Integrated Care Organisation. Corporate Governance Manual

Transcription

1 Integrated Care Organisation Corporate Governance Manual Approved by the Board of Directors August 2015

2 Foreword Corporate governance is the system by which an organisation is directed and controlled in order to achieve its objectives and meet the necessary standards of accountability and probity. Effective governance is essential for a Trust to achieve its objectives and fundamental to effective corporate governance is having a robust system of internal control. Foreword Legislation such as the NHS Act 2006 and Health and Social Care Act 2012 set out the legal framework within which the Trust must operate. It is a statutory requirement that the Trust Board specify their terms of reference, schedule of reservation and delegation of powers, and the financial framework within which the Trust operates. These key documents comprise the Corporate Governance Manual, which contains: The Standing Orders, as a framework for Board governance The Standing Financial Instructions, as a framework for financial governance The Scheme of Reservation and Delegation, as a framework for internal governance It is essential that all employees know of the existence of these documents and are aware of their responsibilities as set out within as failure to comply with the Corporate Governance Manual could lead to disciplinary proceedings. Any queries relating to the contents of these documents should be directed to the Company Secretary in the first instance who will be pleased to provide clarification. Ann Marr Interim Accountable Officer August 2015 Page 1 of 150

3 Terminology used within the Corporate Governance Manual Any expression to which a meaning is given in the Health Service Acts or in the Regulations or Orders made under the Acts shall have the same meaning in this interpretation and in addition: Term Accountable Officer Board Budget Budget holder Chair of the Board of Directors Chief Executive Committee Company Secretary Contracting & Procuring Director Director of Finance Funds held on Trust Member Nominated Officer Officer Partner Definition The Officer responsible and accountable for funds entrusted to the Trust in accordance with the Accounting Officer Memorandum. They shall be responsible for ensuring the proper stewardship of public funds and assets the Chief Executive of the Trust is the Accountable Officer The Board refers to the Board of Directors comprising the Chair, Executive Director and Non-Executive Director members of the Trust collectively as a body. A resource, expressed in financial or manpower terms, proposed by the Board for the purpose of carrying out, for a specific period, any or all of the functions of the Trust;" The director or employee with delegated authority to manage finances (income and expenditure) for a specific area of the organisation. Is the person appointed by the Secretary of State to lead the Board and to ensure that it successfully discharges its overall responsibility for the Trust as a whole. The expression the Chair of the Trust shall be deemed to include the Vice-Chair of the Trust if the Chair is absent from the meeting or is otherwise unavailable. The chief officer of the Trust A committee or sub-committee created and appointed by the Trust. A person appointed to act independently of the Board to provide advice on corporate governance issues to the Board and the Chair and monitor the Trust s compliance with the law, Standing Orders, and Department of Health guidance. Means the systems for obtaining the supply of goods, materials, manufactured items, services, building and engineering services, works of construction and maintenance and for disposal of surplus and obsolete assets. A member of the Board of Directors; The chief finance officer of the Trust. Those funds which the Trust holds at its date of incorporation, receives on distribution by statutory instrument, or chooses subsequently to accept under powers derived S.90 of the NHS Act 1977, as amended. Such funds may or may not be charitable. An Executive or Non-Executive member of the Board as the context permits. Member in relation to the Board does not include its Chair. An officer charged with the responsibility for discharging specific tasks within Standing Orders and Standing Financial Instructions. An employee of the Trust or any other person holding a paid appointment or office with the Trust. In relation to another person, a member of the same household living together as a family unit; Page 2 of 150 Terminology

4 Term Standing Financial Instructions Standing Orders Trust Definition (SFIs) regulate the conduct of the Trusts financial matters (SOs) regulate the business conduct of the Trust Southport & Ormskirk Hospital NHS Trust Terminology All references to the masculine gender will be deemed to apply equally to the feminine gender when used within these instructions. Page 3 of 150

5 Southport & Ormskirk Hospital NHS Trust Standing Orders STANDING ORDERS Page 4 of 150

6 CONTENTS SECTION INTRODUCTION 1 INTERPRETATION 2 THE TRUST BOARD: COMPOSITION OF MEMBERSHIP, TENURE, AND ROLE OF MEMBERS. MEETINGS OF THE TRUST 4 ARRANGEMENTS FOR THE EXERCISE OF FUNCTIONS BY DELEGATION 5 COMMITTEES AND SUB-COMMITTEES 6 DECLARATION OF INTERESTS AND REGISTER OF INTERESTS 7 DISABILITY OF DIRECTORS IN PROCEEDING ON ACCOUNT OF PECUNIARY INTEREST STANDARDS OF BUSINESS CONDUCT 9 CUSTODY OF THE SEAL AND SEALING OF DOCUMENTS Standing Orders Page 5 of 150

