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Schedule 1

Updated following July 2014 Trust Board

Scheme of Reservation and Delegation of Powersforthe Welsh Ambulance Services NHS Trust

July 2014

Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru Welsh Ambulance Services NHS Trust

MODEL SCHEME OF RESERVATIONAND DELEGATION OF POWERS

This Schedule forms part of, and shall have effect as if incorporated in the Trust Standing Orders

Introduction

As set out in Standing Order 2, the Board - subject to any directions that may be made by the Welsh Ministers - shall make appropriate arrangements for certain functions to be carried out on its behalf so that the day to day business of the Trust may be carried out effectively, and in a manner that secures the achievement of the organisation’s aims and objectives. The Board may delegate functions to:

i) a Committee, e.g., Quality, Safety and Governance Committee;

ii) a sub-Committee e.g., a locality based Quality and Patient Safety Committee taking forward matters within a defined area. Any such delegation would, subject to the Board’s authority, usually be via a main Committee of the Board; and

iii) Officers of the Trust (who may, subject to the Board’s authority, delegate further to other officers and, where appropriate, other third parties, e.g. shared/support services, through a formal scheme of delegation)

and in doing so, must set out clearly the terms and conditions upon which any delegation is being made. These terms and conditions must include a requirement that the Board is notified of any matters that may affect the operation and/or reputation of the Trust.

The Board’s determination of those matters that it will retain, and those that will be delegated to others are set out in the following:-

Schedule of matters reserved to the Board; Scheme of delegation to Committees and others; and Scheme of delegation to officers.

all of which form part of the Trust’s Standing Orders.

DECIDING WHAT TO RETAIN AND WHAT TO DELEGATE:GUIDING PRINCIPLES

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The Board will take full account of the following principles when determining those matters that it reserves, and those which it will delegate to others to carry out on its behalf:

Everything is retained by the Board unless it is specifically delegated in accordance with the requirements set out in SOs or SFIs

The Board must retain that which it is required to retain (whether by statute or as determined by the Welsh Ministers) as well as that which it considers is essential to enable it to fulfil its role in setting the organisation’s direction, equipping the organisation to deliver and ensuring achievement of its aims and objectives through effective performance management

Any decision made by the Board to delegate functions must be based upon an assessment of the capacity and capability of those to whom it is delegating responsibility

The Board must ensure that those to whom it has delegated powers (whether a Committee, partnership or individuals) remain equipped to deliver on those responsibilities through an ongoing programme of personal, professional and organisational development

The Board must take appropriate action to assure itself that all matters delegated are effectively carried out

The framework of delegation will be kept under active review and, where appropriate, will be revised to take account of organisational developments, review findings or other changes

Except where explicitly set out, the Board retains the right to decide upon any matter for which it has statutory responsibility, even if that matter has been delegated to others

The Board may delegate authority to act, but retains overall responsibility and accountability

When delegating powers, the Board will determine whether (and the extent to which) those to whom it is delegating will, in turn, have powers to further delegate those functions to others.

HANDLING ARRANGEMENTS FOR THE RESERVATION AND DELEGATION OF POWERS: WHO DOES WHAT

The Board

The Board will formally agree, review and, where appropriate revise schedules of 3

reservation and delegation of powers in accordance with the guiding principles set out earlier. The Chief Executive

The Chief Executive will propose a Scheme of Delegation to Officers, setting out the functions they will perform personally and which functions will be delegated to other officers. The Board must formally agree this scheme.

In preparing the scheme of delegation to officers, the Chief Executive will take account of:

the guiding principles set out earlier (including any specific statutory responsibilities designated to individual roles)

their personal responsibility and accountability to the Chief Executive, NHS Wales in relation to their role as designated Accountable Officer

associated arrangements for the delegation of financial authority to equip officers to deliver on their delegated responsibilities (and set out in SFIs).

The Chief Executive may re-assume any of the powers they have delegated to others at any time.

The Board Secretary

The Board Secretary will support the Board in its handling of reservations and delegations by ensuring that:

a proposed schedule of matters reserved for decision by the Board is presented to the Board for its formal agreement;

effective arrangements are in place for the delegation of Trust functions within the organisation and to others, as appropriate; and

arrangements for reservation and delegation are kept under review and presented to the Board for revision, as appropriate.

The Audit Committee

The Audit Committee will provide assurance to the Board of the effectiveness of its arrangements for handling reservations and delegations.

Individuals to whom powers have been delegated

Individuals will be personally responsible for:

equipping themselves to deliver on any matter delegated to them, through the conduct of appropriate training and development activity; and

exercising any powers delegated to them in a manner that accords with the Trust’s values and standards of behaviour.

Where an individual does not feel that they are equipped to deliver on a matter 4

delegated to them, they must notify the Board Secretary of their concern as soon as possible in so that an appropriate and timely decision may be made on the matter.

In the absence of an officer to whom powers have been delegated, those powers will normally be exercised by the individual to whom that officer reports, unless the Board has set out alternative arrangements.

If the Chief Executive is absent their nominated Deputy (the Deputy Chief Executive in the first instance) may exercise those powers delegated to the Chief Executive on their behalf. However, the guiding principles governing delegations will still apply, and so the Board may determine that it will reassume certain powers delegated to the Chief Executive or reallocate powers, e.g., to a Committee or another officer.

SCOPE OF THESE ARRANGEMENTS FOR THE RESERVATION AND DELEGATION OF POWERS

The Scheme of Delegation to officers referred to here shows only the "top level" of delegation within the Trust. The Scheme is to be used in conjunction with the system of control and other established procedures within the Trust.

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SCHEDULE OF MATTERS RESERVED TO THE BOARD1

THE BOARD AREA DECISIONS RESERVED TO THE BOARD1 FULL GENERAL The Board may determine any matter for which it has statutory or delegated authority,

in accordance with SOs.

2 FULL OPERATING ARRANGEMENTS

Adopt the standards of governance and performance (including the quality and safety of healthcare, and the patient experience) to be met by the Trust, including standards/requirements determined by professional bodies/others, e.g., Royal Colleges.


Approve, vary and amend:

SOs; SFIs; Schedule of matters reserved to the Trust; Scheme of delegation to Committees and others; and Scheme of delegation to officers.

In accordance with any directions set by the Welsh Ministers.


Approve the Trust’s Values and Standards of Behaviour framework.


Approve the Trust’s framework for performance management, risk and assurance.

6 FULL OPERATING Approve the introduction or discontinuance of any significant activity or operation. Any

1 Any decision to reserve a matter, and the manner in which that retained responsibility is carried out will be in accordance with any regulatory and/or Assembly Government requirements

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ARRANGEMENTS activity or operation shall be regarded as significant if the Board determines it so based upon its contribution/impact on the achievement of the Trust’s aims, objectives and priorities.


Ratify any urgent decisions taken by the Chair and the Chief Executive in accordance with Standing Order requirements.


Ratify in public session any instances of failure to comply with SOs.


Approve arrangements relating to the discharge of the Trust’s responsibility as a bailee for patients’ property


Approval of all Strategies, together with policies for dealing with complaints and incidents and All Wales Employment Policies.


Approve individual compensation payments in line with SFIs


Approve individual cases for the write off of losses or making ofspecial payments above the limits of delegation to the Chief Executive and officers


Approve proposals for action on litigation on behalf of the Trust where the financial impact is expected to exceed £250,000 or be contentious or novel or likely to lead to extreme adverse publicity (excluding claims covered by the NHS risk pooling schemes)


Authorise use of the Trust’s official seal

15 FULL ORGANISATION STRUCTURE &

STAFFING

Ratify appointment and [arrange the] appraisal, discipline and dismissal of the Chief Executive


Approve the appointment, discipline and dismissal of the Executive Directors and any other Board level appointments, e.g., the Board Secretary and those constituting the

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STAFFING Management Team17 FULL ORGANISATION

STRUCTURE & STAFFING

Require, receive and determine action in response to the declaration of Trust members’ interests, in accordance with advice received, e.g. from Audit Committee


STAFFING

Approve, [arrange the] review, and revise the Trust’s top level organisation structure and corporate policies


STAFFING

Appoint, [arrange the] review, revise and dismiss Trust Committees directly accountable to the Board


STAFFING

Appoint, equip, review and (where appropriate) dismiss the Chair and members of any Committee or Group set up by the Board


STAFFING

Appoint, equip, review and (where appropriate) dismiss individuals appointed to represent the Board on outside bodies and groups


STAFFING

Approve the terms of reference and reporting arrangements of all Committees and groups established by the Board


STAFFING

Approve the arrangements relating to the discharge of the Trust’s responsibilities as a corporate trustee for funds held on trust

24 FULL STRATEGY & PLANNING

Determine the Trust’s strategic aims, objectives and priorities


Approve the Trust’s Integrated Medium Term Plan, including the balanced Medium Term Financial Plan and Annual Quality/Delivery Plans


Approve the Trust’s Risk Management Strategy and plans


Approve the Trust’s citizen engagement and involvement strategy, including communication

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Ratify proposals for the acquisition, disposal or change of use of land and/or buildings


Approve the Trust’s partnership and stakeholder engagement and involvement strategies


Approve the Trust’s key strategies and programmes related to: The development and delivery of patient centred clinical services Improving quality and patient safety outcines Workforce and Organisational Development Infrastructure, including IM &T, Estates and Capital (including major capital

investment and disposal plans)


