s Anti-Fraud, Bribery and Corruption Policy and Response Plan.
13.2.4 For losses apparently caused by theft, fraud, bribery, corruption, arson, neglect of
duty or gross carelessness, except if trivial and where fraud, bribery or corruption is not suspected, the Executive Director of Finance must immediately notify:
(a) the Board of Directors, and (b) the External Auditor. 13.2.5 Within limits delegated to it by the Department of Health, the Group CiC shall
approve the writing-off of losses. For losses below the level set out in the Scheme of Delegation this function may be delegated to the Audit Committee (6 monthly report to be made to the committee on Losses and Special Payments).
13.2.6 The Executive Director of Finance shall be authorised to take any necessary steps to
safeguard the Trust's interests in bankruptcies and company liquidations. 13.2.7 For any loss, the Executive Director of Finance should consider whether any
insurance claim could be made. 13.2.8 The Executive Director of Finance shall maintain a Losses and Special Payments
Register in which write-off action is recorded. 13.2.9 No special payments exceeding delegated limits shall be made without the prior
approval of the Department of Health, or in the case of non-contractual payments to employees relating to loss of employment, without prior approval of HM Treasury.
13.3 Insurance 13.3.1 The Executive Director of Finance shall ensure that insurance arrangements exist in
accordance with the risk management programme. SECTION 14 INFORMATION TECHNOLOGY 14.1 The Executive Director of Finance, who is responsible for the accuracy and security
of the computerised financial data of the Trust, shall:
(a) be responsible for ensuring the design, implementation and documentation of effective information systems.
(b) devise and implement any necessary procedures to ensure adequate
(reasonable) protection of the Trust's data, programs and computer hardware, for which he/she is responsible, from accidental or intentional disclosure to unauthorised persons, deletion or modification, theft or damage, having due
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regard for the Data Protection Act 1998, (c) ensure that adequate (reasonable) controls exist over data entry, processing,
storage, transmission and output to ensure security, privacy, accuracy, completeness, and timeliness of the data, as well as the efficient and effective operation of the system,
(d) ensure that adequate controls exist such that the computer operation is
separated from development, maintenance and amendment, (f) ensure that an adequate management (audit) trail exists through the
computerised system and that such computer audit reviews, as he/she may consider necessary are being carried out.
(g) maintain a ‘Freedom of Information Publication Scheme’ 14.2 The Executive Director of Finance shall satisfy him/herself that new financial
systems and amendments to current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. Where this is undertaken by another organisation, assurances of adequacy will be obtained from them prior to implementation.
14.3 In the case of computer systems which are proposed general applications (i.e.
normally those applications which the majority of organizations in the NHS locally or nationally wish to sponsor jointly) all responsible directors and employees will send to the Executive Director of Finance:
(a) details of the outline design of the system, (b) in the case of packages acquired either from a commercial organisation, from
the NHS, or from another public sector organisation, the operational requirement.
14.4 The Executive Director of Finance shall ensure that contracts for computer services
for financial applications with another health organisation or any other agency shall clearly define the responsibility of all parties for the security, privacy, accuracy, completeness, and timeliness of data during processing, transmission and storage. The contract should also ensure rights of access for audit purposes.
14.5 Where another health organisation or any other agency provides a computer service
for financial applications, the Executive Director of Finance shall periodically seek assurances that adequate controls are in operation.
14.6 Where computer systems have an impact on corporate financial systems the
Executive Director of Finance shall satisfy him/herself that: (a) systems acquisition, development and maintenance are in line with corporate
policies such as an Information Technology Strategy, (b) data produced for use with financial systems is adequate, accurate, complete
and timely, and that a management (audit) trail exists,
Item
14
Page 35 of 62
36
(c) Executive Director of Finance staff have access to such data, and
(d) such computer audit reviews as are considered necessary are being carried out.
14.7 The Trust shall disclose to the Independent Regulator and directly to any third
parties, as may be specified by the Secretary of State, the information, if any, specified in the Terms of Authorisation, Schedule 6. Other information, as requested shall be provided to the Independent Regulator.
SECTION 15 PATIENTS' PROPERTY 15.1 The Trust has a responsibility to provide safe custody for money and other personal
property (hereafter referred to as "property") handed in by patients, in the possession of unconscious or confused patients, or found in the possession of patients dying in hospital or dead on arrival.
15.2 The Chief Executive is responsible for ensuring that patients or their guardians, as
appropriate, are informed before or at admission by:
- notices and information booklets, - hospital admission documentation and property records, - the oral advice of administrative and nursing staff responsible for admissions, that the Trust will not accept responsibility or liability for patients' property brought
into Health Service premises, unless it is handed in for safe custody and a copy of an official patients' property record is obtained as a receipt.
15.3 The Executive Director of Finance must provide detailed written instructions on the
collection, custody, investment, recording, safekeeping, and disposal of patients' property (including instructions on the disposal of the property of deceased patients and of patients transferred to other premises) for all staff whose duty is to administer, in any way, the property of patients. Due care should be exercised in the management of a patient's money in order to maximise the benefits to the patient.
15.4 Where NHS instructions require the opening of separate accounts for patients'
moneys, these shall be opened and operated under arrangements agreed by the Executive Director of Finance.
15.5 In all cases where property of a deceased patient is of a total value in excess of
£5,000 (or such other amount as may be prescribed by any amendment to the Administration of Estates, Small Payments, Act 1965), the production of Probate or Letters of Administration shall be required before any of the property is released. Where the total value of property is £5,000 or less, forms of indemnity shall be obtained.
15.6 Staff should be informed, on appointment, by the appropriate departmental or senior
manager of their responsibilities and duties for the administration of the property of patients.
Page 36 of 62
37
15.7 Where patients' property or income is received for specific purposes and held for
safekeeping the property or income shall be used only for that purpose, unless any variation is approved by the donor or patient in writing.
SECTION 16 ACCEPTANCE OF GIFTS BY STAFF 16.1 The Executive Director of Finance (via the Trust Secretary) shall ensure that all staff
are made aware of the Trust policy on acceptance of gifts and other benefits in. This policy should follow the guidance contained in the Department of Health Standards of Business Conduct for NHS staff. (see Governance Framework Manual)
SECTION 17 RETENTION OF DOCUMENTS 17.1 The Chief Executive shall be responsible for maintaining archives for all documents
required to be retained under the direction contained in Department of Health: NHS Code of Practice.
17.2 The documents held in archives shall be capable of retrieval by authorised persons. 17.3 Documents held under Department of Health: NHS Code of Practise shall only be
destroyed at the express instigation of the Chief Executive. Records shall be maintained of documents so destroyed.
SECTION 18 RISK MANAGEMENT & INSURANCE 18.1 Risk Management 18.1.1 The Chief Executive shall ensure that the Trust has a programme of risk
management, which must be approved and monitored by the Group CIC.
18.1.2 The programme of risk management shall include:
(a) a process for identifying and quantifying risks and potential liabilities; (b) engendering among all levels of staff a positive attitude towards the
control of risk; (c) management processes to ensure all significant risks and potential
liabilities are addressed including effective systems of internal control, cost effective insurance cover, and decisions on the acceptable level of
Item
14
Page 37 of 62
38
retained risk; (d) contingency plans to offset the impact of adverse events; (e) audit arrangements including; internal audit, clinical audit, health and
safety review; (f) decision on which risks shall be insured. (g) arrangements to review the risk management programme.
The existence, integration and evaluation of the above elements will assist in providing a basis to make a statement on the effectiveness of Internal Control within the Annual Report and Accounts as required by current Department of Health guidance.
18.2 Insurance 18.2.1 The Group CiC shall decide if the Trust (bearing in mind the Trusts independent
legal status) will insure through the risk pooling schemes administered by the NHS Litigation Authority or self insure for some or all of the risks covered by the risk pooling schemes, along with those risks not covered by the pooling scheme. If the Group CiC decides not to use the risk pooling schemes for any of the risk areas (clinical, property and employers/third party liability) covered by the scheme this decision shall be reviewed annually.
18.2.2 Where the Group CiC decides to use the risk pooling schemes administered by
the NHS Litigation Authority the Chief Financial Officer shall ensure that the arrangements entered into are appropriate and complementary to the risk management programme. The Chief Financial Officer shall ensure that documented procedures cover these arrangements.
18.2.3 Where the Group CiC decides not to use the risk pooling schemes administered
by the NHS Litigation Authority for one or other of the risks covered by the schemes, the Chief Financial Officer shall ensure that the Group CiC is informed of the nature and extent of the risks that are self-insured as a result of this decision. The Executive Director of Finance will draw up formal documented procedures for the management of any claims arising from third parties and payments in respect of losses that will not be reimbursed.