7 RECORD OF AMENDMENTS NO SECTION DATE 1 Updated document Issued for implementation July Document reviewed November Document updated May 2010 Standing Orders 4 Document reviewed August Document reviewed May Document reviewed May Document reviewed July Page 6 of 150

8 1 INTRODUCTION 1.1 Statutory Framework Southport & Ormskirk Hospital NHS Trust (the Trust) is a body corporate which was established under the Southport & Ormskirk Hospital NHS Trust National Health Service Trust (Establishment) Order 1999 No 890 (the Establishment Order) The principal place of business of the Trust is Southport District General Hospital, Town Lane, Kew, PR8 6PN NHS Trusts are governed by statute, mainly the National Health Service and Community Care Act 1990 (NHS & CC Act 1990) and the National Health Service Act 1977 (NHS Act 1977) the NHS Act 1999, the Health and Social Care Act 2001, the National Health Service Act 2006 and the Health and Social Care Act The statutory functions are conferred on the Trust by this legislation As a statutory body the Trust has specific powers to contract in its own name and to act as a corporate trustee. In the latter role it is accountable to the Charity Commission for those funds deemed to be charitable as well as to the Secretary of State for Health The Code of Accountability (See Appendices) requires the Trust to adopt Standing Orders (S.O.s) for the regulation of its proceedings and business. The Trust must also adopt Standing Financial Instructions (SFIs) as an integral part of Standing Orders setting out the responsibilities of individuals The Trust will also be bound by such other statutes and legal provisions which govern the conduct of its affairs. Standing Orders 1.2 NHS Framework In addition to the statutory requirements, the Secretary of State, through the Department of Health issues further directions and guidance. These are normally issued under cover of a circular or letter The Code of Accountability requires that, inter alia, Boards draw up a schedule of decisions reserved to the Board known as the Reservation of Powers, and ensure that management arrangements are in place to enable responsibility to be clearly delegated to senior executives (a Scheme of Delegation). The code also requires the establishment of audit and remuneration committees with formally agreed terms of reference. The Codes of Conduct - (see Appendices) - makes various requirements concerning possible conflicts of interest of Board members The Code of Practice on Openness in the NHS (see Appendices) and Freedom of Information Act 2000 sets out the requirements for public access to information on the NHS. 1.3 Delegation of Powers The Trust has powers to delegate and make arrangements for delegation. The Standing Orders set out the detail of these arrangements. Under the Standing Order relating to the Arrangements for the Exercise of Functions (SO 5) the Trust is given powers to "make arrangements for the exercise, on behalf of the Trust of any of their functions by a committee, sub-committee or joint committee appointed by virtue of (SO 6) or by an officer of the Trust, in each case subject to such restrictions and conditions as the Trust thinks fit or as the Secretary of State may direct". Delegated powers are covered in a separate document (Scheme of Reservation and Delegation). This document has effect as if incorporated into the Standing Orders. 1.4 Standing Orders It is the duty of the Chief Executive to ensure that existing and new Directors and senior officers are notified of and understand their responsibilities within Standing Orders and Standing Page 7 of 150

9 Financial Instructions. Updated copies shall be issued Directors and senior officers. The Company Secretary will maintain a record of all recipients Standing Orders shall be reviewed annually by the Trust. The requirement for review extends to all documents having the effect as if incorporated in SOs. 1.5 Policy Statements Standing Orders The Trust Board will from time to time agree and approve Policy statements/ procedures which will apply to all or specific groups of staff employed by the Trust. The decisions to approve such policies and procedures will be recorded in an appropriate Trust Board minute and will be deemed where appropriate to be an integral part of the Trust's Standing Orders and Standing Financial Instructions. The Standing Orders and Standing Financial Instructions must be read in conjunction with the following guidance and any other issued by the Secretary of State for Health: - Caldicott Guardian 1997; - Human Rights Act 1998; - Freedom of Information Act 2000; - Data Protection Act 1998; - Equality Act 2010; - Bribery Act Notwithstanding the application of SO 1.5.1, these Standing Orders and Standing Financial Instructions must be read in conjunction with the following Policy statements: - the Staff Code of Personal and Business Conduct and Declarations of Interest Policy for the Trust staff; - the Trust Disciplinary Policy which shall have effect as if incorporated in these Standing Orders. 2. INTERPRETATION 2.1 Chair s Responsibility Save as permitted by law, at any meeting the Chair of the Trust shall be the final authority on the interpretation of Standing Orders (on which he should be advised by the Chief Executive or Company Secretary). 3. THE TRUST BOARD: COMPOSITION OF MEMBERSHIP, TENURE AND ROLE OF MEMBERS 3.1 Introduction All business shall be conducted in the name of the Trust All funds received in trust shall be in the name of the Trust as corporate trustee. In relation to funds held on trust, powers exercised by the Trust as corporate trustee shall be exercised separately and distinctly from those powers exercised as a Trust The powers of the Trust established under statute shall be exercised by the Board meeting in public session except as otherwise provided in Standing Order The Trust has resolved that certain powers and decisions may only be exercised or made by the Board in formal session. These powers and decisions are set out in Reservation of Powers and have effect as if incorporated into the Standing Orders. Page 8 of 150