Approve the Trust’s budget and financial framework (including overall distribution and unbudgeted expenditure)


Approve individual contracts (other than NHS contracts) above the limit delegated to the Chief Executive set out in the Standing Financial Instructions

33 FULL PERFORMANCE & ASSURANCE

Approve the Trust’s audit and assurance arrangements


Receive reports from the Trust’s Executive on progress and performance in the delivery of the Trust’s strategic aims, objectives and priorities and approve action required, including improvement plans


Receive reports from the Trusts Committees, groups and other internal sources on the Trust’s performance and approve action required, including improvement plans


Receive reports on the Trust’s performance produced by external regulators and inspectors (including, e.g., WAO, HIW, etc) that raise issues or concerns having an impact on the Trust’s ability to achieve its aims and objectives and approve action required, including improvement plans, taking account of the advice of Trust Committees (as appropriate)


Receive the annual opinion of the Trust’s Chief Internal Auditor and approve action required, including improvement plans

38 FULL PERFORMANCE Receive the annual management letter/report from the Auditor General for Wales and

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& ASSURANCE approve action required, including improvement plans39 FULL PERFORMANCE

& ASSURANCEReceive the annual opinion on the Trust’s performance against Doing Well, Doing Better: Standards for Health Services in Wales (formally the Healthcare Standards) and approve action required, including improvement plans

40 FULL REPORTING Approve the Trust’s Reporting Arrangements, including reports on activity and performance to citizens, partners and stakeholders and nationally to the Assembly Government

41 FULL REPORTING Receive, approve and ensure the publication of Trust reports, including its Annual Report and annual financial accounts

ADDITIONAL AREAS OF RESPONSIBILITY DELEGATED TO CHAIR, VICE CHAIR AND INDEPENDENT MEMBERSSee Appendix 7 to Schedule 6 – Nominated Trust Leads/Champions

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DELEGATION OF POWERS TO COMMITTEES AND OTHERS2

Standing Order 2 provides that the Board may delegate powers to Committees and others. In doing so, the Board has formally determined:

the composition, terms of reference and reporting requirements in respect of any such Committees; and the governance arrangements, terms and conditions and reporting requirements in respect of any delegation to others,

in accordance with any regulatory requirements and any directions set by the Welsh Ministers.

The Board has delegated a range of its powers to the following Committees and others:

Audit Committee Quality Delivery Committee Remuneration Committee Charitable Funds Committee

The scope of the powers delegated, together with the requirements set by the Board in relation to the exercise of those powers are as set out in i) Committee terms of reference, and ii) Formal arrangements for the delegation of powers to others. Collectively, these documents form the Trust’s Scheme of Delegation.

DELEGATION TO COMMITTEES (to be read in conjunction with Committee Terms of Reference)

DELEGATED MATTER DELEGATED TO OPERATIONAL RESPONSIBILITY

1. Standing Orders/Standing Financial Instructions

2 As defined in Standing Orders

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a) Review suspension of Standing Orders Audit Committee Audit Committee

b) Review, appraise and report in accordance with Government Internal Audit Standards (GIAS) and best practice.

Audit Committee Director of Internal Audit

c) Provide an independent and objective view on internal control and probity.

Audit Committee Internal Audit / External Audit

d) Ensure cost-effective audit service. Audit Committee Director of Finance and ICT

2. Commercial Sponsorship

Agreement to proposal Audit Committee Chief Executive

3. Funds Held on Trust (Charitable and Non Charitable Funds)

Fundraising Appeals Charitable Funds Committee

Corporate Accountant

Investments: Charitable Funds Committee


Funds held on Trust are managed appropriately Charitable Funds Committee

Director of Finance and ICT

4. Policies and Strategies Review and recommend to the Board Draft Policies and Strategies

Relevant Committee* Executive Team

* Approval of all Strategies remains a matter for the Board. In respect of Policies certain ones are reserved to the Board however others may be signed off by the Quality Delivery Committee. For further guidance please refer to the process for policy development and approval as set out in Annex 10 to Schedule 3 of the Trust’s Standing Orders or seek guidance from Corporate Secretary.

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SCHEME OF DELEGATION TO EXECUTIVE DIRECTORS, OTHER DIRECTORS AND OFFICERS

The Trust SOs and SFIs specify certain key responsibilities of the Chief Executive, the Director of Finance and ICT and other officers. The Chief Executive’s Job Description, together with their Accountable Officer Memorandum sets out their specific responsibilities, and the individual job descriptions determined for Director level posts on the Trust’s Management Team also define in detail the specific responsibilities assigned to those post holders. These documents, set out in schedule 6, together with the schedule of additional delegations below and the associated financial delegations set out in the SFIs form the basis of the Trust’s Scheme of Delegation to Officers.


1. Standing Orders/Standing Financial Instructions

a) Final authority in interpretation of Standing Orders

Chairman Chairman

b) Notifying Directors and employees of their responsibilities within the Standing Orders and Standing Financial Instructions and ensuring that they understand the responsibilities

Chief Executive All Line Managers

c) Responsibility for security of the Trust’s property, avoiding loss, exercising economy and efficiency in using resources and conforming with Standing Orders, Financial instructions and financial procedures

Chief Executive All Directors and Employees

d) Suspension of Standing Orders Trust Board Trust Board

e) Variation or amendment to Standing Orders Trust Board Trust Board

f) Emergency powers relating to the authorities retained by the Board.

Chair and Chief Executive with two non-executives

Chair and Chief Executive with two non-executives

g) Disclosure of non-compliance with Standing Orders to the Chief Executive (report to the Board of Directors).

All staff All staff

h) Disclosure of non-compliance with SFIs to the Director of Finance and ICT (report to the Audit Committee)

All staff All staff

i) Advice on interpretation or application of SFIs and this Scheme of Delegation

Director of Finance and ICT Corporate Accountant/Internal Audit

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j) Agreement of all financial arrangements for the recovery of overpayments or any outstanding sums due to the Trust.

Director of Finance and ICT Corporate Accountant

Table A - Delegated Matters


1. Audit Arrangements

a) Ensure that an adequate internal and external audit service, for which they are accountable, is provided Welsh Assembly Government is responsible for the appointment of External Audit. Internal Audit services are provided by the Shared Services Partnership

Director of Finance and ICT/Chief Executive

Director of Finance and ICT (External Audit/Corporate Secretary (Internal Audit)

b) Implement recommendations Chief Executive Relevant Officers

2. Authorisation of Clinical Trials & Research Projects

Chief Executive Director of Medical and Clinical Services in accordance with JRCALC Guidelines)

3. Authorisation of New Drugs Chief Executive Director of Medical and Clinical Services

4. Bank/OPG Accounts/Cash (Excluding Charitable Fund (Funds Held on Trust) Accounts)

Operation:Corporate Accountant

Corporate AccountantTo be completed in accordance with bank mandate/internal proceduresTo be completed in accordance with bank mandate/internal proceduresTo be completed in accordance with bank mandate/internal procedures

Managing banking arrangements and operation of bank accounts (Board of Directors approves arrangements)

Opening bank accounts Authorisation of transfers between Trust

bank accounts



Approve and apply arrangements for the electronic transfer of funds


Authorisation of:- OPG schedules- BACS schedules- Automated cheque schedules- Manual cheques


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b) Investments: Investment of surplus funds in accordance

with the Trust’s investment policy Preparation of an investment procedures


c) Petty Cash Director of Finance and ICT Refer To Table B Delegated Limits

5. Capital Investmenta) Programme:

Ensure that there is adequate appraisal and approval process for determining capital expenditure priorities and the effect that each has on business plans / Service development Strategy

Chief Executive Directors of Finance and ICT Strategy Planning and Performance

Preparation of Capital Investment Programme

Chief Executive Directors of Finance and ICT/ Strategy, Planning and Performance

Preparation of external business cases presented to WAG

Chief Executive Directors of Finance and ICT/Strategy. Planning and Performance

Preparation of internal business cases Chief Executive Directors of Finance and ICT/Strategy Planning and Performance

Financial monitoring and reporting on all capital scheme expenditure including variations to contract


Authorisation of capital requisitions Chief Executive Refer to Table B Delegated Limits

Assessing the requirements for the operation of the construction industry taxation deduction scheme.


Responsible for the management of capital schemes and for ensuring that they are delivered on time and within cost.

Chief Executive Relevant Director

Ensure that capital investment is not undertaken without availability of resources to finance all revenue consequences.

Chief Executive Director of Finance and ICT

Issue procedures to support:o capital investmento Staged payments


Issue procedures governing financial Director of Finance and ICT

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management, including variation to contract, of capital investment projects and valuation for accounting purposes.

Issuing the capital scheme project manager with specific authority to commit capital, proceed / accept tenders in accordance with the SO’s and SFI’s

Chief Executive Director of Finance and ICT,

b) Leases (property and equipment) Granting and termination of leases


(See table B )

6. Clinical Audit Chief Executive Director of Medical and Clinical Services

7. Complaints/Concerns (Patients & Relatives) – Putting Things Right/The National Health Service (Concerns, Complaints and Redress Arrangement (Wales) Regulations 2011.

a) Overall responsibility for ensuring that all Concerns/complaints are dealt with in line with PTR Regulations; allow for the consideration of qualifying liabilities; and provide for incidents, complaints and claims to be dealt with under a single governance arrangement

Chief Executive (as Accountable officer)

Director of Medical and Clinical Services (as Responsible Officer)

b) Responsibility for ensuring concerns/complaints relating to a division / department are investigated thoroughly and in accordance with the PTR regulations.