18.2.4 All the risk-pooling schemes require members to make some contribution to the
settlement of claims (the ‘deductible’). The Executive Director Finance should ensure documented procedures also cover the management of claims and payments below the deductible in each case.
End.
Page 38 of 62
39
DE
TA
ILE
D S
CH
EM
E O
F D
EL
EG
AT
ION
A
PP
EN
DIX
B
Th
is d
ocum
en
t p
rovid
es a
fra
me
wo
rk f
or
de
cis
ion
-ma
kin
g r
espo
nsib
ilitie
s w
ith
in t
he
Tru
st.
D
ire
cto
rs a
re r
esp
on
sib
le f
or
en
su
rin
g t
ha
t a
ll sta
ff o
pe
rate
s w
ith
in t
he
Sch
em
e o
f D
ele
gatio
n a
nd
in a
cco
rda
nce
with
Sta
nd
ing O
rde
rs a
nd
Sta
nd
ing F
inancia
l In
str
ucti
on
s.
Th
e
Sch
em
e o
f D
ele
ga
tio
n i
den
tifie
s t
he
lo
we
st
leve
l to
wh
ich
a p
art
icu
lar
respo
nsib
ility
ma
y b
e d
ele
ga
ted
. T
he
re i
s n
o r
equ
ire
men
t fo
r D
ire
cto
rs t
o d
ele
ga
te t
o t
his
le
ve
l.
The
le
ve
ls o
f m
ana
ge
me
nt/d
ele
ga
tio
n r
efe
rre
d t
o in t
his
Sche
me a
re a
s f
ollow
s (
de
fin
itio
ns o
f th
ese
role
s a
re s
et
ou
t in
th
e S
tand
ing F
ina
ncia
l In
str
uctio
ns):
Ch
ief
Exe
cu
tive
(In
the a
bsen
ce
of
the
Ch
ief
Exe
cu
tive
, u
rge
nt
ma
tte
rs m
ay b
e d
ea
lt w
ith
by t
he
re
leva
nt
Dire
cto
r a
nd
/or
the
C
ha
irm
an
)
Ch
ief
Fin
an
cia
l O
ffic
er
Oth
er
(Gro
up
) C
hie
f O
ffic
ers
Exe
cu
tive
Dire
cto
r o
f F
ina
nce (
In th
e a
bsen
ce o
f th
e D
ire
cto
r of
Fin
an
ce
, u
rge
nt m
atte
rs m
ay b
e d
ea
lt w
ith
by t
he
De
pu
ty D
ire
cto
r of
Fin
an
ce
)
Oth
er
Exe
cu
tive
Dire
cto
rs
Ca
re O
rga
nis
atio
n (
CO
) C
hie
f O
ffic
ers
(a
cco
un
tab
le o
ffic
ers
)
Dire
cto
r of
Fin
an
ce
(C
O)
Oth
er
CO
Dire
cto
rs
Ma
na
ge
me
nt B
oa
rds
Gro
up
CiC
Div
isio
na
l M
an
agin
g D
ire
cto
rs a
nd
Ch
airs o
f D
ivis
ion
Se
rvic
e M
an
age
rs /
Assis
tan
t D
ire
cto
rs o
f N
urs
ing
Se
nio
r M
an
age
r A
uth
orise
d S
ign
ato
rie
s
Th
is S
ch
em
e o
f D
ele
ga
tio
n a
pp
lies e
qu
ally
to a
ll se
rvic
es “
Ho
ste
d”
by S
RF
T w
ith
de
tail
of
au
tho
rised
sig
na
torie
s fo
und
with
in t
he
d
eta
iled
au
tho
rise
d s
ign
ato
rie
s lis
t fo
r th
ose
se
rvic
es.
It i
s f
or
Exe
cu
tive
Dire
cto
rs t
o i
de
ntify
with
in t
he
ir D
ire
cto
rate
th
ose
Off
ice
rs w
hom
the
y w
ish
to
au
tho
rise
(A
uth
orise
d S
ign
ato
rie
s)
to
exe
rcis
e d
ele
ga
ted
au
tho
rity
with
in t
his
Schem
e o
f D
ele
ga
tion
. F
orm
s f
or
this
pu
rpo
se
are
ava
ilab
le f
rom
th
e D
ire
cto
r of
Fin
an
ce a
nd
po
ste
d o
n th
e in
tra
net.
Item
14
Page 39 of 62
40
1.
Pa
y a
nd
Non
Pa
y,
Re
ve
nue
and
Cap
ita
l E
xp
en
ditu
re/R
equ
isitio
nin
g/O
rde
rin
g/P
aym
en
t of
Go
od
s &
S
erv
ice
s/B
ud
ge
t vire
me
nts
. A
ll lim
its e
xclu
de
VA
T.
(No
te r
estr
ictio
ns a
t sectio
n 4
c r
e le
ase
s)
Up
to
£5
,00
0
C
ate
go
ry A
Up
to
£1
0,0
00
Ca
tego
ry B
Up
to
£2
5,0
00
Ca
tego
ry C
Up
to
£1
00
,00
0
C
ate
go
ry D
£1
00
,000
- £
249
,99
9
C
are
Org
an
isa
tio
n
An
y C
O D
ire
cto
r,
su
bje
ct to
p
rocu
rem
ent
sig
n
off
Gro
up
:
Ch
ief
Off
ice
r
£2
50
,000
- £
499
,99
9
C
are
Org
an
isa
tio
n
CO
Acco
un
tab
le
Off
ice
r a
nd
D
ire
cto
r of
Fin
an
ce
(C
O)
Where
this
is t
he s
am
e
pers
on, th
is m
ust in
clu
de
CO
Manag
ing D
irecto
r
Gro
up
Ch
ief
Off
ice
r a
nd
C
hie
f F
inan
ce
Off
ice
r
£5
00
,000
- £
2,9
99
,99
9*
*Anyth
ing
£1m
+ m
ust be n
otified to G
roup S
&I fo
r in
form
ation
Ca
re O
rga
nis
atio
n
CO
Ma
na
ge
me
nt
Bo
ard
Gro
up
Gro
up
Man
agem
ent
Bo
ard
£3
,00
0,0
00
+
Gro
up
CiC
2.
Ma
inte
na
nce/O
pe
ration
of
Ba
nk A
ccou
nts
Page 40 of 62
41
Ma
inte
na
nce/O
pe
ration
of
Ba
nk A
ccou
nts
G
rou
p C
iC
3.
Ma
na
ge
me
nt of
Bu
dgets
– G
en
era
l
SF
Is S
ectio
n 3
Re
sp
on
sib
ility
of
kee
pin
g e
xp
en
ditu
re w
ith
in b
ud
ge
ts, a
nd
fo
r e
nsu
rin
g in
co
me
is r
ece
ive
d fo
r se
rvic
es p
rovid
ed
.
At
ind
ivid
ua
l bu
dge
t le
ve
l (
Inco
me,
Pa
y a
nd
No
n P
ay)
B
ud
ge
t M
an
age
r
At
se
rvic
e le
ve
l
Se
rvic
e M
an
age
r
At
Dire
cto
rate
/De
pa
rtm
en
tal le
ve
l D
ivis
ion
al D
ire
cto
rs/D
ep
art
me
nt D
ire
cto
r
Fo
r a
ll o
the
r a
rea
s
D
oF
(C
O)
or
Ap
pro
priate
De
lega
ted
M
an
age
r
Vire
men
ts -
th
e t
ran
sfe
r of
fun
ds b
etw
ee
n s
ubje
ctive
lin
es w
ith
in
a b
ud
ge
t o
r b
etw
ee
n b
ud
ge
ts.
Virem
en
t of
fun
ds is a
va
ilab
le
with
in t
he
de
lega
ted lim
its p
rovid
ed
th
at
the
re is n
o a
dve
rse
eff
ect o
n t
he
Tru
sts
fin
an
cia
l po
sitio
n -
Vire
me
nt
is a
va
ilab
le
be
twe
en
pa
y a
nd
non
-pa
y b
ud
ge
ts p
rovid
ed
th
at
it is a
uth
orise
d
by t
he
Dire
cto
r of
Fin
an
ce
As p
er
the
bud
ge
tary
lim
its d
ete
rmin
ed
a
bo
ve
***
3.1
Ma
na
gem
en
t of
Bud
ge
ts –
Pa
y
Pa
y b
ud
ge
ts a
re b
ased
upo
n a
pp
rove
d e
sta
blis
hm
ents
an
d th
ese
are
an e
ssen
tia
l a
sp
ect of
the m
an
agem
en
t of
the
pa
y b
ud
ge
ts.