10 3.2 Composition of the Trust In accordance with the Establishment Order and Membership and Procedure Regulations 1990 (as amended) the composition of the Board of the Trust shall be: A Non-Executive Chair, appointed by the Secretary of State (advised by the NHS Trust Development Authority) Up to 5 Non-Executive Directors excluding the Chair (appointed by the NHS Trust Development Authority) Up to 5 Executive Directors (but not exceeding the non-executive membership) including:- the Chief Executive the a medical practitioner a registered nurse or midwife Standing Orders The Trust shall have not more than 11 and not less than 8 members (unless otherwise determined by the Secretary of State for Health and set out in the Trust s Establishment Order or such other communication from the Secretary of State). 3.3 Terms of Office The regulations governing the period of tenure of office of the Chair and Directors and the termination or suspension of office of the Chair and Directors are contained in the Membership and Procedure Regulations 1990 (as amended) Chair and Non-executive Directors The Chair and non-executive directors shall be appointed for a term of office not exceeding four years as the Secretary of State may specify on making the appointment. The Chair may resign their office at any time during the period of which they were appointed by giving notice in writing to the Secretary of State. The non-executive directors may resign their office at any time during the period of which they were appointed by giving notice in writing to the Chair. Where during the period of directorship a non executive director of a trust is appointed Chair of the trust, their tenure of office as a non-executive director shall be terminated when their appointment as the Chair takes effect. If the Secretary of State is of the opinion that it is not in the interests of the health service for a person appointed as a Chair or non-executive director of an NHS trust to continue to hold office, the Secretary of State may forthwith terminate the person s tenure of office. If a Chair or non-executive director of an NHS trust has not attended a meeting of the trust for a period of three months, the Secretary of State shall forthwith terminate their tenure of office unless the Secretary of State is satisfied that- (a) the absence was due to a reasonable cause; and (b) the Chair or non-executive director will be able to attend meetings of the trust within such period as the Secretary of State considers reasonable. Where a person has been appointed the Chair or non-executive director of an NHS trust- (a) if he becomes disqualified for appointment under regulation 11 Membership and Procedure Regulations 1990 (as amended) the appointing authority shall forthwith notify them in writing of such disqualification; or (b) if it comes to the notice of the appointing authority that at the time of their appointment he was so disqualified it shall forthwith declare that he was not duly appointed and so notify them in writing, and upon receipt of any such notification, their tenure of office, if any, shall be terminated and he shall cease to act as Chair or non-executive director. Page 9 of 150

11 If it appears to the Secretary of State that the Chair or non-executive director of an NHS trust has failed to comply with regulation 20 (disclosure etc. on account of pecuniary interest) he may forthwith terminate that person's tenure of office Accountable Officer and Chief Finance Officer The Accountable Officer (Chief Executive) and the Chief Finance Officer () shall hold office for as long as they hold the post in the trust. Standing Orders Executive Directors If an executive director is suspended from their post in the trust they shall be suspended from performing their function as a director for the period of the suspension. An executive director may resign their office at any time by giving notice in writing to the Chief Executive, who will in turn notify the Remuneration & Nominations Committee. The Chief Executive may resign their office at any time by giving notice in writing to the Chair who will in turn notify the Remuneration & Nominations Committee Appointing Chief Executive & Other Directors The Trust shall appoint a Nominations committee whose members shall be the Chair and Non-Executive Directors of the Trust whose function will be to appoint the Chief Executive as a Director of the Trust. The Committee will co-opt the Chief Executive as a member when appointing the Executive directors of the Trust. 3.4 Disqualification as a Director The following may not become or continue as a Director: (a) A person who has received a prison sentence or suspended sentence of three months or more in the last five years. (b) A person who has been the subject of a bankruptcy restriction order or interim order.. (c) Anyone who has been dismissed (except by redundancy) by any NHS body. (d) Anyone who is under a disqualification order under the Company Directors Disqualification Act (e) Anyone who has been removed from trusteeship of a charity. 3.5 Appointment of Vice-Chair For the purpose of enabling the proceedings of the Trust to be conducted in the absence of the Chair, the Directors of the Trust may appoint a Non-Executive Director from amongst them to be Vice-Chair for such a period, not exceeding the remainder of their term as Non- Executive Director, as they may specify on appointing him/her Any Non-Executive Director so elected may at any time resign from the office of Vice-Chair by giving notice in writing to the Chair and the Directors of the Trust may thereupon appoint another Non-Executive Director as Vice-Chair in accordance with Standing Order In order to appoint the Vice-Chair, nominations, including self-nominations, will be invited within a period of time set by the Board. Where there is more than one nomination a postal vote will be conducted and the results announced at the subsequent meeting of the Board. In the event of there being only one nomination and this being acceptable to the Directors present, the Board will be requested to confirm that person as Vice-Chair at the meeting in Page 10 of 150