Director of Medical and Clinical Services

Head of Clinical Operations (who is formally designated as the Senior Investigations Manager under PTR).

c) Medico - Legal Concerns/Complaints and compensation cases being managed via Redress – including overall co-ordination of their management.

Chief Executive Director of Medical and Clinical Services

8. Confidential Information

Monitoring of the Trust's compliance with the Chief Executive Director of Quality and Nursing

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Caldicott report on protecting patients’ confidentiality in the NHS

Freedom of Information Act compliance code Chief Executive Corporate Secretary

9. Data Protection Act

a) Monitoring of Trust’s complianceb) Senior Information Risk Owner (SIRO)

Chief Executive Director of Finance and ICTDirector of Finance and ICT

10. Declaration of Interest

Maintaining a register Chief Executive Corporate Secretary

Declaring relevant and material interest Board of Directors Board of Directors / Senior Managers / all staff.

11. Disposal and Condemnations

Items obsolete, redundant, irreparable or cannot be repaired cost effectively

Develop arrangements for the sale of assets


Director of Finance and ICT and ICT

Head of Relevant DepartmentRefer to Table B Delegated Limits

Disposal of Protected Property (as defined in the Terms of Authorisation)

Chief Executive (with authorisation from WAG)

Chief Executive

12. Environmental Regulations

Monitoring of compliance and ensuring compliance with environmental regulations, for example those relating to clean air and waste disposal

Director of Finance and ICT Head of Capital Planning and Estates

13. External Borrowing

a) Advise Trust Board of the requirements to repay / draw down Public Dividend Capital.


b) Approve a list of employees authorised to make short term borrowings on behalf of the Trust.

Board Chief Executive, Director of Finance and ICT

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c) Application for draw down of Public Dividend Capital, overdrafts and other forms of external borrowing.

d) Preparation of procedural instructions concerning applications for loans and over- drafting.

Chief Executive / Director of Finance and ICT




14. Financial Planning / Budgetary Responsibilitya) Setting:

Submit budgets to the Trust Board Director of Finance and ICT Director of Finance and ICT

Submit to Board financial estimates and forecasts

Director of Finance and ICT Director of Finance and ICT

Compile and submit to the Board an annual business plan which takes into account financial targets and forecast limits of available resources. The business plan will contain: o a statement of the significant

assumptions on which the plan is based;

o details of major changes in workload, delivery of services or resources required to achieve the plan.

Chief Executive Director of Strategy, Planning and Performance

b) Monitoring: Devise and maintain systems of budgetary

control.Director of Finance and ICT Corporate Accountant

Monitor performance against budget Director of Finance and ICT Corporate Accountant

Delegate budgets to budget holders Chief Executive Director of Finance and ICT

Ensuring adequate training is delivered to budget holders to facilitate their management of the allocated budget.


Submit in accordance with the Independent Regulators requirements for financial monitoring returns


Identify and implement cost improvements Chief Executive All budget holders

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and income generation activities in line with the Business Plan

Preparation of: Annual Accounts Director of Finance and

ICTCorporate Accountant

Annual Report Chief Executive Corporate Secretary/ Head of Communications

c) Budget Responsibilities

Ensure that no overspend or reduction of income that

cannot be met from virement is incurred without prior consent of Board;

approved budget is not used for any other than specified purpose subject to rules of virement;

no permanent employees are appointed without the approval of the Chief Executive other than those provided for within available resources and manpower establishment.


Budget Holders

c) Authorisation of Virement:It is not possible for any officer to vire from non-recurring headings to recurring budgets or from capital to revenue / revenue to capital. Virement between different budget holders requires the agreement of both parties.

Chief Executive Refer To Table B Delegated Limits

15. Financial Procedures and Systems

a) Maintenance & Update on Trust Financial Procedures


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b) Responsibilities:- Implement Trust’s financial policies and

co-ordinate corrective action. Ensure that adequate records are

maintained to explain Trust’s transactions and financial position.

Providing financial advice to members of the Board of Directors and staff.

Ensure that appropriate statutory records are maintained.

Designing and maintaining compliance with all financial systems


16. Fire precautions Ensure that the Fire Precautions and

prevention policies and procedures are adequate and that fire safety and integrity of the estate is intact.


Head of Capital Planning

17. Fixed Assets

a) Maintenance of asset register including asset identification and monitoring


b) Ensuring arrangements for financial control and financial audit of building and engineering contracts and property transactions comply with CONCODE and ESTATECODE.

Director of Finance and ICT National Estates Manager

c) Calculate and pay capital charges in accordance with the requirements of the Independent Regulator


d) Responsibility for security of Trust’s assets including notifying discrepancies to the Director of Finance and ICT and reporting losses in accordance with Trust’s procedures

Chief Executive All staff

18. Fraud (See also 26, 36)

a) Monitor and ensure compliance with Minister for Health and Social Services Directions on fraud and corruption including the appointment of the Local Counter Fraud Specialist.

Chief Executive and Director of Finance and ICT

Local Counter Fraud Specialist.

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b) Notify Counter Fraud and Security Management Service and External Audit of all Frauds

All Staff Local Counter Fraud Specialist.

19. Funds Held on Trust (Charitable and Non Charitable Funds)

a) Management:Funds held on trust are managed appropriately.

Charitable Funds Committee Director of Finance and ICT

b) Maintenance of authorised signatory list of nominated fund holders.


c) Expenditure Limits Director of Finance and ICT Refer To Table B Delegated Limits

d) Developing systems for receiving donations Director of Finance and ICT Corporate Accountant

e) Dealing with legacies Director of Finance and ICT Corporate Accountant

See table B – Delegated financial limits


f) Fundraising Appeals ● Monitoring of Expenditure from Designated Fundg) Operation of Bank Accounts:

Managing banking arrangements and operation of bank accounts



Opening bank accounts Director of Finance and ICT Director of Finance and ICT

Nominating deposit taker Director of Finance and ICT Corporate Accountant

Placing transactionsh) Investments: ● Nominating Deposit Taker ● Placing transactions

Director of Finance and ICTCharitable Funds CommitteeDirector of Finance and ICTDirector of Finance and ICT

Corporate AccountantCorporate AccountantCorporate AccountantCorporate Accountant

i) Regulation of funds with Charities CommissionDirector of Finance and ICT Corporate Accountant

20. Health and Safety

Monitor and ensure statutory compliance with all legislation and Health and Safety requirements including control of Substances Hazardous to Health Regulations

Director of Workforce and OD National Risk and Health and Safety Manager

21. Hospitality/Gifts

a) Keeping of hospitality register Chief Executive Corporate Secretary

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b) Applies to both individual and collective hospitality receipt items. See Appendix B for limits.

All staff declarations required in Trust’s Hospitality Register

22. Infectious Diseases & Notifiable Outbreaks

Chief Executive Director of Quality and Nursing

23. Information Management & Technology

Financial Systems Developing financial systems in

accordance with the Trust’s IM&T Strategy. Implementing new financial systems to

ensure they are developed in a controlled manner and thoroughly tested.

Seeking third party assurances regarding financial systems operated externally.

All other Business Critical Systems


Ensure that contracts for computer services for financial applications define responsibility re security, privacy, accuracy, completeness and timeliness of data during processing and storage.


Ensure that risks to the Trust from use of IT are identified and considered and that disaster recovery plans are in place.

Developing Business Critical Systems in accordance with the Trust’s IM&T Strategy.

Developing new systems to ensure they are developed in a controlled manner and thoroughly tested.

Seeking third party assurances regarding Business Critical Systems operated externally.


Director of Finance and ICT Director of Finance and ICT



ICT Operations Manager ICT Operations Manager

ICT Operations Manager

24. Legal Proceedings

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a) Engagement of Trust’s Solicitors / Legal Advisors

Chief Executive Corporate Secretary who can nominate in relation to all matters

b) Approve and sign all documents which will be necessary in legal proceedings, i.e. executed as a deed.

Chief Executive/Chairman Corporate Secretary (to arrange/verify)

f) Sign on behalf of the Trust any agreement or document not requested to be executed as a deed.

Chief Executive Relevant member of Management Team (ie Director)(See table B for limits)

25. Losses, Write-off & Compensation

a) Prepare procedures for recording and accounting for losses and special payments including preparation of a Fraud Response Plan and informing Counter Fraud Management Services of frauds


b) Losses Losses of cash due to theft, fraud, overpayment & others.


Fruitless payments (including abandoned Capital Schemes)

Bad debts and claims abandoned.