(a)
A
uth
orisa
tio
n o
f T
ime
sh
ee
ts /
clo
ck c
ard
s /
cla
ims fo
r sp
ecia
l du
ty /
ove
rtim
e, o
n-c
all
etc
. L
ead
HR
Off
ice
r fo
r th
e C
O lis
ted u
nd
er
Ca
tego
ry D
(H
R w
ill w
ork
with
CO
’s t
o
define
de
lega
tio
n r
equ
ire
men
ts)
Item
14
Page 41 of 62
42
(b)
Au
tho
risa
tio
n o
f W
aitin
g L
ists
In
itia
tive
s (
with
in t
he
cu
rre
nt
pa
y t
erm
s a
nd c
ond
itio
ns)
Le
ad
HR
Off
ice
r fo
r th
e C
O lis
ted u
nd
er
Ca
tego
ry D
(H
R w
ill w
ork
with
CO
’s t
o
define
de
lega
tio
n r
equ
ire
men
ts)
(c)
A
uth
orisa
tio
n o
f u
se
of
tem
po
rary
sta
ff f
rom
Age
ncie
s,
cla
ims f
or
med
ica
l se
ssio
na
l pa
ym
en
ts a
nd
inte
rna
l ba
nk /
ca
su
al sta
ff.
i.
Cle
rica
l ii.
M
ed
ica
l lo
cum
s
iii.
Nu
rsin
g
Le
ad
HR
Off
ice
r fo
r th
e C
O lis
ted u
nd
er
Ca
tego
ry D
(H
R w
ill w
ork
with
CO
’s t
o
define
de
lega
tio
n r
equ
ire
men
ts)
(d)
A
pp
rova
l of
reque
sts
to
fill
va
ca
nt
po
sts
with
in t
he
bu
dge
ted
e
sta
blis
hm
en
t.
Se
rvic
e M
an
age
r /
De
pa
rtm
en
tal
Ma
na
ge
r su
bje
ct
to a
pp
rova
l
(e)
A
pp
rova
l of
ch
an
ge
s to b
ud
ge
ted
esta
blis
hm
en
t fu
nde
d
from
with
in t
he
CO
’s o
wn
bu
dge
t M
an
agin
g D
ire
cto
r, C
ha
ir o
f D
ivis
ion
or
equ
iva
len
t
(f)
A
pp
rova
l of
ch
an
ge
s to b
ud
ge
ts w
hic
h a
re b
acke
d b
y
ad
ditio
na
l in
co
me
Va
lue
to
be
ap
pro
ve
d b
y D
ire
cto
r o
f F
ina
nce
(C
O).
A
lloca
tio
n to
in
div
idu
al
bu
dge
t lin
es b
y M
an
agin
g D
ire
cto
r,
Ch
air o
f D
ivis
ion
or
equ
iva
len
t
(g)
Ap
pro
va
l of
oth
er
incre
ase
in
bu
dge
ted
esta
blis
hm
en
t fu
nde
d f
rom
re
so
urc
es n
ot
cu
rre
ntly w
ith
in t
he
CO
’s o
wn
b
ud
ge
t.
Ch
ief
Fin
an
cia
l O
ffic
er
S
FI
Se
ctio
n 8
3.3
Ma
na
gem
en
t of
Bud
ge
ts –
No
n P
ay
S
FIs
Se
ctio
n 9
S
tand
ing O
rde
rs
Se
c.9
S
tand
ing O
rde
rs –
A
nn
ex A
Page 42 of 62
43
(Th
e lim
its s
et
ou
t be
low
ap
ply
equ
ally
to
Ca
pita
l E
xp
en
ditu
re /
Re
quis
itio
nin
g /
Ord
erin
g /
Pa
ym
en
t of
Go
od
s
& S
erv
ice
s)
N
o O
rde
r sho
uld
be
art
ific
ially
arr
an
ge
d s
o a
s to
circu
mve
nt fin
an
cia
l lim
its.
All
ord
ers
mu
st b
e p
lace
d u
sin
g
the
Tru
sts
app
rove
d e
-ord
erin
g s
yste
m e
xce
pt
wh
ere
exp
ressly
ap
pro
ve
d b
y t
he
Dire
cto
r of
Fin
an
ce.
T
he
lim
its b
elo
w a
pp
ly t
o b
oth
sto
ck a
nd n
on
-sto
ck a
nd
no
n-r
eco
ve
rab
le V
AT
is t
o b
e in
clu
de
d (
sta
ff s
ho
uld
e
nsu
re th
at
qu
ote
s a
re o
bta
ine
d v
ia t
he
Pro
cure
men
t D
epa
rtm
en
t)
Up
to
£1
0,0
00
(m
in.
of
2 v
erb
al qu
ote
s)*
Au
tho
rise
d S
ign
atu
re a
s a
gre
ed
by
Exe
cu
tive
Dire
cto
r, M
an
agin
g D
ire
cto
r o
r e
qu
iva
len
t o
r D
ep
uty
Ma
na
gin
g D
ire
cto
r
Be
twe
en
£1
0,0
00
& £
25
,000
(m
in.
of
3 w
ritt
en
qu
ote
s1)*
Se
rvic
e M
an
age
r /
De
pa
rtm
en
tal H
ea
d /
Se
lecte
d D
ep
uty
De
part
me
nta
l H
ead
s
(as lis
ted
in
au
tho
rise
d s
ign
ato
ry d
ata
ta
ble
in
Tru
st’s f
ina
ncia
l le
dge
r).
Be
twe
en
£2
5,0
00
and
th
e E
U P
rocu
rem
en
t T
hre
sh
old
s (
wh
ich
fo
r th
e m
ajo
rity
of
go
od
s a
nd
se
rvic
es p
urc
ha
se
d b
y t
he
Tru
st
is
cu
rre
ntly £
16
4,1
76
exclu
din
g V
AT
(€
20
9,0
00
), t
he r
equ
ire
d
go
od
s o
r se
rvic
es s
hou
ld b
e o
bta
ine
d b
y issu
ing a
te
nd
er
or
utilis
ing a
n a
pp
rop
ria
te f
ram
ew
ork
agre
em
ent. T
he s
ele
cte
d
rou
te s
ho
uld
be
ba
se
d o
n o
bta
inin
g b
est
va
lue
fo
r m
on
ey.
In
all
ca
se
s, a
dvic
e f
rom
th
e P
rocu
rem
ent
De
pa
rtm
en
t m
ust b
e s
ou
gh
t
Ap
pro
va
l lim
its a
s p
er
se
ctio
n 1
Be
twe
en
th
e E
U p
rocure
men
t th
resh
old
, a
s d
eta
iled a
bo
ve
, &
£
2,9
99
,99
9 a
fu
lly c
om
plia
nt
EU
pro
cu
rem
en
t p
roce
ss m
ust b
e
follo
we
d.
Whe
re p
ossib
le,
a m
inim
um
of
5 t
en
de
rs s
ho
uld
be
so
ugh
t to
en
su
re b
est va
lue
is o
bta
ine
d.
Ap
pro
va
l lim
its a
s p
er
se
ctio
n 1
Item
14
Page 43 of 62
44
Ove
r £
3,0
00
,00
0 a
fu
lly c
om
plia
nt E
U p
rocu
rem
en
t p
roce
ss m
ust
be
fo
llow
ed
. W
he
re p
ossib
le,
a m
inim
um
of
5 te
nde
rs s
hou
ld b
e
so
ugh
t to
en
su
re b
est va
lue
is o
bta
ine
d
Gro
up
CiC
/Boa
rd o
f D
ire
cto
rs
a)
Sig
nin
g o
f co
ntr
acts
fo
r go
od
s &
se
rvic
es a
nd
su
bse
qu
en
t va
ria
tio
ns t
o c
on
tra
cts
, (f
ollo
win
g t
he
co
nclu
sio
n o
f th
e
pro
cu
rem
ent
with
in t
he le
ve
ls s
et
at 1
.2 a
bo
ve
).
Ch
ief
Exe
cu
tive
, E
xe
cu
tive
Dire
cto
r o
r o
the
r off
ice
r a
s d
uly
auth
orise
d b
y t
he
G
rou
p C
iC.