12 which the nomination is made In the event of nominations recording equal number of votes Standing Orders will apply, and the Chair of the Board will use a casting vote at the meeting following the postal vote. 3.6 Powers of Vice-Chair Where the Chair of an NHS Trust has died or has otherwise ceased to hold office or where he has been unable to perform their duties as Chair owing to illness, absence from England and Wales or any other cause, references to the Chair in the Schedule to these Regulations shall, so long as there is no Chair able to perform their duties, be taken to include references to the Vice-Chair. Standing Orders 3.7 Joint Members Where more than one person is appointed jointly to a post mentioned in regulation 2(4)(a) of the Membership, Procedure and Administration Arrangements Regulations those persons shall count for the purpose of Standing Order 3.2 as one person Where the office of a member of the Board is shared jointly by more than one person: (a) (b) (c) (d) either both of those persons may attend or take part in meeting of the Board; if both are present at a meeting they should cast one vote if they agree; in the case of disagreements no vote should be cast; the presence of either or both of those persons should count as the presence of one person for the purposes of Standing Order Role of Members The Board will function as a unitary Board, Non-Executive and Executive Directors will be full and equal members. Their role as members of the Board of Directors will be to consider the key strategic and managerial issues facing the Trust in carrying out its statutory and other functions. (1) Chief Executive The Chief Executive will be responsible for the overall performance of the executive functions of the Trust. He/she is the Accountable Officer for the Trust and will be responsible for ensuring the discharge of obligations under Financial Directions and in line with the requirements of the Accountable Officer Memorandum for Trust Chief Executives. (2) The will be responsible for the provision of financial advice to the Trust and to its members and for the supervision of financial control and accounting systems. He/she will be responsible along with the Chief Executive for ensuring the discharge of obligations under relevant Financial Directions. (3) Executive Members Executive Members will exercise their authority within the terms of these Standing Orders and Standing Financial Instructions and Scheme of Reservation and Delegation. (4) Non-Executive Members (5) Chair The Non-Executive Members will not be granted nor will they seek to exercise any individual executive powers on behalf of the Trust. They may however, exercise collective authority when acting as members of or when chairing a committee of the Trust which has delegated powers. Page 11 of 150

13 The Chair will be responsible for the operation of the Board and chair all Board meetings. The Chair has certain delegated executive powers. The Chair must comply with the terms of appointment and with these Standing Orders. The Chair will liaise with the NHS Trust Development Authority over the appointment of Non-Executive Directors and once appointed will take responsibility either directly or indirectly for their induction, their portfolios of interests and assignments, and their performance. The Chair will work in close harmony with the Chief Executive and will ensure that key and appropriate issues are discussed by the Board in a timely manner with all the necessary information and advice being made available to the Board to inform the debate and ultimate resolutions. (6) Non-Voting Members In preparation for Foundation Trust status the Board appointed two non-voting Members, one Non-Executive and one Executive, to strengthen the Board composition. Both Nonvoting members may exercise their authority within the terms of these Standing Orders, Standing Financial Instructions and Scheme of Reservation and Delegation. Non-voting members may participate in discussions at Board but do not have voting rights. Standing Orders 3.9 Schedule of Matters Reserved to the Board and Scheme of Delegation The Board has resolved that certain powers and decisions may only be exercised by the Board in formal session. These powers and decisions are set out in the Schedule of Matters Reserved to the Board and shall have effect as if incorporated into the Standing Orders. Those powers which it has delegated to officers and other bodies are contained in the Scheme of Delegation Lead Roles for Board Members The Chair will ensure that the designation of lead roles or appointments of Board Members as required by any statutory or regulatory guidance will be made in accordance with that statutory requirement. 4. MEETINGS OF THE TRUST 4.1 Openness All ordinary meetings of the Board are open meetings and members of the public can attend these meetings. As such they are considered to be meetings where the public may observe the decision-making process of the Trust. They are not open meetings where the public have a right to contribute to the debate. Contributions from the public at such meetings can be considered at the discretion of the Chair Exceptionally, there may be items of a confidential nature on the agenda of these ordinary meetings from which the public may be excluded. Such items will be business that:- relates to a member of staff; relates to a patient; would commercially disadvantage the Trust if discussed in public; or, would be detrimental to the operation of the Trust. Members and Officers or any employee of the Trust in attendance shall not reveal or disclose the contents of papers marked In Confidence or minutes headed Items Taken in Private outside of the Trust, without the express permission of the Trust. This prohibition shall apply equally to the content of any discussion during the Board meeting which may take place on such reports or papers. Page 12 of 150