Damage to buildings, fittings, furniture and equipment and loss of equipment and property in stores and in use due to:Culpable causes (e.g. fraud, theft, arson).

c) Reviewing appropriate requirement for insurance claims


g) A register of all of the payments should be maintained by the Finance Department and made available for inspection


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h) A report of all of the above payments should be presented to the Audit Committee at regular intervals


Special Payments Compensation payments by Court Order

Chief Executive Chief Executive/Director of Finance and ICT/Corporate Secretary

Exgratia Payments:-

To patients/staff for loss of personal effects Director of Finance and ICT/Corporate Secretary

For clinical negligence after legal advice Director of Medical and Clinical Services/Corporate Secretary

For personal injury after legal advice Director/ of Medical and Clinical Services/Corporate Secretary

Other clinical negligence and personal injury

Director of Medical and Clinical Services/Corporate Secretary

Other ex-gratia payments Director of Finance and ICT

26. Meetings

a) Calling meetings of the Trust Board Chairman Corporate Secretary

b) Chair all Trust Board meetings and associated responsibilities

Chairman Chairman

27. Medical

Clinical Governance arrangements Director of Medical and Clinical Services

Director of Medical and Clinical Services/Director of Quality and Nursing

Clinical Leadership Director of Medical and Clinical Services with Director of Quality and Nursing for nurse and Clinical Leadership

Consultant Paramedic/Assistant Director of Quality and Nursing

Programmes of clinical education Director of Workforce & OD National Training Manager

Clinical staffing plans Director of Medical and Clinical Services


Clinical Research Director of Medical and Clinical Services

Consultant Paramedic/Assistant

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Director of Quality and Nursing

Responsible officer for Medical Revalidation Director of Medical and Clinical Services

28. Non Pay Expenditure

a) Maintenance of a list of managers authorised to place requisitions/orders and accept goods in accordance with Table B


b) Obtain the best value for money when requisitioning goods / services


c) Non-Pay Expenditure for which no specific budget has been set up and which is not subject to funding under delegated powers of virement. (Subject to the limits specified above in (a)


d) Develop systems for the payment of accounts Director of Finance and ICT Shared Services Partnership (SSP)

e) Prompt payment of accounts Director of Finance and ICT SSP

f) Financial Limits for ordering / requisitioning goods and services

Director of Finance and ICT Refer To Table B Delegated Limits

g) Approve prepayment arrangements Director of Finance and ICT Director of Finance and ICT

29. Paramedic/Nursing

Compliance with statutory and regulatory arrangements relating to professional Paramedic/ practice.

Compliance with statutory and regulatory arrangements relating to professional Nursing and Midwifery practice


Director of Quality and Nursing

Consultant Paramedic/

Assistant Director of Quality and Nursing

Matters involving individual professional competence of paramedic/nursing staff.



Compliance with professional training and development of Paramedic/nursing staff.

Director of Medical and Clinical Services/ Director of Quality and Nursing


Quality assurance of Paramedic/nursing processes.



30. Patient Services Agreements

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DELEGATED MATTER DELEGATED TO OPERATIONAL RESPONSIBILITYa) Negotiation of Trust Contracts and Non

Commercial ContractsChief Executive Director of Finance and ICT

b) Quantifying and monitoring out of area treatments


c) Reporting actual and forecast income Director of Finance and ICT Corporate Accountant d) Costing Trust Contract and Non Commercial

ContractsDirector of Finance and ICT Corporate Accountant

e) Ad hoc costing relating to changes in activity, de -velopments, business cases and bids for funding


31. Patients’ Property (in conjunction with financial advice)

a) Ensuring patients and guardians are informed about patients’ monies and property procedures

Chief Executive Director of Service Delivery

b) Prepare detailed written instructions for the administration of patients’ property


c) Informing staff of their duties in respect of patients’ property

Director of Finance and ICT Director of Service Delivery

32. Personnel & Pay

a) Nomination of officers to enter into contracts of employment regarding staff, agency staff or consultancy service contracts

Chief Executive Director of Workforce & OD

b) Develop Human resource policies and strategies for approval by the Board including training, industrial relations.

Director of Workforce & OD Director of Workforce & OD

c) Authority to fill funded posts on the establishment with permanent staff.

d) The granting of additional increments to staff upon initial appointment.

Director of Workforce & OD

Chief Executive

Heads of Department in accordance with Trust policy


e) All requests for re-grading shall be dealt with in accordance with Trust Procedure

Director of Workforce & OD Director of Workforce & OD / Assistant Director of Workforce, Head of Operational HR

26


f) Establishments Additional staff to the agreed establishment

with specifically allocated finance.Director of Finance and ICT Corporate Accountant

Additional staff to the agreed establishment without specifically allocated finance.


Self financing changes to an establishment Director of Finance and ICT Corporate Accountant

g) Pay

Presentation of proposals to the Trust Board for the setting of remuneration and conditions of service for those staff not covered by the Remuneration Committee.

Chief Executive Director of Workforce and OD

Authority to complete standing data forms effecting pay, new starters, variations and leavers

Director of Workforce & OD Heads of Department

Authority to complete and authorise positive reporting forms (SVLS)

Director of Finance and ICT Heads of Department

Authority to authorise overtime Director of Workforce & OD/Director of Finance and ICT

Heads of Department

Authority to authorise travel & subsistence expenses


h) Leave (Note entitlement may be taken in hours) Director of Workforce & OD

Heads of Department./Line Managers

Annual Leave

- Approval of annual leave Individual Directors Line Manager

- Annual leave - approval of carry forward up to maximum of 5 days (and pro rata for part time staff)

Directors Head of Department

27


- Annual leave – approval of carry forward over 5 days (and pro rata for part time staff) (to occur in exceptional circumstances only)

Director of Workforce & OD Director of Workforce & OD

Special Leave

- Compassionate leave Director of Workforce & OD Heads of Department

Special leave arrangements for domestic/personal/family reasons

paternity leave carers leave adoption leave

(to be applied in accordance with Trust Policy)


Special Leave – this includesJury Service, Armed Services, School Governor (to be applied in accordance with Trust Policy)


Leave without pay Heads of Department

Time off in lieu Maternity Leave - paid and unpaid Director of Workforce & OD

Line /Departmental ManagerAutomatic approval within approved guidance

Sick Leave Director of Workforce & ODi) Extension of sick leave on pay Assistant Director of Workforce ,

Head of Operational HR in conjunction with Director of Workforce & OD

ii) Return to work part-time on full pay to assist recovery

Director of Workforce & OD Heads of Department/Heads of Service in conjunction with HR Business Partners

Study Leave Director of Workforce & OD Heads of Department

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DELEGATED MATTER DELEGATED TO OPERATIONAL RESPONSIBILITYi) Removal Expenses, Excess Rent and House

Purchases maximum £8,000

Authorisation of payment of removal expenses incurred by officers taking up new appointments (providing consideration was promised at interview)



Directors

Refer to Table B Delegated Limits

j) Grievance ProcedureAll grievances cases must be dealt with strictly in accordance with the Grievance Procedure

Director of Workforce & OD As per procedure

k) Authorised - Car Usersd) Leased care) Regular user allowance

Chief ExecutiveDirector of Finance and ICT

Relevant DirectorRelevant Director

l) Mobile Phone Users / Blackberries Director of Finance and ICT Relevant Director

m) Renewal of Fixed Term Contract

n) Approval of Secondary Employment



Head of Department on advice from Human Resources and Management Accountant Head of Department

o) Staff Retirement Policy

Authorisation of extensions of contract beyond normal retirement age in exceptional circumstances


Authorisation of return to work in part time capacity under the flexible retirement scheme.


p) Redundancy/Severance/Vers/Compromise Payments (see also Section 2 of Table B1 – Litigation Claims in relation to HR issues)

Remuneration Committee Director of Workforce & OD/ Director of Finance and ICT

29


q) Disciplinary Procedure (excluding Executive Directors)

r) Ensure that all employees are issued with a Contract of employment in a form approved by the Board of Directors and which complies with employment legislation.

s) Engagement of staff not on the establishment ● Management Consultants

Chief Executive


Chief Executive

To be applied in accordance with the Trust’s Disciplinary Procedure

Director of Workforce & OD/Heads of Service

Refer to Table B

Booking of bank staff

a. nursing Director of Medical and Clinical Services/Director of Service Delivery/Director of Quality and Nursing

Heads of Departments

b. other Director of Service Delivery Heads of Departments

Booking of agency staff

a. nursing Director of Medical and Clinical Services/Director of Service Delivery/Director of Quality and Nursing

Heads of Department

b. other Relevant Director Heads of Department

33. Quotation, Tendering & Contract Procedures

a) Services: Best value for money is demonstrated for all

services provided under contract or in-house


Nominate officers to oversee and manage the contract on behalf of the Trust.

Chief Executive Heads of Department

b) Competitive Tenders: Authorisation Limits Chief Executive Refer To Table B Delegated Limits Maintain a register to show each set of

competitive tender invitations despatched.Chief Executive SSP

30


Receipt and custody of tenders prior to opening

Chief Executive SSP

Opening Tenders Chief Executive SSP

Decide if late tenders should be considered Chief Executive Director of Finance and ICT /Corporate Secretary

Ensure that appropriate checks are carried out as to the technical and financial capability of the firms invited to tender or quote.


c) Quotations Chief Executive Refer To Table B Delegated Limits

d) Waiving the requirement to request tenders - subject to SOs (reporting to the

Board)Chief Executive Refer To Table B Delegated Limits

quotes - subject to SOs Director of Finance and ICT Corporate Accountant

34. Records

a) Review and ensure Trust’s compliance with the Records Management Code of Practice


b) Ensuring the form and adequacy of the financial records of all departments


35. Reporting of Incidents to the Police

a) Where a criminal offence is suspected criminal offence of a violent nature arson or theft other

b) Breaches of Professional Standard

c) Where a fraud is involved (reporting to the Directorate of Counter Fraud Services)

Chief Executive

Relevant Director


Manager On-call/ Head of Department

Relevant Director

Local Counter Fraud Specialist

d) Deciding at what stage to involve the police in cases of misappropriation and other irregularities not involving fraud or corruption.