SO
(B
oa
rd)
Pa
ra
10
.1
b)
Wave
rin
g o
f qu
ota
tio
ns &
ten
de
rs s
ub
ject to
SF
Is
U
p t
o th
e v
alu
e E
U p
rocu
rem
en
t th
resho
ld £
16
4,1
76
(€
20
9,0
00
)
Ch
ief
Fin
an
cia
l O
ffic
er
- A
ll w
aiv
ers
to
be
re
po
rted
to A
ud
it C
om
mitte
e
SF
Is 9
.2.1
c)
Op
en
ing T
en
de
rs a
nd
Qu
ota
tio
ns
He
ad
of
Pro
cu
rem
en
t a
nd
De
pu
ty D
oF
o
r A
ssis
tant
Do
F p
lus o
ne
oth
er
Sen
ior
Ma
na
ge
r
3.3
Te
nde
r V
aria
tion
s
Ap
pro
vin
g T
en
de
r V
aria
tio
ns:
up
to
10
%
up
to
£1
5k
wh
ich
eve
r is
th
e lo
we
r (w
ith
in a
va
ilab
le b
ud
ge
t)
In a
cco
rda
nce
with
th
e a
gre
ed
a
uth
orisa
tio
n le
ve
ls w
ith
in e
ach
spe
cia
lty
/ d
ep
art
me
nt
Ap
pro
vin
g T
en
de
r V
aria
tio
ns >
10
% o
r £
15
k u
p to
a m
axim
um
of
£2
5k (
with
in b
ud
ge
t a
va
ilab
le).
Exe
cu
tive
Dire
cto
r, M
an
agin
g D
ire
cto
r o
r e
qu
iva
len
t, D
ep
uty
Ma
na
gin
g D
ire
cto
r,
Ch
air o
f D
ivis
ion
or
equ
iva
len
t
Page 44 of 62
45
Ap
pro
vin
g T
en
de
r V
aria
tio
ns >
10
% o
r £
15
k u
p to
a m
axim
um
of
£2
5k (
ou
tsid
e b
ud
ge
t ava
ilab
le).
Exe
cu
tive
Dire
cto
r, M
an
agin
g D
ire
cto
r,
Ch
air o
f D
ivis
ion
or
equ
iva
len
t D
ep
uty
D
oF
Ap
pro
vin
g T
en
de
r V
aria
tio
ns >
th
an
10%
an
d o
ve
r £
25
k
C
hie
f F
inan
cia
l O
ffic
er
– r
ep
ort
ed
to
A
ud
it c
om
mitte
e
SF
Is 9
.2.1
4.
Ca
pita
l P
rogra
mm
e /
Sch
em
es
SF
Is S
ectio
n 1
1
Sta
nd
ing O
rde
rs
Se
c.9
S
tand
ing O
rde
rs –
A
nn
ex A
Au
tho
risa
tio
n o
f C
ap
ital P
roje
cts
/ C
ap
ita
l P
rogra
mm
e.
Gro
up
CiC
with
da
y t
o d
ay e
xp
en
ditu
re
co
mm
itte
d in
lin
e w
ith
1.2
ab
ove
with
th
e
exce
ptio
n o
f th
e E
U P
rocu
rem
ent
Th
resh
old
wh
ich
fo
r cap
ita
l (w
ork
s)
sch
em
es is £
4,1
04
,394
(€
5,2
25,0
00
)
Waiv
ing o
f fo
rma
l te
nde
rin
g p
roce
du
res /
re
qu
ire
men
t fo
r w
ritt
en
qu
ota
tio
n /
acce
pta
nce o
f lo
we
st
qu
ota
tio
n o
the
r th
an
th
e lo
we
st
qu
ota
tio
n.
Au
tho
risa
tio
n to
exce
ed
sch
em
e a
pp
rove
d b
ud
ge
t.
Gro
up
CF
O / D
ire
cto
r of
Fin
an
ce
(C
O)
su
bje
ct to
ap
pro
va
l le
ve
ls in
se
ction
1
Gro
up
CiC
Se
lection
of
arc
hite
cts
, qu
an
tity
su
rve
yo
rs,
co
nsu
ltan
t en
gin
ee
r a
nd
oth
er
pro
fessio
na
l a
dvis
ors
with
in E
U r
egu
latio
ns
Exe
cu
tive
Dire
cto
r, M
an
agin
g D
ire
cto
r o
r e
qu
iva
len
t
F
ina
ncia
l m
on
ito
rin
g a
nd
re
po
rtin
g o
n a
ll ca
pita
l sch
em
e
exp
en
ditu
re
Assis
tan
t D
ire
cto
r of
Fin
an
ce
, D
epu
ty
Dire
cto
r of
Fin
an
ce
Item
14
Page 45 of 62
46
Gra
ntin
g a
nd
te
rmin
atio
n o
f le
ase
s o
f >
£1
00
,00
0
G
rou
p C
iC
5.
Se
ttin
g o
f F
ee
s a
nd
Cha
rge
s
SF
Is S
ectio
ns 6
& 7
a)
Priva
te P
atie
nt,
Ove
rse
as V
isito
rs, In
co
me
Ge
ne
ratio
n
an
d o
the
r p
atie
nt re
late
d s
erv
ice
s.
Gro
up
CF
O a
nd
Dire
cto
r of
Fin
an
ce
(CO
) in
agre
em
en
t
b)
Price
of
NH
S S
erv
ice
Le
ve
l A
gre
em
ents
Dire
cto
r of
Fin
an
ce
(C
O)/
De
pu
ty
Dire
cto
r of
Fin
an
ce
(C
O)
an
d M
an
agin
g
Dire
cto
rs
c)
Sig
nin
g o
f S
erv
ice
Le
ve
l a
gre
em
en
ts w
ith
Com
mis
sio
ne
rs
SL
A v
alu
es u
p to
£1
0 m
illio
n
SL
A v
alu
es o
ve
r £
10 m
illio
n
CO
De
pu
ty D
ire
cto
r of
Fin
an
ce
CO
Acco
un
tab
le o
ffic
er
/ D
ire
cto
r of
Fin
an
ce
(C
O)
6
. E
nga
ge
men
t of
Ma
na
ge
men
t C
on
su
lta
ncy S
taff
SF
Is S
ectio
n 9
a)
No
n M
ed
ica
l C
on
su
ltan
cy S
taff
(sub
ject
to p
rocu
rem
ent
rou
tes in 1
ab
ove
an
d a
ny e
xta
nt
regu
lato
ry r
equ
ire
me
nts
e
.g.
the M
on
ito
r co
nsu
lta
ncy c
ap
).
Ma
na
gin
g D
ire
cto
r o
r equ
iva
len
t, C
ha
ir
of
Div
isio
n.
or
equ
iva
len
t/ D
ire
cto
r of
Fin
an
ce
b)
Where
aggre
ga
te c
om
mitm
en
t in
an
y o
ne
yea
r (o
r to
tal
co
mm
itm
en
t) is le
ss t
ha
n £
25
,00
0
Ma
na
gin
g D
ire
cto
r, C
ha
ir o
f D
ivis
ion
or
equ
iva
len
t /
Re
leva
nt D
ire
cto
r
c)
Where
aggre
ga
te c
om
mitm
en
t in
an
y o
ne
yea
r is
mo
re
tha
n £
25
,00
0
Ch
ief
Exe
cu
tive
or
Exe
cu
tive
Dire
cto
r of
Fin
an
ce
Page 46 of 62
47
d)
En
ga
ge
men
t of T
rust's S
olic
ito
rs
C
hie
f E
xe
cu
tive
/ E
xe
cu
tive
Dire
cto
r of
Fin
an
ce
/ R
ele
va
nt
Dire
cto
r / A
uth
orise
d
Ma
na
ge
rs
7.
Exp
en
ditu
re o
n C
ha
rita
ble
an
d E
ndo
wm
en
t F
un
ds
Up
to
£5
,00
0
Up
to
£1
5,0
00
U
p t
o £
25,0
00
U
p t
o £
50,0
00
O
ve
r £
50
,00
0
Ch
arita
ble
Fu
nd
s C
om
mitte
e (
CF
C)
sh
ou
ld a
gre
e in
prin
cip
le e
xp
en
ditu
re o
n
ch
arita
ble
and
en
do
wm
ent fu
nd
s,
exp
en
ditu
re s
ign
ato
ries t
he
reaft
er
are
a
s f
ollo
ws:
Fu
nd
ho
lde
rs
Div
isio
na
l D
ire
cto
rs
CO
Dire
cto
rs
Ch
ief
Fin
an
cia
l O
ffic
er
CF
C
8.