14 4.1.3 Before each meeting of the Trust a public notice of the time and place of the meeting, and the public part of the agenda, shall be displayed at the Trust s office at least three clear days before the meeting (required by the Public Bodies (Admission to Meetings) Act 1960 SI(4)(a) Admission of the Public and the Press The public and representatives of the press shall be afforded facilities to attend all formal meetings of the Board but shall be required to withdraw upon the Board resolving as follows: That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest (Section 1(2) Public Bodies (Administration to Meetings) Act 1960) The Chair (or person presiding the meeting) shall give such directions as he thinks fit in regard to the arrangements for meetings and accommodation of the public and representatives of the press such as to ensure that the Board s business shall be conducted without interruption and disruption and, without prejudice to the power to exclude on grounds of the confidential nature of the business to be transacted. The public will be required to withdraw upon the Board resolving as follows: That in the interests of public order the meeting adjourn for (the period to be specified) to enable the Board to complete business without the presence of the public (Section 1 (8) Public Bodies (Administration to Meetings Act 1960) Nothing in the Standing Orders shall require the Board to allow members of the public or representatives of the press to record proceedings in any manner whatsoever, other than in writing, or to make any oral report of proceedings as they take place without the prior agreement of the Board. Standing Orders 4.2 Calling Meetings The ordinary meetings of the Board shall be held at regular intervals unless the Board shall by resolution otherwise decide. The meetings shall be held at such places as the Board may from time to time appoint. These meetings are open to the public to enable staff and members of the public to attend The Chair may call a meeting of the Board at any time One third or more members of the Board may requisition a meeting in writing. If the Chairman refuses, or fails to call a meeting within seven days of a requisition being presented, the members signing the requisition may forthwith call a meeting. 4.3 Notice of Meetings Regular Meetings of the Trust Agendas will be sent to members at least 6 days before the meeting and supporting papers, whenever possible, shall accompany the agenda, they will be despatched no later than three clear days before the meeting, except in an emergency. Failure to serve such a notice on more than three Directors will invalidate the meeting. A notice shall be presumed to have been served at the time one day after posting or ing Exceptional Meetings of the Trust Before each meeting of the Trust, a notice of the meeting, specifying the business proposed to be transacted at it, and signed by the Chair or by an officer of the Trust authorised by the Chair to sign on their behalf shall be delivered to every Director/member electronically, or sent by post to their usual place of residence, so as to be available to them at least three clear days before the meeting. Lack of service of the notice on any Director/member shall not affect the validity of a meeting Meetings Called By Directors Page 13 of 150

15 In the case of a meeting called by Directors in the event the Chair has not called the meeting, the notice shall be signed by those Directors and no business shall be transacted at the meeting other than that specified in the notice Public Notice- Before each meeting of the Board a public notice of the time and place of the meeting, and the public part of the agenda, shall be displayed at the Trust's office at least three clear days before the meeting. (Required by the Public Bodies (Admission to Meetings) Act 1960 S.I. (4) (a).) Standing Orders 4.4 Agendas and Petitions The Trust may determine that certain matters shall appear on every agenda for a meeting of the Trust and shall be addressed prior to any other business being conducted A Director/member desiring a matter to be included on an agenda shall make their request in writing to the Company Secretary at least 10 clear days before the meeting. The request should state whether the item of business is proposed to be transacted in the presence of the public and should include appropriate supporting information. Requests made less than 10 days before a meeting may be included on the agenda at the discretion of the Chair who will approve the agenda 9 clear days before the meeting Where a petition has been received by the Trust the Chair of the Board shall include the petition as an item for the agenda of the next Board meeting. 4.5 Notice of Motion Subject to the provision of Standing Orders Motions: Procedure at and during a meeting and Motions to rescind a resolution a member of the Board wishing to move a motion shall send a written notice to the Company Secretary who will ensure that it is brought to the immediate attention of the Chair The notice shall be delivered at least fifteen clear days before the meeting. The Company Secretary shall include in the agenda for the meeting all notices so received that are in order and permissible under governing regulations. This Standing Order shall not prevent any motion being withdrawn or moved without notice on any business mentioned on the agenda for the meeting. 4.6 Emergency Motions Subject to the agreement of the Chair, and subject also to the provision of Standing Order Motions: Procedure at and during a meeting, a member of the Board may give written notice of an emergency motion after the issue of the notice of meeting and agenda, up to one hour before the time fixed for the meeting. The notice shall state the grounds of urgency. If in order, it shall be declared to the Board at the commencement of the business of the meeting as an additional item included in the agenda. The Chair's decision to include the item shall be final. 4.7 Motions: Procedure at and during a meeting i) Who may propose - A motion may be proposed by the Chair of the meeting or any member present. It must also be seconded by another member. ii) Contents of motions - The Chair may exclude from the debate at their discretion any such motion of which notice was not given on the notice summoning the meeting other than a motion relating to: - the reception of a report; - consideration of any item of business before the Board; - the accuracy of minutes; - that the Board proceed to next business; Page 14 of 150