36 Risk Management

31


a) • Ensuring the Trust has a Risk Management Strategy and a programme of risk management

Chief Executive National Risk and Health and Safety Manager

b) • Developing systems for the management of risk.

Corporate Secretary National Risk and Health and Safety Manager

c) Developing incident and accident reporting systems


Consultant Paramedic

d) • Compliance with the reporting of incidents and accidents


All staff

37. Seal

a) The keeping of a register of seal and safekeeping of the seal

Chief Executive Corporate Secretary

b) Attestation of seal in accordance with Standing Orders

Chairman /Chief Executive Chairman or Non Executive Director and the Chief Executive or his nominated Director

c) Property transactions and any other legal requirement for the use of the seal.

Chairman /Chief Executive Chairman or Non Executive Director and the Chief Executive or his nominated Director

38. Security Managementa) Provide an oversight and assurance within the

context of security management within NHS Wales; working in conjunction with the following leads on specific functional areas of security management Finance, Fraud etc

Estates, Premises Security etc

ICT

Information/Data Security/Records Management

Violence & Aggression

Patient Confidentiality

Chief Executive

Chief Executive

Chief Executive

Chief Executive

Chief Executive

Chief Executive

Chief Executive





Director of Workforce and OD Director

Director of Medical and Clinical Services (as Caldicott Guardian).

32

DELEGATED MATTER DELEGATED TO OPERATIONAL RESPONSIBILITY39. Setting of Fees and Charges (Income)

a) Private Patient, Overseas Visitors, Income Generation and other patient related services.


b) Non patient care income Director of Finance and ICT Corporate Accountant

c) Informing the Director of Finance and ICT of monies due to the Trust

Director of Finance and ICT All Staff

d) Recovery of debt Director of Finance and ICT Corporate Accountant

e) Security of cash and other negotiable instruments


40. Stores and Receipt of Goods

a) Responsibility for systems of control over stores and receipt of goods, issues and returns

Director of Finance and ICT SSP /Heads of Service/ Heads of Department as appropriate.

b) Stocktaking arrangements Director of Finance and ICT Corporate Accountant

c) Responsibility for controls of pharmaceutical stock.


Heads of Department as appropriate

This scheme only relates to matters delegated by the Board to the Chief Executive and their Directors, together with certain other specific matters referred to in SFIs.

Each Director is responsible for delegation within their department. They shall produce a scheme of delegation for matters within their department, which shall also set out how departmental budget and procedures for approval of expenditure are delegated.

33

Table B – Delegated Financial Limits

All thresholds are inclusive of VAT irrespective of recovery arrangements.Details of procurement thresholds from 31 January 2006 are provided (net of VAT)

Proposed Financial Limits (Subject to funding available in budget) Includes:-1 CHARITABLE FUNDS

Charitable Funds Committee Over £50,000Director of Finance and ICT Up to £50,000 – but reported to Management TeamDirector of Service Delivery £251 to £25,000Fundholder/Head of Service Up to £250

2.LITIGATION CLAIMS

Limits for each Payment

Chief Executive Above £100k Medical Negligence and other litigation payments made on the advice of Welsh Risk Pool /Legal and Risk Services. Board to be informed of all cases over £25k retrospectively

Director of Finance and ICT Up to £100kCorporate Secretary Below £25kHeads of Service , Corporate Accountant, Assistant Corporate Secretary Up to £10kAny litigation settlement claims in relation to employment/HR issues which are not subject to any reimbursement by the WRP/L+RS will require the approval of the Chief Executive in consultation with the Director of Finance and ICT and Director of Workforce and Organisational Development up to a value of £50k, these are then to be reported retrospectively to Remuneration Committee. Any such settlements over £50k will require prior authorisation from Remuneration Committee.

3. LOSSES AND SPECIAL PAYMENTSBoard (and subsequently WAG)Chief ExecutiveExecutive Directors/DirectorsHeads of Service /Heads of DepartmentBudget Holders

£250k and aboveBelow £250KUp to £100kUp to £50KUp to £10k

LossesFruitless payments (including abandoned capital schemes)All VERS payments above £50k to be referred to WG and then approved by Remuneration Committee

Other Losses

34

Proposed Financial Limits (Subject to funding available in budget) Includes:-Director of Finance and ICTChief ExecutiveTrust Board (and subsequently WG)

Up to £10kBelow £50k£50k and above

Losses of cash due to theft, fraud, overpayment and others

Bad debts and claims abandoned

Damage to buildings, fittings, furniture and equipment and loss of equipment and property in stores and in use due to culpable causes (e.g. fraud, theft, arson etc)

4. REQUISITIONING GOODS AND SERVICES AND APPROVING PAYMENTS4.1 Agency Staff:-

Board

Chief Executive Executive Directors /Directors Heads of Service/Heads of Department Budget Holders

Over £250k

Up to £250kUp to £100kUp to £50k

Up to £10k

Any agency staff, including medical locums

No other managers can authorise use of agency staff

4.2 Building and Engineering Works (non capital):-

BoardChief ExecutiveExecutive Directors/DirectorsHeads of Service Heads of DepartmentBudget Holders

Over £250kUp to £250kUp to £100kUp to £50k

Up to £10k

4.3 Call Off Orders(Annual Value):-High cost medical consumables, provisions, routine supplies, excluding locums or agency staff.Board Over £250k

35

Proposed Financial Limits (Subject to funding available in budget) Includes:-

Chief ExecutiveExecutive Directors/DirectorsHeads of Service /Heads of DepartmentBudget Holders

Up to £250kUp to £100kUp to £50k

Up to £10k

4.4 Capital Expenditure (Subject to annual programme being approved by Trust Board)Board Chief ExecutiveExecutive Directors/Directors and Corporate Accountant

Over £250kUp to £250kUp to £100k The Board to approve cases outside

discretionary allowances. Capital programme agreed annually by the Board.

Heads of Service/Heads of Department Up to £50kBudget Holders Up to £10k

4.5 Information Technology:-Board Over £250k

Major IT systems, software purchase, p.c. and printer purchase, networking, computer consumables. Includes software or hardware maintenance contracts.

Chief Executive Up to £250kExecutive Directors/Directors Up to £100kHeads of Service/Heads of DepartmentBudget Holders

Up to £50kUp to £10k

4.6 Management Consultants (Incl Professional Services):-Trust Board Over £100,000Chief Executive Up to £100,000Executive Directors / Directors Up to £10,000

4.7 Periodic Payments (Invoice Value):-

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Proposed Financial Limits (Subject to funding available in budget) Includes:-BoardChief ExecutiveExecutive Directors/DirectorsHeads of Service/Heads of DepartmentBudget Holders

In relation to Gas, Electricity, Council tax.Telephone, Water and Fleet Fuel invoices, due to the high level of expenditure on a recurring basis, payments up to a value not exceeding £750,000 can be authorised by the Director of Finance and ICT or the Chief Executive

Over £250kUp to £250kUp to £100kUp to £50k

Up to £10k

4.8 Removal Expenses:-

Director of Workforce and OD Up to £8,0004.9 Services (Inc Maint. Contracts) over lifetime of contract:-

Board Over £250k

Routine maintenance contracts, clinical services (eg MRI), legal services, audit, clinical waste etc

Chief Executive Up to £250kExecutive Directors/Directors Up to £100kHeads of Service/Heads of Departments Up to £50kBudget Holders Up to £10k

4.10

All Other Requisitions:-

BoardChief ExecutiveExecutive Directors/Directors

Over £250kUp to £250kUp to £100k

Heads of Service/Heads of Department Up to £50k

Budget HoldersUp to £10k

5. QUOTATIONS AND TENDERS Quotations- a minimum of 3 written quotations for goods/services must be sought where the anticipated value is likely to be above £5,000.

37

Proposed Financial Limits (Subject to funding available in budget) Includes:-

Competitive Tenders- a minimum of 3 written competitive tenders for goods/services must besought where the anticipated value is likely to beabove £25,000.

Tenders for Supplies and Services above the limit setEU Procurement matters for works above set limitsmust be sought in compliance with EC Directives (Updated Jan 2008) (OJEU Regulations) as appropriate. All Tenders and Quotations must be sought, registered, and opened via the SSP.

Authorisation of Tenders and Competitive Quotations Providing all the conditions and circumstances set out in these Standing Financial Instructions have been fully complied with, formal authorisation and awarding of a contract may be decided by the following staff to the value of the contract as follows:Designated budget holders up to £10kHeads of Department up to £50kDirectors up to £100kChief Executive up to £250kChairman up to £250kTrust Board over £250kThese levels of authorisation may be varied or changed and need to be read in conjunction with the Trust Board’s Scheme of Delegation.Formal authorisation must be put in writing. In the case of authorisation by the Trust Board this shall be recorded in their minutes.Exceptions and Instances where formal tendering need not be applied will require authorisation in the form of a request to waive SFIs (pre numbered document from SSP) and authorisation in advance from the Director of Finance and ICT or Corporate Accountant (or in their absence the Corporate Secretary)

6. VIREMENT See S0/SFIs 2.9 and 2.10 Conditions:-

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Proposed Financial Limits (Subject to funding available in budget) Includes:-Trust Board Over £50,000 p.a. Trust must still meet Financial TargetsChief Executive Up to £50,000 p.a. Total Trust budget remains underspentDirector of Finance and ICT Up to £25,000 p.a. Total Trust budget remains underspent

7. HOSPITALITY/GIFTS

All Employees

Any gifts/hospitality estimatedat being at or above £10 mustbe recorded in the Gifts and Hospitality Register kept bythe Corporate Secretary.Any collective gifts where theCollective value is thought toExceed £10 (i.e. from acompany given to a numberof individuals in the Trust e.g.mugs, wine etc) must be notified to the Corporate Secretary and will be recordedas a single entry in the Gifts and Hospitality Register. All staff should complete declaration forms even wheregifts/hospitality is refused.