Agre
em
en
ts/L
ice
nce
s/L
ea
se
s
S
FI
Se
ctio
n 7
a)
Pre
pa
ratio
n a
nd s
ign
atu
re o
f a
ll te
na
ncy
agre
em
en
ts/lic
en
ce
s fo
r a
ll sta
ff s
ub
ject
to T
rust
Po
licy o
n
acco
mm
od
atio
n fo
r sta
ff
Dire
cto
r of
Fin
an
ce
(F
ina
nce
will
wo
rk
with
CO
’s t
o d
efine
de
lega
tio
n
requ
ire
me
nts
)
b)
Exte
nsio
ns to
exis
tin
g le
ase
s
Exe
cu
tive
Dire
cto
r o
f F
ina
nce o
r D
ire
cto
r fo
r S
erv
ice
Str
ate
gy a
nd
De
ve
lop
me
nt
(or
no
min
ate
d d
epu
ty)
c)
Le
ttin
g o
f p
rem
ise
s to
ou
tsid
e o
rga
nis
ation
s
C
hie
f E
xe
cu
tive
& E
xecu
tive
Dire
cto
r of
Fin
an
ce
d)
Ap
pro
va
l of
ren
t b
ased o
n p
rofe
ssio
na
l a
sse
ssm
ent
E
xe
cu
tive
Dire
cto
r o
f F
ina
nce /
De
pu
ty
Do
F
Item
14
Page 47 of 62
48
e)
Sig
nin
g o
f L
ea
se
Do
cum
enta
tion
Gro
up
CiC
9.
Co
nd
em
nin
g &
Dis
po
sa
l
S
FIs
Se
ctio
n 1
3
It
em
s o
bso
lete
, ob
so
lesce
nt,
red
un
dan
t, irr
epa
rab
le o
r ca
nno
t be
re
pa
ire
d c
ost
eff
ective
ly
Exe
cu
tive
Dire
cto
r, M
an
agin
g D
ire
cto
r,
Ch
air o
f D
iv.
or
equ
iva
len
t /
Se
nio
r M
an
age
r In
vo
lve
d
Do
F o
r D
ep
uty
10
. Lo
sse
s, W
rite
-off
& C
om
pen
sa
tio
n
(all
ite
ms to
be
re
po
rted
to
th
e A
ud
it C
om
mitte
e b
i-a
nnu
ally
)
All
limits in
th
is s
ection a
pp
ly p
er
ca
se
.
Ma
nu
al fo
r A
ccou
nts
S
FI
Se
ctio
n 1
3
CN
ST
an
d R
PS
T
(NH
SL
A)
Me
mbe
rsh
ip R
ule
s.
a)
Lo
sse
s a
nd C
ash
due
to
theft
, fr
au
d,
ove
rpa
ym
ent
&
oth
ers
–
i.
Up
to
£5
0,0
00
ii.
Ove
r £
50
,00
0
i.
Dire
cto
r of
Fin
an
ce
(C
O)
ii.
CO
Ma
na
ge
me
nt B
oa
rd
b)
Fru
itle
ss P
aym
ents
(in
clu
din
g a
ban
do
ned
Cap
ita
l S
ch
em
es)
i.
Up
to
£2
50
,00
0
ii.
Ove
r
£2
50,0
00
i.
Dire
cto
r of
Fin
an
ce
(C
O)
ii.
CO
Ma
na
ge
me
nt B
oa
rd
c)
Ba
d D
eb
ts a
nd C
laim
s A
ba
nd
on
ed.
Priva
te P
atie
nts
, O
ve
rse
as V
isito
rs &
Oth
er
i.
Ind
ivid
ua
l d
eb
ts u
p to
£5
,00
0
ii.
Ind
ivid
ua
l d
eb
ts o
ve
r £
5,0
00
i.
Dire
cto
r of
Fin
an
ce
(C
O)
ii.
CO
Ma
na
ge
me
nt B
oa
rd
Page 48 of 62
49
d)
Da
ma
ge
to
bu
ildin
gs, fitt
ings, fu
rnitu
re a
nd
equ
ipm
en
t a
nd
lo
ss o
f e
qu
ipm
en
t a
nd
pro
pe
rty in
sto
res a
nd
in
use d
ue
to
cu
lpa
ble
ca
use
s (
eg f
rau
d, th
eft
, a
rso
n)
or
oth
er
i.
Up
to
£5
0,0
00
ii.
Ove
r £
50
,00
0
i.
Dire
cto
r of
Fin
an
ce
(C
O)
ii.
CO
Ma
na
ge
me
nt B
oa
rd
e)
Co
mpe
nsatio
n p
aym
en
ts m
ade
un
de
r le
ga
l ob
liga
tio
n
Le
ad
HR
Off
ice
r fo
r th
e C
O
liste
d u
nd
er
Ca
tego
ry D
- f
or
sta
ff c
om
pe
nsa
tio
n
CO
Dire
cto
r of
Fin
an
ce -
fo
r n
on
-sta
ff
co
mpe
nsa
tio
n
f)
Extr
a C
on
tra
ctu
al p
aym
ents
to c
ontr
acto
rs
i.
Up
to
£5
0,0
00
ii.
Ove
r £
50
,00
0
i.
Dire
cto
r of
Fin
an
ce
(C
O)
ii.
CO
Ma
na
ge
me
nt B
oa
rd
E
x-G
ratia
Pa
ym
en
ts (
all
rep
ort
ed t
o A
ud
it C
om
mitte
e in
h
alf y
ea
rly lo
sse
s r
ep
ort
s).
g)
Pa
tie
nts
an
d s
taff
fo
r lo
ss o
f pe
rso
na
l eff
ects
: i.
Le
ss th
an
£2
,000
(pa
tie
nts
) ii.
L
ess th
an £
1,0
00
(sta
ff)
iii.
Ove
r £
1,0
00
i.
CO
Dire
cto
r of
Nu
rsin
g
ii.
Ma
na
gin
g D
ire
cto
r o
r equ
iva
len
t iii
. E
xe
cu
tive
Dire
cto
r
h)
Fo
r se
ttle
men
t of
insu
red
ris
ks:
C
linic
al
N
on
-Clin
ica
l –
Up
to
va
lue
of
Exce
ss
N.B
. a
bo
ve
exce
ss le
ve
l is
in
su
red r
isk a
nd t
he
refo
re n
o issue
fo
r th
e T
rust
Ma
na
gin
g D
ire
cto
r o
r equ
iva
len
t
Item
14
Page 49 of 62
50
i)
Se
ttle
men
t of
no
n-in
sura
nce
cla
im r
isks:
U
p t
o £
10,0
00
(C
linic
al &
No
n-C
linic
al)
Ma
na
gin
g D
ire
cto
r o
r equ
iva
len
t
£2
0,0
01 -
£50
,00
0 (
Clin
ica
l &
Non
-Clin
ica
l)
C
O A
cco
un
tab
le O
ffic
er
or
Dire
cto
r of
Fin
an
ce
(C
O)
£
50
,001
an
d a
bo
ve
(C
linic
al &
No
n-C
linic
al)
G
rou
p C
iC
j)
Em
plo
ym
en
t re
late
d s
ett
lem
en
ts:
-
Up
to
£1
0,0
00
HR
Le
ad f
or
the
CO
lis
ted
un
de
r C
ate
go
ry D
- O
ve
r £
10
,00
0
C
O A
cco
un
tab
le O
ffic
er
or
Dire
cto
r of
Fin
an
ce
(CO
)
Oth
er,
exce
pt
ca
se
s o
f m
ala
dm
inis
tra
tion
wh
ere
th
ere
wa
s n
o
fina
ncia
l lo
ss b
y c
laim
an
t
i.
Up
to
£5
0,0
00
ii.
Ove
r £
50
,00
0
i.
De
pu
ty D
ire
cto
r of
Fin
an
ce
(C
O)
ii.
Dire
cto
r of
Fin
an
ce
(C
O)
k)
Write
ba
ck o
f N
HS
Deb
tors
i.
Up
to
£2
5,0
00
ii.
Ove
r £
25
,00
0
*all
insta
nce m
ust
be r
eport
ed t
o A
udit C
om
mitte
es
i.
De
pu
ty D
ire
cto
r of
Fin
an
ce
(C
O)
ii.
Dire
cto
r of
Fin
an
ce
(C
O)
Page 50 of 62
51
11
. Re
po
rtin
g o
f In
cid
en
ts to
the
Po
lice
SF
Is S
ectio
ns 2
&
11
Tru
st P
olic
y o
n
Vio
len
ce &
A
ggre
ssio
n
Ap
pen
dix
6
a)
Where
a c
rim
ina
l off
ence
is s
uspe
cte
d:
crim
ina
l off
en
ce
of
a v
iole
nt n
atu
re
oth
er
(exce
pt fr
aud
)
CO
Dire
cto
r o
r
Se
nio
r M
an
age
r o
n c
all
b)
Where
a f
rau
d is in
vo
lve
d th
e p
olic
e a
re n
otifie
d in
a
cco
rdan
ce
with
the
Tru
st’s F
rau
d R
esp
on
se
Pla
n
Dire
cto
r of
Fin
an
ce
(C
O)/
De
pu
ty
Dire
cto
r of
Fin
an
ce
12
. Pe
tty C
ash
Dis
bu
rsem
en
ts (
no
t ap
plic
ab
le to
ce
ntr
al C
ash
iers
Off
ice)
S
FIs
Se
ctio
ns 6
a)
Exp
en
ditu
re u
p to
£3
0 p
er
item
Pe
tty C
ash
Ho
lde
r
b)
Re
imb
urs
em
en
t of
pa
tie
nts
mon
ies u
p to
£1
00
c)
Re
imb
urs
em
en
t of
pa
tie
nts
mon
ies in
exce
ss o
f £1
00
All
pa
tien
t m
on
ies m
ust
be
lo
dge
d w
ith
th
e c
en
tra
l ca
sh
iers
dep
art
me
nt of
the
rele
va
nt
ho
sp
ita
l an
d r
ece
ipte
d.