16 iii) iv) - that the Board adjourn; - that the question be now put. Amendments to motions - A motion for amendment shall not be discussed unless it has been proposed and seconded. Amendments to motions shall be moved relevant to the motion, and shall not have the effect of negating the motion before the Board. If there are a number of amendments, they shall be considered one at a time. When a motion has been amended, the amended motion shall become the substantive motion before the meeting, upon which any further amendment may be moved. Rights of reply to motions a) Amendments The mover of an amendment may reply to the debate on their amendment immediately prior to the mover of the original motion, who shall have the right of reply at the close of debate on the amendment, but may not otherwise speak on it. b) Substantive/original motion The member who proposed the substantive motion shall have a right of reply at the close of any debate on the motion. v) Withdrawing a motion - A motion, or an amendment to a motion, may be withdrawn. vi) Motions once under debate - When a motion is under debate, no motion may be moved other than: - an amendment to the motion; - the adjournment of the discussion, or the meeting; - that the meeting proceed to the next business; - that the question should be now put; - the appointment of an 'ad hoc' committee to deal with a specific item of business; - that a member/director be not further heard; - a motion under Section l (2) or Section l (8) of the Public Bodies (Admissions to Meetings) Act l960 resolving to exclude the public, including the press (see Standing Order). Standing Orders In those cases where the motion is either that the meeting proceeds to the next business or that the question be now put in the interests of objectivity these should only be put forward by a member of the Board who has not taken part in the debate and who is eligible to vote. If a motion to proceed to the next business or that the question be now put, is carried, the Chair should give the mover of the substantive motion under debate a right of reply, if not already exercised. The matter should then be put to the vote. 4.8 Motion to Rescind a Resolution (1) Notice of motion to rescind any resolution (or the general substance of any resolution) which has been passed within the preceding six calendar months shall bear the signature of the member who gives it and also the signature of three other members, and before considering any such motion of which notice shall have been given, the Board may refer the matter to any appropriate Committee or the Chief Executive for recommendation. (2) When any such motion has been dealt with by the Board it shall not be competent for any director/member other than the Chair to propose a motion to the same effect within six months. This Standing Order shall not apply to motions moved in pursuance of a report or recommendations of a Committee or the Chief Executive. Page 15 of 150

17 4.9 Chair of Meeting At any meeting of the Board, the Chair, if present, shall preside. If the Chair is absent from the meeting the Vice-Chair, if there is one and he is present, shall preside. If the Chair and Vice- Chair are absent the Directors present shall choose a Non-Executive Director to preside Chair s Ruling Statements of Directors made at meetings of the Trust shall be relevant to the matter under discussion at the material time and the decision of the Chair of the meeting on questions of order, relevancy, regularity (including procedure on handling motions) and any other matters shall be final including their interpretation of the Standing Orders and Standing Financial Instructions. Standing Orders 4.11 Quorum No business shall be transacted at a meeting of the Board unless one third of the whole number of voting directors are present including at least one Executive Director and one Non- Executive Director. Directors attending via video or telephone conferencing will be considered present and count towards the quorum. An officer in attendance for an Executive Director but without formal acting up status may not count towards the quorum. If the Chair or a member has been disqualified from participating in the discussion on any matter and/or from voting on any resolution by reason of the declaration of a conflict of interest SO 7 he shall no longer count towards the quorum. If a quorum is then not available for the discussion and/or the passing of a resolution on any matter, that matter may not be discussed further or voted upon at that meeting. Such a position shall be recorded in the minutes of the meeting. The meeting must then proceed to the next business. The above requirement for at least one executive director to form part of the quorum shall not apply where the executive Directors are excluded from a meeting due to a conflict of interests Voting Save as provided under SO 4.16 Suspension of Standing Orders - If a consensus decision is not reached at a meeting then the question shall be determined by a majority of the votes of the Directors present. Directors attending via telephone or video conferencing are considered present and therefore have a vote. In the case of any equality of votes, the Chair presiding the meeting shall have a second and casting vote. All questions put to the vote shall, at the discretion of the Chair of the meeting, be determined by oral expression or by a show of hands. A paper ballot may also be used if a majority of the Directors present so request. If at least one-third of the Directors present so request, the voting (other than by paper ballot) on any question may be recorded to show how each Director /member present voted or abstained. If a Director/member so requests, their vote shall be recorded by name upon any vote (other than by paper ballot). In no circumstances may an absent Director/member vote by proxy. Absence is defined as being absent at the time of the vote. An officer who has been appointed formally by the Board to act up for an Executive Director during a period of incapacity or temporarily to fill an Executive Director vacancy, shall be entitled to exercise the voting rights of the Executive Director. An officer attending the Board to represent an Executive Director without formal acting up status may not exercise the voting rights of the Executive Director. An officer s status when attending a meeting shall be recorded in the minutes. Page 16 of 150