8. LEASE AGREEMENTS

Leases – Authorised Signatories(ie those not required to be executed as a deed). Over 250k

Up to £250k

Up to £100k

To be authorised by the Board and then signed by Chief Executive and Chair

Chief Executive or a nominated Deputy.

Relevant Director or Corporate Secretary (NB copies of all leases are to be kept once signed by the Estates Manager for property related leases and by the Corporate Secretary for all other leases/contracts)

39

SCHEDULE 6

Management Team Structure/Operating Arrangements

Management Team

1) *Chief Executive2) *Director of Finance and ICT3) *Director of Medical and Clinical Services 4) *Director of Quality and Nursing5) *Director of Workforce and Organisational Development6) Director of Service Delivery7) Director of Strategy, Planning and Performance 8) Corporate Secretary

*Executive Director Posts

Organisational Chart – see Appendix 1 Accountable Officer Memorandum see Appendix 2 Management Team Portfolios– see Appendix 3

40

SCHEDULE 7

Non Executive Directors

NAME 1st Term 2nd Term 1st/2nd Term

Mick Gianniasi (Chair)

1 September 2013 – 31 March 2016

1

John Morgan 1 October 2009 – 31 March 2014

01 April 2014 – 31 March 2017

2

David Scott 01 April 2014 – 31 March 2017

1

Pamela Hall 01 April 2014 – 31 March 2018

1

VacancyJames Mycroft 01 April 2014 –

31 March 20161

Emrys Davies 01 April 2014 – 31 March 2017

1

Martin Woodford 07 April 2014- 31 March 2018

1

Chairmanship and Membership of Committees – Appendix 4Champions/Leads/Outside Bodies Schedule – Appendix 5PADR/Accountability Framework – Appendix 6

41

APPENDIX 1

42

CHIEF EXECUTIVE

Corporate Secretary

Director of Strategy,

Planning and Performance

Executive Director of

Finance and ICT

Director of Service Delivery


Workforce and Organisational Development

Executive Director of Quality and Nursing


Medical and

Clinical Services

APPENDIX 2ACCOUNTABLE OFFICER MEMORANDUM FOR CHIEF

EXECUTIVES OF NHS TRUSTS

Introduction

1 This Memorandum describes your responsibilities as an Accountable Officer. In doing so, it sets out:

● The responsibilities I have conferred on you;● The exercise of your responsibilities in relation to the role of your NHS Trust: its governing Board and overall governance framework; and● The direct relationship between your responsibilities as Accountable

Officer, and my overall role and responsibility as additional Accounting Officer, for funds drawn by Welsh Ministers for the National Health Service in Wales.

Your specific responsibilities as an Accountable Officer

2 The essence of your role as an Accountable Officer is a personal responsibility for the propriety and regularity of the public finances for which you are answerable.

3 In particular, you are responsible for:

● the overall organisation, management and staffing of the Trust and its arrangements related to quality and safety of care as well as matters of finance, together with any other aspect relevant to the conduct of the Trust’s business in pursuance of the strategic direction set by the Trust Board, and in accordance with its statutory responsibilities;

● ensuring that all items of expenditure, including payments to staff, fall within the legal powers of the Trust;

● acting within the scheme of delegations and ensuring that you comply with guidance on classes of payment that you should authorise personally;

● ensuring that in delegating functions to officers you are satisfied of their ongoing capacity and capability to deliver on those functions, facilitating access to the information they need, ongoing training and development, as well as professional or specialist advice where appropriate;

● prudent and economical administration, for the avoidance of waste and extravagance, and for the efficient and effective use of all resources;

● ensuring that the assets for which you are responsible, such as land, buildings or other property (including stores and equipment) are properly safeguarded, particularly:

♦ information, including systems for maintaining the trust of patients and the public by ensuring that the Trust will store, share and use information, including their personal information safely, and securely, and

♦ land, buildings or other property (including stores and

43

equipment);● ensuring that, in the consideration of policy proposals relating to the

expenditure or income for which you have responsibility, all relevant financial considerations (including any issues of propriety, regularity or value for money) are taken into account;

● ensuring that risks to the achievement of the Trust’s objectives and fulfilment of its statutory responsibilities are identified, that their significance is assessed, and that a sound system of internal control is in place to manage them;

● implementing an appropriate framework of assurance covering all aspects of Trust business, ensuring that research and evaluation work is planned so that strategic objectives and spending programmes for which you have responsibility are routinely evaluated to assess their effectiveness and value for money;

● ensuring, as a key source of your internal assurance, that you establish arrangements for internal audit in accordance with the International Standards for the professional practice of Internal Audit as adopted by the NHS in Wales, Welsh Assembly Government and HM Treasury, and ensuring that appropriate action is taken in response to reports produced by Internal Audit;

● ensuring that there are appropriate arrangements to counter fraud and that procedures for dealing with suspected cases of fraud are complied with;

● ensuring that the Trust co-operates fully with external auditors, regulators and inspectors – including the Wales Audit Office (WAO), Healthcare Inspectorate Wales (HIW), and the Care and Social Services Inspectorate Wales (CSSIW), and ensuring that appropriate action is taken in response to any reports produced by such bodies;

● signing the Trust’s accounts and, in doing so, accepting personal responsibility for their proper presentation fully supported by sound financial procedures and records, and in accordance with the Trust Accounts Directions issued by Welsh Ministers, ensuring that losses or special payments are properly identified and handled in accordance with defined requirements.

The exercise of your Accountable Officer role within the Trust framework

4 Your role as Accountable Officer is to see that the Trust carries out its responsibilities in a way that fulfils its duty to ensure the quality and safety of healthcare and the proper stewardship of public money. In fulfilling your role as Accountable Officer, you must also take account of your corporate responsibilities and accountability to the Trust Board of which you are a member.

5 In exercising your role as Accountable Officer therefore, you must do so in accordance with the principles set out within Managing Welsh Public Money and the framework and standards of good governance set for the NHS in Wales. You should also assist the Chair in ensuring that his/her establishment and implementation of the Trust’s governance framework accords with these standards and principles.

44

Partnership Working

6 The Trust may work in partnership with other organisations to achieve its strategic aims and objectives. Your Trust may also contribute to a joined up activity led or hosted by another organisation in pursuit of its objectives. You must ensure that the wider impact of the activities for which you are responsible are properly identified and, where appropriate, taken into account in determining the governance and accountability arrangements overseeing such work. Specifically, you will need to ensure that the governance arrangements are formally recorded and that you put in place appropriate arrangements to provide you with assurance on those areas for which you are accountable.

7 Accountable Officers may take joint responsibility for the delivery of a service through joint arrangements that involve the pooling of budgets. Such arrangements may be handled under a specific statutory authority, e.g., Section 33 of the National Health Service (Wales) Act 2006. Where you and another Accountable Officer or Officers take joint responsibility, you will need to ensure that there is absolute clarity on all aspects of the service for which you are responsible and accountable. Specifically, you must set down, in a formal agreement, the governance and financial accounting arrangements, including audit and assurance requirements, in accordance with any requirements determined by the Assembly Government. You are reminded of the guidance issued by the Assembly Government, which can be found at:

http://new.wales.gov.uk/topics/improvingservices/poolbudgets/;jsessionid=s7hkJv0JWLnqpBV56hykHzhK2znyP4dppDnRLhc0JL4qNknk9KSD!-1130397166?lang=en

8 You must ensure that where your Trust contracts with a third party for the provision of goods or services it does so in accordance with all relevant legislation together with any requirements determined by the Assembly Government. In doing so, you must make sure that appropriate systems are in place to provide assurance that such funds are allocated in accordance with the terms of the Contract and are not misappropriated.

Advice to the Board

9 As Accountable Officer of the Trust, you have a responsibility to see that appropriate advice is tendered to the Board on all matters of financial propriety, regularity and value for money, and more broadly on all considerations of prudent and economic administration, efficiency and effectiveness. You will need to determine how and in what terms such advice should be given, and whether in a particular case to make specific reference to your own duty as Accountable Officer. You must inform me of any such issues that you consider to be of a novel and contentious nature, and of any action you propose to take before tendering advice to the Trust Board.

45




10 If the Board or the Chair is contemplating a course of action which you consider would infringe the requirements of propriety, regularity or value for money, you should set out in writing to the Chair and the Board your objection to the proposal, the reason for your objection and your duty to inform me and the external auditors if your advice is overruled. Wherever possible, you should inform me before the Board takes its decision. If it is not possible, due to the urgency of the situation, to notify me beforehand, and if the Board decides nonetheless to proceed against your advice, you should seek a written instruction to take the action in question. Your request for the instruction and the instruction itself should be communicated to me and to the external auditors without undue delay, and before the decision is implanted, so that I can if necessary intervene with the Board and inform Welsh Ministers.