Re
imb
urs
em
en
t m
ust b
e r
equ
este
d b
y
the
Se
rvic
e M
an
age
r.
13
. Re
ce
ivin
g /
Re
gis
terin
g H
osp
ita
lity
A
pp
lies to
bo
th in
div
idu
al an
d c
olle
ctive
ho
spita
lity ite
ms o
f a
ll va
lue.
SF
I S
ectio
n 1
7 &
C
od
e o
f C
ond
uct fo
r N
HS
Sta
ff (
pa
ge
13
se
ctio
n 1
.3.1
.6).
S
FI
Se
ctio
n
9.2
.6(d
)
Item
14
Page 51 of 62
52
a)
De
cla
ratio
n r
equ
ire
d in T
rust’s H
osp
ita
lity R
egis
ter
he
ld b
y
the
Dire
cto
r of
Co
rpo
rate
Se
rvic
es
All
sta
ff
In s
itua
tion
s w
he
re indiv
idu
als
be
lieve
th
at
a s
up
plie
r h
as o
ffe
red
an
ina
pp
rop
ria
te i
nd
uce
men
t th
is s
ho
uld
be
re
po
rted
to t
he
lin
e
ma
na
ge
r w
ho
will
re
fer
it u
pw
ard
s a
s a
pp
rop
ria
te.
14
. Co
mp
lian
ce
with
Re
leva
nt L
aw
s
E
nsu
re c
om
plia
nce w
ith
re
leva
nt
law
s a
nd r
egu
latio
ns,
inte
rna
l p
olic
ies a
nd
pro
ce
du
res a
nd
th
at a
ll exp
en
ditu
re
is la
wfu
l.
All
Se
nio
r M
an
age
rs, G
en
era
l M
an
age
rs,
Lin
e, W
ard
an
d
De
pa
rtm
en
tal M
ana
ge
rs.
(Th
e D
ecla
ration
of
Inte
rests
do
cum
ent
sig
ne
d e
ach
ye
ar
will
pro
vid
e a
ssu
ran
ce
tha
t co
mp
lian
ce
with
this
pro
vis
ion
is
evid
en
ce
d.)
Co
rpo
rate
G
ove
rna
nce
F
ram
ew
ork
Ma
nu
al.
15
. Im
ple
me
nta
tio
n o
f In
tern
al an
d E
xte
rna
l A
ud
it
Re
co
mm
en
datio
ns
Re
leva
nt
Ma
na
ge
r p
lus E
xe
cu
tive
D
ire
cto
r of
Fin
an
ce
Se
ctio
n 1
.4 (
P.2
0)
plu
s s
ectio
n 2
.4
(p.4
3).
S
FI
Se
ctio
n 2
&
Ap
pen
dix
7A
Page 52 of 62
53
16
. Ma
inte
na
nce &
Upd
ate
on
Tru
st F
ina
ncia
l P
roce
du
res
Gro
up
Ch
ief
Fin
an
ce
Off
ice
r
Se
ctio
n 1
.5 (
pa
ge
2
2)
17
. In
ve
stm
en
t of
Fun
ds
C
O C
hie
f O
ffic
er
S
FIs
Se
ctio
n 8
18
. Co
ntr
acte
d P
ers
onn
el &
Pa
y a
dd
itio
na
l item
s w
ith
in e
xis
tin
g T
erm
s a
nd
Con
ditio
ns o
f E
mp
loym
en
t. (
The
se
lim
its a
pp
ly t
o
ite
ms w
ith
in t
he
bu
dge
ts a
va
ilab
le)
NO
TE
: E
xp
end
itu
re r
ela
ted t
o n
on
co
ntr
acte
d p
ay is d
eta
iled
at
se
ction
3.1
a)
Ad
ditio
na
l In
cre
me
nts
T
he
gra
ntin
g o
f a
dd
itio
na
l in
cre
me
nts
to s
taff
with
in
b
ud
ge
t:
o
S
en
ior
Med
ica
l S
taff
o
Oth
er
Sta
ff
HR
Le
ad in
the
CO
lis
ted
un
de
r C
ate
go
ry D
b)
Up
gra
din
g &
Re
gra
din
g
All
requ
ests
fo
r u
pgra
din
g/r
egra
din
g s
ha
ll b
e d
ea
lt w
ith
in
a
cco
rdan
ce
with
app
rove
d P
roce
du
re (
va
lue
re
late
s to
th
e
incre
ase
in p
ay).
HR
Le
ad in
the
CO
lis
ted
un
de
r C
ate
go
ry D
c)
Pro
tecte
d W
age
/ S
ala
ry P
aym
en
ts
The
pro
tection
of
wa
ge
s /
sa
lary
pa
ym
ents
will
be
in
acco
rda
nce
with
th
e a
pp
rove
d P
olic
y.
HR
Le
ad in
the
CO
lis
ted
un
de
r C
ate
go
ry D
Item
14
Page 53 of 62
54
d)
Cre
atio
n o
f N
ew
Ma
nage
me
nt P
osts
(w
ith
in a
va
ilab
le
reso
urc
es a
nd
ma
na
gem
ent
co
sts
ta
rge
ts)
i.
Up
to
Tru
st G
rade
4 / u
p t
o A
FC
Ban
d 7
ii.
T
rust G
rad
e 3
to
1 /
AF
C B
an
d 7
an
d a
bo
ve
iii
. E
xe
cu
tive
Dire
cto
r
i.
Ch
air o
f D
ivis
ion
ii.
D
ire
cto
r of
OD
& C
orp
ora
te A
ffa
irs +
re
leva
nt
dire
cto
rs/C
ha
irs o
f D
ivis
ion
iii
. G
rou
p C
iC
e)
Au
tho
rity
to
co
mp
lete
sta
nd
ing d
ata
fo
rms e
ffectin
g p
ay,
ne
w s
tart
ers
, va
ria
tio
ns a
nd le
ave
rs.
Le
ad
HR
Off
ice
r fo
r th
e C
O lis
ted u
nd
er
Ca
tego
ry D
(H
R w
ill w
ork
with
CO
’s t
o
define
de
lega
tio
n r
equ
ire
men
ts)
f)
Au
tho
rity
to
co
mp
lete
an
d a
uth
orise
po
sitiv
e r
ep
ort
ing
form
s
Le
ad
HR
Off
ice
r fo
r th
e C
O lis
ted u
nd
er
Ca
tego
ry D
(H
R w
ill w
ork
with
CO
’s t
o
define
de
lega
tio
n r
equ
ire
men
ts)
g)
Au
tho
rity
to
au
tho
rise
ove
rtim
e
L
ead
HR
Off
ice
r fo
r th
e C
O lis
ted u
nd
er
Ca
tego
ry D
(H
R w
ill w
ork
with
CO
’s t
o
define
de
lega
tio
n r
equ
ire
men
ts)
h)
Au
tho
rity
to
app
rove
wo
rkin
g in
a t
em
po
rary
gra
de
:
i.
Co
ve
rin
g v
aca
ncie
s
ii.
Tem
po
rary
Re
gra
din
g
Le
ad
HR
Off
ice
r fo
r th
e C
O lis
ted u
nd
er
Ca
tego
ry D
(H
R w
ill w
ork
with
CO
’s t
o
define
de
lega
tio
n r
equ
ire
men
ts)
i)
Va
ria
tio
n t
o O
ve
rtim
e P
aym
en
t R
ate
s
All
pa
ym
en
ts t
o b
e m
ad
e in
acco
rda
nce w
ith
Na
tio
na
l T
erm
s a
nd
Co
nd
itio
ns a
nd
ap
pro
ve
d T
erm
s a
nd
Con
ditio
ns a
s a
pp
rop
ria
te
Ch
ief
Str
ate
gy a
nd
Org
an
isa
tion
al
De
ve
lop
men
t O
ffic
er
k)
Au
tho
rity
to
au
tho
rise
ad
-ho
c p
aym
en
ts (
ou
tsid
e o
f n
orm
al
term
s a
nd c
ond
itio
ns)
su
bje
ct to
co
mp
lian
ce w
ith
an
y
Tru
st o
r n
atio
na
l re
qu
ire
men
ts a
bou
t ra
tes o
f p
ay.