18 Non-voting Directors are able to take part within Board discussions and provide their opinion but do not have voting rights on the Board Minutes The Minutes of the proceedings of a meeting shall be drawn up and submitted for agreement at the next ensuing meeting where they will be approved by the Board No discussion shall take place upon the minutes except upon their accuracy or where the Chair considers discussion appropriate. Any amendment to the minutes shall be agreed and recorded at the next meeting. The names of the Chair and Members present and those in attendance at the meetings shall be recorded. Any matters arising from the Minutes shall be subject to discussion at Chair s discretion. Where providing a record of a public meeting the minutes shall be made available to the public (required by Code of Practice on Openness in the NHS). Standing Orders 4.15 Annual Public Meeting The Trust will publicise and hold an annual public meeting in accordance with the NHS Trusts (Public Meetings) Regulations 1991 (SI(1991)482). The meeting shall take place no later than 30 September each year. The Annual Report and Annual Accounts of the preceding year shall be presented at that meeting Suspension of Standing Orders Except where this would contravene any statutory provision or any direction made by the Secretary of State, any one or more of the Standing Orders may be suspended at any meeting, provided that at least two-thirds of the Board are present, including one Executive Director and one Non-Executive Director, and that a majority of those present vote in favour of suspension. A decision to suspend SOs shall be recorded in the minutes of the meeting. A separate record of matters discussed during the suspension of SOs shall be made and shall be available to the Directors. No formal business may be transacted while SOs are suspended. The Audit Committee shall review every decision to suspend SOs Variation and Amendment of Standing Orders These Standing Orders shall be amended only if: a notice of motion under SO 4.7 has been given; and upon recommendation of the Chair or Chief Executive included on the agenda for the meeting; and no fewer than half the total of the Trust s Non-Executive Directors vote in favour of amendment; and at least two-thirds of the Directors were present at the meeting where the variation or amendment was being discussed; and the variation proposed does not contravene a statutory provision or direction made by the Secretary of State. 5. ARRANGEMENTS FOR THE EXERCISE OF FUNCTIONS BY DELEGATION Page 17 of 150

19 5.1 Introduction Subject to the Scheme of Reservation and Delegation, and such directions as may be given by the Secretary of State, the Board may make arrangements for the exercise, on behalf of the Trust, of any of its functions by a committee or sub-committee, appointed by virtue of SO 6.0 or by a Director /member or an officer of the Trust in each case subject to such restrictions and conditions as the Board thinks fit S16B of the NHS Act 1977 allows for regulations to provide for the functions of Trusts to be carried out for the Trust by third parties. The Trusts (Membership, Procedure and Administration Arrangements) Regulations 2000 also allow for functions of the Trust to be carried out in the following ways: (i) by another Trust; (ii) jointly with one or more NHS Trust; (iii) by arrangement with the appropriate Trust, by a joint committee or joint sub-committee of the Trust and one or more other health service bodies; (iv) in relation to arrangements under s63 (1) of the Health Services and Public Health Act 1968, jointly with one or more Trusts Where a function is delegated by these regulations to another NHS body, then that Trust or health service body exercises the function in its own right; the receiving Trust has responsibility to ensure that the proper delegation is in place. In other situations, i.e. delegation to committees, sub committees or officers, the Trust delegating the function retains full responsibility. 5.2 Framework for Delegation of Trust Board Authority The ultimate responsibility for decisions taken under delegated powers remains with the Board, and the Trust must ensure that due regard has been given and can clearly demonstrate it has not come to an unreasonable decision. To avoid possible allegations of unlawful exercise of discretion by the Board, a committee or Director/member acting under delegated powers record in writing the matters which have been taken into account in reaching that decision, especially where significant sums or legal commitments are involved. In making any decisions under delegated powers, a committee or Director/member must have due regard to the established policies of the Trust and shall not depart from them without due reason and consideration. Any such departure and the reason for it shall be drawn to the attention of the Board at the earliest opportunity. In exercising any delegated power a committee or Director/member must comply with any statutory provisions or requirements. In cases of doubt or difficulty and/or where no policy guidelines exist, decisions should be referred to the Board. The Board may require any particular delegated matter to be referred back to them for a decision. Standing Orders 5.3 Emergency Powers The powers which the Board has retained to itself within these Standing Orders, SO 1.3.1, may in emergency be exercised by the Chair and the Chief Executive after having consulted at least two Non-Executive Directors. The exercise of such powers by the Chair and the Chief Executive shall be reported to the next formal meeting of the Board for ratification in public session. 5.4 Delegation to Committees The Board shall agree from time to time to the delegation of executive powers to be exercised by committees or sub-committees, which it has formally constituted in accordance with directions issued by the secretary of State. The constitution and terms of reference of these committees, Page 18 of 150