Absence of Accountable Officer

11 As an Accountable Officer you should ensure that you are generally available for consultation and that in any temporary period of unavailability, e.g., due to illness, or during normal periods of annual leave, there will be a senior officer of the Trust who can act on your behalf if required.

12 If it becomes clear that you are so incapacitated that you will not be able to discharge these responsibilities over a period of four weeks or more, I should be notified so that I can formally designate an officer as Acting Accountable Officer pending your return. The same applies if, exceptionally, you plan an absence of more than four weeks during which you cannot be contacted.

The Relationship between the Chief Executive, NHS Wales as Accounting Officer and Accountable Officers within NHS Wales

13 As Accounting Officer for the NHS in Wales, I am responsible for ensuring that there is a high standard of financial management across NHS Wales as a whole.

14 It is within that framework that you as an Accountable Officer are responsible for the Budgets assigned to you. I will hold you to account for the exercise of your responsibilities as Accountable Officer directly.

15 I may be summoned to appear before the Audit Committee or the Public Accounts Committee (PAC) to deal with questions arising from NHS accounts or from a wider examination into the economy, efficiency and effectiveness with which the NHS has used its resources.

16 I am regarded as the main respondent to any enquiries about matters relevant to the proper stewardship of funds within the NHS in Wales, especially where the issues are wider than an individual Trust although I may require you to accompany me. The Audit Committee or the PAC may call other witnesses, and you may be required to appear before the

46

Committee separately, in your own right, depending on the matter under consideration. I shall in any event look to you for support and information in my dealings with the National Assembly for Wales, its Audit Committee and the PAC.

17 In practice, you will have delegated authority widely within your Trust, but cannot on that account disclaim responsibility. Nor, by convention, can you decline to answer any questions where the events took place before your designation. The Audit Committee and the PAC may be expected not to press personal responsibility in circumstances where matters it is considering relate to a period before your designation.

18 High importance is attached to accuracy of evidence and the responsibility of witnesses to ensure this. You must provide me with, and ensure that you

are yourself adequately and accurately briefed on matters that are likely to arise at the meeting. Either Committee may be asked for leave to supply information not within your immediate knowledge by means of a later note. If it is discovered subsequently that the evidence provided to the Committee has contained errors, these should be made known to the Committee and rectified at the earliest possible moment.

47

APPENDIX 3DIRECTOR PORTFOLIOS

Director of Service Delivery Executive Director of Finance and ICT

Emergency Medical Service ( Unscheduled Care)

Patient Care Service( Planned Patient care)

Control – including EMS,PCS,Resources.

NHSDW Service Implementation of Business

Continuity, Civil Contingencies and Emergency Planning

Operational Management of CFR/Co-responder schemes

Fleet management and deployment including stores and logistics

Member of Strategic Planning Committee

Financial Health, Planning and Strategy Financial Accounting Procurement Financial Assurance, Governance and

Risk Management Managing financial functions;

- Audit- Counter Fraud- SLAs- BSP/Shared Services- Car Leasing- Contract management

Information and Communications Technology

Health Informatics, Records Management and Data Protection

Senior Information Risk Owner (SIRO) Capital Planning and Estates including

facilities management, waste, environmental management and sustainability

Health Courier Service

Lead Director for Audit CommitteeMember of Strategic Planning Committee

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Executive Director- Medical and Clinical Services

Director- Strategy, Planning and Performance

Executive Director - Workforce and Organisational Development

Executive Director of Quality and Nursing

Clinical/Professional Leadership of Paramedicine

Specialist Medical Advice

Professional Practice and Review

Research & Development

Partners in Health PGDs 1000 Lives Clinical Governance,

Quality& Concerns Prevention and Public

Health Emergency Planning Safeguarding Clinical Effectiveness Overall management of

the process for Concerns

- ‘Putting Things Right’- Coroners- Claims

Joint Lead for Quality, Safety and Governance Committee

Corporate Business Planning and co-ordination of Service Planning Process

Performance Commissioning Programme

Management and Modernisation Programme

Service Improvement Unscheduled Care and

Planned Care Development

Joint Lead Director for Strategic Planning Committee

Strategic HR and Organisational Development

Operational HR Workforce

Policies and practice

Education and Development

Talent Management

Leadership and Management development

Staff Engagement and Partnership Working

Equality and Diversity

Workforce Planning and Modernisation

Violence and Aggression

Health ,Safety and Wellbeing at Work

Volunteer Strategy

Joint Lead Director for Strategic Planning Committee

Lead for Remuneration Committee

Nursing Strategy• Professional Nurse Leadership• Professional Nurse Regulation• Provide support for the establishment of the Clinical Contact Centre• Fundamentals of Care and Patient Experience• Career Framework for Nursing• Partners in

Health• Quality (inc

QDP)• Caldicott

Guardian• Infection

Prevention and Control

Joint Lead Director for Quality Safety and Governance

The following post is not a Director role but included for completeness in respect of portfolios

Corporate Secretary

• Corporate Governance• Legal Services• Freedom of Information• Corporate Communications• Welsh Language• Strategic Risk Management• Coordination of all external inspections

49

APPENDIX 4

Chairmanship & Membership of Committees (including Membership of the Strategic Transformation Board)

Audit Committee (5 NEDS) Chairman Quorum

Non Executive DirectorsDavid Scott David Scott 3 (1 of whom to be

Chair or Vice Chair of the Committee)

Pam HallJohn MorganMartin WoodfordEmrys DaviesQuality, Delivery Committee (5 NEDS)Emrys Davies Emrys Davies 3 (1of whom should

be the Chair or Vice Chair of the Committee)

Pam HallJohn MorganJames MycroftMartin WoodfordStrategic Transformation Board All Executive Team Chief Executive No formal quorum

Non Executive Directors (4)James Mycroft (Communication, Performance, Organisation Culture)

David Scott (Modernising the Workforce)Martin Woodford (Resource Utilisation)Vacancy (Clinical Transformation)

Remuneration & Conditions of Service Committee (4 NEDS)

Non Executive DirectorsM Giannasi M Giannasi 3

50

James MycroftDavid ScottMartin Woodford

(Chief Executive and Director (or nominee) of Workforce & Organisational Development to be ex officio members (except on issues relating to their remuneration & terms & conditions of service)

Charitable Funds Committee (4 NEDS + 2 Exec Directors)

Non Executive DirectorsJohn Morgan John Morgan 3 (2 NEDS, I of

whom is Chair or Vice Chair and 1 Director)

Pam HallEmrys DaviesVacancyExecutive DirectorsDirector of Service DeliveryDirector of Finance and ICT

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Appendix 5

The Model Standing Orders, Reservation and Delegation of Powers and Standing Financial Instructions, state that the “Chair will ensure that individual Board members are designated as lead roles or “champions” as required by the Assembly Government or as set out in any statutory or other guidance.

Below is a summary of the statutory and other guidance setting out a requirement for a Board Lead or “ champion “.

1. Legislation

Title Extract Board Level/ Executive Lead

Area of Responsibility

National Health Service, Wales - Directions To NHS Trusts And Powys Local Health Board, September 2006.

Ministerial Letter ML031 09

Section 2(a): Each NHS Trust must nominate and publicise the nomination and identity of one of its non-executive directors to undertake the following: (a) to act as a ‘patient’s champion’ on issues relating to cleaning, hygiene and infection management;

Non-Executive Director

Emrys DAVIES

Cleaning, Hygiene and Infection Management

The Children’s Act 2004, Chapter 31

A Local Health Board must—

(a) appoint an officer, to be known as the Board’s “lead officer for children and young people’s services”, for the purposes of the Board’s functions under section 25; and

(b) designate one of the Board’s members who is not an officer as its “lead member for children and young people’s services” to have the discharge of those functions as his special care.

(3) An NHS trust to which section 25 applies must—

(a) appoint an executive director, to be known as the trust’s “lead executive director for children and young people’s services”, for the purposes of the trust’s functions under that section; and

LHBsLead Officer and Lead Member

TrustsLead Executive Director and lead Non-Executive Director

DIRECTOR of MEDICAL AND CLINICAL SERVICES AND (NON EXEC DIRECTOR)

Children and young people’s services

52

http://www.opsi.gov.uk/acts/acts2004/ukpga_20040031_en_1

http://www.opsi.gov.uk/acts/acts2004/ukpga_20040031_en_1

http://howis.wales.nhs.uk/doclib/EH-ML-031-09.pdf

http://howis.wales.nhs.uk/doclib/EH-ML-031-09.pdf

http://cymru.gov.uk/legislationcs/inforcenonsi/nationalhealth/DirectNHSTrustsPowysLHB2006e.doc;jsessionid=vbnTK1ZY5FdqJdLPB5pHMvMXZNVhQD7bGmLv121wJQCHLJHpcFzw!1981341735?lang=en





(b) designate one of the trust’s non-executive directors as its “lead non-executive director for children and young people’s services” to have the discharge of those functions as his special care.

2. Welsh Health Circulars/Ministerial Letters

Title Extract Board Level/ Executive Lead Area of Responsibility

WHC 2003(108) The Nomination of Design Champions

All NHS Trusts, including Local Health Boards, should appoint a member of their Board as their Design Champion to ensure that the principles of good design are reflected at every stage.