Le
ad
HR
Off
ice
r fo
r th
e C
O lis
ted u
nd
er
Ca
tego
ry D
(H
R w
ill w
ork
with
CO
’s t
o
define
de
lega
tio
n r
equ
ire
men
ts)
Page 54 of 62
55
l)
Sa
lary
/ w
age
pa
ym
en
ts f
rom
Ch
arita
ble
Fu
nds
F
un
d S
ign
ato
rie
s (
see
se
ctio
n 7
)
m)
R
ene
wa
l o
f F
ixe
d T
erm
Co
ntr
act
Ma
na
gin
g D
ire
cto
r, C
ha
ir o
f D
ivis
ion
of
Equ
iva
len
t
19
. Tra
ve
l a
nd
asso
cia
ted
Exp
en
se
s R
e-im
bu
rsem
ent
A
uth
ority
to
au
tho
rise
tra
ve
l a
nd
asso
cia
ted
exp
en
se
s:
Exe
cu
tive
Dire
cto
rs
Oth
er
Sta
ff
Ch
airm
an /
Ch
ief
Exe
cu
tive
Lin
e M
an
age
r o
r ap
pro
ve
d D
ep
uty
20
. Le
ave
C
on
ditio
ns o
f S
erv
ice
T
rust L
ea
ve
P
olic
y
a)
Ap
pro
va
l of
an
nu
al le
ave
Ward
/Lin
e/D
ep
art
men
tal M
an
age
r
b)
An
nua
l le
ave
- a
pp
rova
l of
ca
rry f
orw
ard
(u
p to
ma
xim
um
of
5 d
ays
Ward
/Lin
e/D
ep
art
men
tal M
an
age
r
c)
An
nua
l le
ave
- a
pp
rova
l of
ca
rry o
ve
r in
exce
ss o
f 5 d
ays
bu
t le
ss t
ha
n 1
0 d
ays.
Se
rvic
e M
an
age
r /
SN
M
Item
14
Page 55 of 62
56
d)
An
nua
l le
ave
- a
pp
rova
l to
ca
rry f
orw
ard
10
da
ys o
r m
ore
.
Ma
na
gin
g D
ire
cto
r, C
ha
ir o
f D
iv o
r e
qu
iva
len
t
e)
Co
mpa
ssio
na
te L
ea
ve
C
om
pas
Ward
/Lin
e/D
ep
art
men
tal M
an
age
r
f)
Specia
l le
ave a
rrange
ments
viiS
M
ate
rnity L
eave
P
ate
rnity L
ea
ve
A
doption L
eave
Au
tom
atic A
pp
rova
l w
ith
gu
ida
nce
Au
tom
atic A
pp
rova
l w
ith
gu
ida
nce
Au
tom
atic A
pp
rova
l w
ith
gu
ida
nce
C
are
rs lea
ve
D
om
estic
T
rade U
nio
n D
uties / A
ctivitie
s
Ward
/Lin
e/D
ep
art
men
tal M
an
age
r
Ward
/Lin
e/D
ep
art
men
tal M
an
age
r
Ward
/Lin
e/D
ep
art
men
tal M
an
age
r
viii
) g)
Leave w
ithout pay
W
ard
/Lin
e/D
ep
art
men
tal M
an
age
r
ix
) h)
Medic
al S
taff L
eave o
f A
bsence -
paid
and u
npaid
Me
dic
al D
ire
cto
r
i)
Tim
e o
ff in lie
u
Au
tom
atic A
pp
rova
l w
ith
gu
ida
nce
j)
Sic
k L
ea
ve
Exte
nsio
n o
f sic
k le
ave o
n h
alf p
ay u
p to
th
ree
mo
nth
s
Ma
na
gin
g D
ire
cto
r o
r equ
iva
len
t, C
ha
ir o
f D
iv o
r e
qu
iva
len
t &
Sen
ior
HR
Ma
na
ge
r
Tru
st S
ickn
ess
Ha
nd
ling
Gu
ide
line
s
Ph
ased
re
turn
to
wo
rk o
n a
dju
ste
d p
ay t
o a
ssis
t re
co
ve
ry,
revie
wa
ble
on
a m
on
thly
ba
sis
in
a
cco
rdan
ce
with
sic
kne
ss g
uid
an
ce
.
Se
rvic
e M
an
age
r
Page 56 of 62
57
Dis
cre
tio
na
ry e
xte
nsio
n o
f sic
k le
ave
on
fu
ll pa
y,
revie
wa
ble
mon
thly
.
HR
Le
ad in
the
CO
lis
ted
un
de
r C
ate
go
ry D
k)
Stu
dy L
ea
ve
T
rust P
olic
y
No
n M
ed
ica
l S
tud
y le
ave
Ma
na
gin
g D
ire
cto
r, C
ha
ir o
f D
ivis
ion
or
equ
iva
len
t
Me
dic
al sta
ff s
tud
y le
ave
Me
dic
al D
ire
cto
r
A
ll o
the
r stu
dy le
ave
Se
rvic
e M
an
age
r /
De
pa
rtm
en
tal M
an
age
r
21
. Re
mo
va
l E
xp
en
se
s,
Exce
ss R
en
t a
nd
Ho
use P
urc
ha
se
s
A
uth
orisa
tio
n o
f p
aym
en
t of
rem
ova
l e
xp
en
ses in
cu
rre
d b
y o
ffic
ers
ta
kin
g u
p n
ew
ap
po
intm
ents
(p
rovid
ing c
on
sid
era
tion
wa
s p
rom
ised
at in
terv
iew
)
Up
to
£8
,00
0
HR
Le
ad in
the
CO
lis
ted
un
de
r C
ate
go
ry D
Exp
en
se
s o
ve
r a
nd
abo
ve
th
e a
bo
ve
lim
it c
an o
nly
b
e a
wa
rde
d in
exce
ptio
na
l circum
sta
nce
s o
n a
ca
se
-by-c
ase
ba
sis
.
Ch
ief
Exe
cu
tive
22
. Grie
va
nce
Pro
ced
ure
All
grie
va
nce
s c
ase
s m
ust
be
de
alt w
ith
str
ictly in
a
cco
rdan
ce
with
the
Grie
va
nce
Pro
ce
du
re a
nd
the
ad
vic
e
of
a H
um
an
Re
so
urc
es O
ffic
er
mu
st b
e s
ou
ght
wh
en
the
grie
va
nce
re
ache
s th
e le
ve
l o
f G
ene
ral M
anage
r
Ward
/Lin
e/D
ep
art
men
tal M
an
age
r
Tru
st G
rie
va
nce
P
roce
du
re
Item
14
Page 57 of 62
58
2
3. A
uth
orise
d C
ar
& M
ob
ile P
hon
e U
se
rs
a)
Re
qu
ests
fo
r n
ew
po
sts
to
be
au
tho
rise
d a
s c
ar
use
rs
W
ard
/Lin
e/D
ep
art
men
tal M
an
age
r
b)
Le
ase
Ca
r A
pp
rova
l
Ma
na
gin
g D
ire
cto
r o
r equ
iva
len
t
c)
Le
ase
Ca
r M
ilea
ge
Ra
tes
E
xe
cu
tive
Dire
cto
r o
f F
ina
nce
d)
Re
qu
ests
fo
r n
ew
po
sts
to
be
au
tho
rise
d a
s m
ob
ile
tele
ph
one
use
rs
Ma
na
gin
g D
ire
cto
r, C
ha
ir o
f D
iv o
r e
qu
iva
len
t
e)
Re
qu
ests
fo
r n
ew
po
sts
to
be
au
tho
rise
d a
s te
lep
ho
ne
use
rs
Ma
na
gin
g D
ire
cto
r, C
ha
ir o
f D
iv o
r e
qu
iva
len
t
24
. Re
du
nd
an
cy
Re
du
nd
an
cy
Ch
ief
Exe
cu
tive
/Ch
ief
Fin
an
cia
l O
ffic
er/
Ch
ief
Str
ate
gy a
nd
Org
an
isatio
na
l D
eve
lopm
en
t O
ffic
er
Vo
lun
tary
se
ve
ran
ce
arr
an
ge
me
nts
(a
s d
ete
rmin
ed
an
d a
gre
ed
fro
m t
ime t
o tim
e b
y t
he
N
om
inatio
ns, R
em
une
ratio
n a
nd T
erm
s o
f S
erv
ice
C
om
mitte
e)
Gro
up
CiC
25
. Ill
He
alth
Re
tire
men
t
D
ecis
ion
to
te
rmin
ate
on
the
gro
un
ds o
f ill
-health
S
en
ior
Man
age
r o
r E
qu
iva
len
t w
ith
HR
a
dvic
e.