Board Member

Martin WoodfordAll schemes, which have an impact on the patient environment, should be championed; whether they are refurbishments or new build projects; financed either privately or publicly.

WHC (2008) 002 Strengthening Welsh Language provision within NHS services in Wales

Every NHS organisation should have nominated a Welsh Language Champion (ideally a board member) who is able to drive the strategic agenda forward.

Ideally, a Board Member

Emrys DaviesWelsh Language

Ministerial Letter 30/10/08: Delayed Transfers of Care

A named Executive Director level lead is identified in each organisation to be held accountable for performance.

All Executive Directors Delayed Transfers of

Care

3. National Service Frameworks


NSF for Children, Young People & Maternity Services

2.52 There is a lead officer and lead member in each LHB; a lead executive and non-executive in each NHS trust and a Lead director and lead member for each LA for children and young people. They are responsible for co-

Lead Officer and Lead Member in each LHB; a lead Executive and non-Executive in each NHS Trust

Children and young people’s services

53

http://www.wales.nhs.uk/sites3/home.cfm?OrgID=441



http://howis.wales.nhs.uk/doclib/WHC(2008)002.pdf



http://howis.wales.nhs.uk/whcirculars.cfm?search=champion




ordinating and monitoring the implementation of the child protection procedures in line with Working Together to Safeguard Children13 and local ACPC procedures.

DIRECTOR OF MEDICAL AND CLINICAL SERVICES AND VACANCY (NON EXECUTIVE DIRECTOR)

Older People NSF

The Strategy for Older People called for each Local Authority Executive to designate an Older Person’s ‘Champion’, and similar leadership is also required at managerial level within local authorities, NHS Trusts and Local Health Boards. Each Chief Executive must be responsible and accountable, where appropriate through a delegated named leader, for ensuring that older people, as the largest population group and main users of health and social services, become and remain a priority within their respective organisations and partnerships. They will be responsible for ensuring that older people’s needs are reflected in local Health, Social Care and Wellbeing strategies, and are met by the policies and practices of their respective organisations.

‘Champion’ within NHS Trusts and Local Health Boards – at managerial level.

DIRECTOR OF MEDICAL AND CLINICAL SERVICES AND James MYCROFT (NON EXECUTIVE DIRECTOR)

Older People

54

http://www.wales.nhs.uk/sites3/home.cfm?orgid=439

4. Other



Ministerial Taskforce on Violence and Aggression in NHS (Wales) Report and Recommendations March 2008

Violence and Aggression GuidanceAudit Committee Report - NHS taking steps to protect staff from violence and aggression

All-Wales NHS Trust Boards should appoint an appropriate Executive level person to become a ‘V&A champion’ who will be responsible formonitoring performance and reviewing incidents of violence and aggression As well as the dissemination of organisational learning from reported incidents. This individual should also update the Board at leastquarterly.

(Extract from Audit Committee report) In May 2008, the Minister for Health and Social Services appointed an all-Wales champion to help take forward the recommendations of the Task Force. By November 2008, the Minister’s nominated lead and the new director ‘champions’ from each NHS Trust had drafted an employers’ action plan with 26 specific actions to be taken forward by health bodies. Each NHS Trust is expected to have agreed a detailed action plan by the end of February 2009 setting out how they will deliver those specific actions that have been agreed by the Minister’s nominated lead.

Executive level person

DIRECTOR OF WORKFORCE AND OD

David SCOTT (NON EXECUTIVE DIRECTOR)

Violence and aggression

The National Health Service (Concerns, Complaints and

Section 2 of the Regulations requires the following key

Concerns/Redress

55

http://assembly/cabinet/content/statements/2008/8.4.08%20violence%20and%20aggression.doc

http://assembly/cabinet/content/statements/2008/8.4.08%20violence%20and%20aggression.doc



Redress arrangements (Wales) Regulations 2011

appointments:-

Strategic Oversight

Responsible Officer

Senior Investigating Manager

Non Executive Director/Independent Member (James Mycroft)

Director of Medical and Clinical Services.

Head of Clinical Services

Caldicott: Principles into Practice (Section 2 - Being a Caldicott Guardian)

Caldicott Guardian

2.11 With the development and growing expertise of those involved in Information Governance since Guardians were first appointed there is agrowing trend towards appointing Caldicott Leads who are Information Governance specialists and who support the role of the Guardian.However it is most important that responsibility for the oversight of the protection of patient-identifiable information is not downgraded in statusand remains in the sight and influence of a post holder who is a member of the Board. In larger organisations, an appropriate post-holder might be a Board Level Clinician while in a smaller one it might be a Board member with Clinical Governance responsibilities.

Board Level Clinician in larger organisations or a Board member with clinical governance responsibilities in smaller organisations.

DIRECTOR OF QUALITY AND NURSING

Pam HALL (NON EXECUTIVE DIRECTOR)

Patient information

WHC(2007)034 “Healthy Sustainable Wales The NHS Contribution – A Sustainable Development Toolkit

Designate a Board Lead and designate a co-ordinator with responsibility for overseeing the development and

Board Lead

VACANCY (NON EXEC DIRECTOR)

Sustainable development

56



http://howis.wales.nhs.uk/whcirculars.cfm?search=Caldicott



for NHS Bodies in Wales ( page 6 )

implementation of a healthy sustainable Wales

WHC (2003)88 Improving Health in Wales: Signposts Two – Putting Public and Patient Involvement into Practice

Under WHC (2003)88 Improving Health in Wales: Signposts Two – Putting Public and Patient Involvement into Practice, as part of their responsibilities, all Trusts and Local Health Boards should nominate an executive director and non-executive director/non-officer to take lead responsibility for PPI

Executive director and Non-executive director/non-office member

DIRECTOR of QUALITY AND NURSING/Emrys DAVIES (NON EXEC DIRECTOR)

Public Patient Involvement

The Security Management Framework for NHS Trusts in Wales

Trusts are to have a single Executive Director with lead responsibility for the management of security across the organisation

Executive Director

DIRECTOR OF FINANCE AND ICT

Security Management

Emergency Planning –for emergency preparedness on behalf of the organisation’.Emergency Planning

The Wales Emergency Planning Guidance states that ‘The Chief Executive Officer must ensure that an Executive Director of the Board is designated to take responsibility

Executive Director

DIRECTOR OF SERVICE DELIVERY

John MORGAN (NON EXEC DIRECTOR)

Emergency Planning

STAKEHOLDER REFERENCE GROUP MEMBERSHIP

(a) Abertawe Bro Morgannwg University (AMBU) – Director of Quality and Nursing

(b) Aneurin Bevan –Director of Workforce and OD

(c) Betsi Cadwaladr University –Director of Medical and Clinical Services

(d) Cardiff and Vale University – Director of Service Delivery

(e) Cwm Taf – Director of Finance and ICT

(f) Powys – Chief Executive

(g) Hywel Dda –Director of Strategy Planning and Performance57

http://wales.gov.uk/resilience/home/wales-resilience/?lang=en

http://cymru.gov.uk/topics/health/publications/health/guidance/security_management_frameworks?lang=en



http://howis.wales.nhs.uk/doclib/whc-2003-088-e.pdf








OTHER APPOINTMENTS

SHARED SERVICES COMMITTEE – CHIEF EXECUTIVE OR HIS NOMINEE SOUTH WALES PLANING BOARD – CHAIRMAN AND CHIEF EXECUTIVE

58

Emrys Davies Patients Champion for Cleaning, Hygiene & Infection

Control Welsh Language Champion Public Patient Involvement

Champion

Mick Giannasi Sustainability Champion Military Veterans Liaison

Meeting South Wales Planning Board AACEE Chairs’ Liaison Ministerial Liaison

Pam Hall Patient Information/Caldicott Champion

ICT PONT

John Morgan Community First Responders EMS Operations PCS Operations/Transporting

Renal Patient 1000 Lives Plus

James Mycroft Complaints/Concerns/ Redress Champion

Community engagement Corporate Communications Emergency

Planning/Preparedness Champion

Vacancy Lead Member for Children & Young Peoples Services (Inc. Safeguarding)

59

COMPOSITE LIST OF NED CHAMPION/OTHER ROLES

Older people/Carers Champion

Maternity Services

David Scott Violence & Aggression Champion

Corporate Health Standard Equality & Diversity Health & Safety WASPT NED representative

Martin Woodford Design Champion Estate/Facilities Management Security

60

FINANCE AND ICT

PDR Objective 6 PDR Objective 6 PDR Objective 6 PDR Objective 6 PDR Objective 6 PDR Objective 6






Directorate

CORPORATE GOVERNANCE

WORKFORCE AND OD

QUALITY AND NURSING

STRATEGIC PLANNING AND PERFORMANCE

MEDICAL DIRECTORATE

EXECUTIVE (DELIVERY)

Personal Development

Objective

Organisational Development Objectives (Delivery)

Performance Delivery

Objectives

Corporate Secretary

(Dawn Sharp)


(Patsy Roseblade)

Director of Workforce & OD (Judith Hardisty)

Director of Quality & Nursing (Sara

Jones)

Director of Strategic Planning

(Mike Coupe)

Medical Director

(Jonathon Whelan)

Strategic Alignment

61

PADR OBJECTIVES/ACCOUNTABILITY FRAMEWORK – Appendix 6

nhs wales€¦ · web viewthe strategy for older people called for each local authority executive...

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