26
. Dis
mis
sa
l
Ma
na
gin
g D
ire
cto
r, C
ha
ir o
f D
ivis
ion
or
equ
iva
len
t w
ith
HR
ad
vic
e.
Tru
st
Dis
cip
lina
ry
Pro
ce
du
res
Page 58 of 62
59
27
. Au
tho
risa
tio
n o
f N
ew
Dru
gs
Me
dic
ine
s M
ana
ge
men
t G
roup
28
. Au
tho
risa
tio
n o
f S
pon
so
rsh
ip d
ea
ls
Gro
up
CE
O a
nd
Ch
ief F
ina
ncia
l O
ffic
er
29
. Au
tho
risa
tio
n o
f R
ese
arc
h P
roje
cts
Dire
cto
r of
R&
D p
lus D
ire
cto
r of
Fin
an
ce
(CO
) T
rusts
Re
se
arc
h
Po
licy
30
. Au
tho
risa
tio
n o
f C
linic
al T
ria
ls
Dire
cto
r of
R&
D p
lus D
ire
cto
r of
Fin
an
ce
(CO
) p
lus H
ea
d o
f P
harm
acy.
Tru
sts
Clin
ica
l T
ria
ls P
olic
y
31
. In
su
ran
ce
Po
licie
s a
nd R
isk M
an
age
me
nt
Gro
up
CiC
S
FIs
Se
ctio
n 1
9
32
. Pa
tie
nts
& R
ela
tive
s C
om
pla
ints
a)
Ove
rall
resp
on
sib
ility
fo
r e
nsu
rin
g t
ha
t a
ll com
pla
ints
are
d
ea
lt w
ith
eff
ective
ly
Ch
ief
Exe
cu
tive
/Ch
ief
Nu
rsin
g O
ffic
er
b)
Re
sp
on
sib
ility
fo
r e
nsurin
g c
om
pla
ints
re
lating t
o a
d
ire
cto
rate
are
in
ve
stig
ate
d t
ho
rou
gh
ly.
Ma
na
gin
g D
ire
cto
r, C
ha
ir o
f D
ivis
ion
or
equ
iva
len
t
c)
Me
dic
o -
Le
ga
l C
laim
s -
Co
ord
ina
tion
of
the
ir
ma
na
ge
me
nt.
C
laim
s M
an
age
r
33
. Re
latio
nsh
ips w
ith
Pre
ss
E
nqu
irie
s :
-
With
in H
ou
rs
Ou
tsid
e H
ou
rs
He
ad
of
Com
mu
nic
ation
s
Se
nio
r M
an
age
r o
n-c
all
34
. Infe
ctio
us D
ise
ase
s &
No
tifia
ble
Ou
tbre
aks
M
ed
ica
l D
ire
cto
r /
Head
of
Infe
ctio
n C
on
tro
l
Item
14
Page 59 of 62
60
35
. Exte
nd
ed R
ole
Activitie
s
A
pp
rova
l of
Nu
rse
s t
o u
nde
rta
ke
du
tie
s /
pro
ce
du
res w
hic
h c
an
p
rop
erly b
e d
escrib
ed
as b
eyo
nd t
he
no
rma
l sco
pe
of
Nu
rsin
g
Pra
ctice
.
CE
or
Dire
cto
r of
Nu
rsin
g /
De
puty
Dire
cto
r of
Nu
rsin
g
Nu
rse
/Mid
wiv
es/
He
alth
Vis
ito
rs
Act
Mid
wiv
es
Ru
les /
Co
de
of
Pra
ctice
UK
CC
C
od
e o
f P
rofe
ssio
na
l C
on
du
ct
36
. Pa
tie
nt
Se
rvic
es
a)
Va
ria
tio
n o
f o
pe
ratin
g a
nd
clin
ic s
essio
ns w
ith
in e
xis
tin
g
nu
mb
ers
:
Ou
tpa
tie
nts
The
atr
es
Oth
er
Ma
na
gin
g D
ire
cto
r, C
ha
ir o
f D
iv o
r e
qu
iva
len
t
b)
All
pro
po
se
d c
ha
nge
s in
bed
allo
ca
tio
n a
nd
use
Tem
po
rary
Ch
an
ge
Pe
rman
en
t C
ha
nge
Co
ntr
act m
on
ito
rin
g
Co
ntr
act
rep
ort
ing
Be
d M
an
age
r
Ma
na
gin
g D
ire
cto
r, C
ha
ir o
f D
iv o
r e
qu
iva
len
t
CO
Dire
cto
r of
Fin
an
ce
CO
Dire
cto
r of
Fin
an
ce
37
. Fa
cili
tie
s f
or
sta
ff n
ot em
plo
ye
d b
y t
he
Tru
st to
ga
in
pra
ctica
l e
xp
erie
nce
Tru
st P
olic
y o
n
Stu
de
nt W
ork
E
xp
erie
nce
Page 60 of 62
61
a)
Pro
fessio
na
l R
eco
gn
itio
n,
Hon
ora
ry C
on
tra
cts
, &
In
su
ran
ce
of
Me
dic
al S
taff
.
R&
D D
ire
cto
r
b)
Work
exp
erie
nce
stu
den
ts e
tc.
A
ssis
tan
t H
R M
an
age
r
38
. Re
vie
w o
f fire
pre
cau
tio
ns
D
ire
cto
r of
Ca
pita
l
39
. Re
vie
w o
f com
plia
nce
with
all
sta
tuto
ry a
nd H
ea
lth
an
d
Safe
ty E
xe
cu
tive
re
qu
ire
men
ts (
inclu
din
g c
ontr
ol of
Su
bsta
nce
s H
aza
rdo
us t
o H
ea
lth
Re
gu
latio
ns)
CO
Ch
ief
Off
ice
rs
40
. Re
vie
w o
f M
ed
icin
es In
sp
ecto
rate
Re
gu
lation
s
C
O M
ed
ica
l D
ire
cto
r
41
. Re
vie
w o
f com
plia
nce
with
en
viro
nm
en
tal re
gu
latio
ns,
e.g
. th
ose r
ela
tin
g t
o c
lean
air a
nd
wa
ste
dis
po
sa
l C
O C
hie
f O
ffic
ers
42
. Re
vie
w o
f T
rust's c
om
plia
nce
with
the
Da
ta P
rote
ctio
n A
ct
Ch
ief
Info
rma
tio
n O
ffic
er
43
. Mo
nito
r p
rop
osa
ls fo
r co
ntr
actu
al a
rran
ge
ments
be
twe
en
th
e T
rust a
nd
ou
tsid
e b
od
ies
Gro
up
Ch
ief
Fin
an
cia
l O
ffic
er/
Dire
cto
r of
Fin
an
ce
(C
O)
44
. Re
vie
w t
he
Tru
st's
com
plia
nce
with
th
e A
ccess t
o H
ea
lth
R
eco
rds A
ct
CO
CIO
/ D
CIO
IG
45
. Re
vie
w o
f th
e T
rust's
co
mp
lian
ce
co
de
of
Pra
ctice
fo
r h
and
ling c
onfide
ntia
l in
form
atio
n in t
he
con
tractin
g
en
viro
nm
ent
an
d th
e c
om
plia
nce
with
"safe
ha
ve
n"
regu
latio
ns
CO
CIO
/ D
CIO
IG
46
. The
kee
pin
g o
f a
De
cla
ratio
n o
f In
tere
sts
Regis
ter.
D
ire
cto
r of
Co
rpo
rate
Se
rvic
es
SO
s S
ectio
n 6
47
. Att
esta
tio
n o
f S
ea
lings in
acco
rda
nce w
ith
Sta
nd
ing O
rde
rs
E
xe
cu
tive
Dire
cto
r o
f F
ina
nce a
nd
CE
O (
or
no
min
ate
d o
ffic
ers
, n
ot w
ith
in t
he
origin
atin
g
de
pa
rtm
en
t)
SO
s S
ectio
n 1
2
Item
14
Page 61 of 62
62
48
. The
kee
pin
g o
f a
re
gis
ter
of
Se
alin
gs
Dire
cto
r of
Co
rpo
rate
Se
rvic
es
SO
s S
ectio
n 1
2
49
. The
kee
pin
g o
f th
e H
osp
ita
lity R
egis
ter
Dire
cto
r of
Co
rpo
rate
Se
rvic
es
50
. Re
ten
tio
n o
f R
eco
rds
Ch
ief
Exe
cu
tive
Page 62 of 62