20 sub-committees or joint committees, and their specific executive powers shall be approved by the Board, in respect of its sub-committees. 5.5 Delegation to Officers Those functions of the Trust which have not been retained as reserved by the Board or delegated to other committee, sub-committee or joint committee shall be exercised on behalf of the Board by the Chief Executive. The Chief Executive shall determine which functions he/she will perform personally and shall nominate officers to undertake the remaining functions for which he/she will still retain accountability to the Board The Chief Executive shall prepare a scheme of delegation (as detailed within the Scheme of Reservation and Delegation ) identifying his/her proposals which shall be considered and approved by the Board, subject to any amendment agreed during the discussion. The Chief Executive may periodically propose amendment to the Scheme of Reservation and Delegation which shall be considered and approved by the Board as indicated above Nothing in the Scheme of Reservation and Delegation shall impair the discharge of the direct accountability to the Board or the or of any other executive director to provide information and advise the Board in accordance with any statutory or Department of Health requirements. Outside these statutory requirements the role of the shall be accountable to the Chief Executive for operational matters The arrangements made by the Board as set out in the Scheme of Reservation and Delegation shall have effect as if incorporated in these Standing Orders. Standing Orders 5.6 Duty to report non-compliance with Standing Orders All members of the Board and staff have a duty to disclose any non-compliance with these Standing Orders to the Chief Executive as soon as possible. Full details of the noncompliance and any justification for non-compliance and the circumstances around the noncompliance, shall be reported to the next formal meeting of the Audit Committee for them to recommend action or ratification to the Board. Failure to comply with the Standing Orders is a disciplinary matter, which could result in dismissal. 6. APPOINTMENT OF COMMITTEES AND SUB-COMMITTEES 6.1 Appointment of Committees Subject to such directions (and to guidance issued by the Department of Health) as may be given by the Secretary of State, the Board may appoint committees of the Board. The Board shall determine the membership and terms of reference of committees and sub-committees and shall if it requires to, receive and consider reports of such committees. 6.2 Joint Committees Joint committees may be appointed by the Board by joining together with one or more other Trusts or health service bodies, consisting wholly or partly of the Chair and members of the Board or other health service bodies or wholly of persons who are not members of the Board or other health service bodies in question A committee or joint committee appointed under this regulation may, subject to such directions as may be given by the Secretary of State or the Trust or other health service bodies in question, appoint sub-committees consisting wholly or partly of members of the committee or joint committee (whether or not they are members of the Trust or other health service bodies in question); or wholly of persons who are not members of the Trust or other health service bodies or the committee of the Trust or other health service bodies in question. Page 19 of 150

21 6.3 Applicability of Standing Orders and Standing Financial Instructions to Committees The Standing Orders of the Trust, as far as they are applicable, shall as appropriate apply to meetings of any committees or sub-committee established by the Trust. In which case the term Chair is to be read as a reference to the Chair of other committee as the context permits, and the term member is to be read as a reference to a member of other committee also as the context permits. (There is no requirement to hold meetings of committees established by the Board in public.) Standing Orders 6.4 Terms of Reference Each such committee or sub-committee shall have such terms of reference and powers and be subject to such conditions (as to reporting back to the Board), as the Board shall decide and shall be in accordance with any legislation and regulation or direction issued by the Secretary of State. Such terms of reference shall have effect as if incorporated into the Standing Orders. 6.5 Delegation of powers by Committees to Sub-Committees Committees may establish sub-committees but may not delegate their executive powers to a sub-committee unless expressly authorised by the Board. 6.6 Approval of Appointments to Committees The Board shall approve the appointments to each of the committees which it has formally constituted. Where the Board determines and regulations permit, that persons, who are neither Directors nor officers, shall be appointed to a committee, the terms of such appointment shall be within the powers of the Board as defined by the Secretary of State The Board shall define the powers of such appointees and shall agree allowances, including reimbursement for loss of earnings, and/or expenses in accordance where appropriate with national guidance Where the Trust is required to appoint persons to a committee and/or to undertake statutory functions as required by the Secretary of State, and where such appointments are to operate independently of the Trust such appointment shall be made in accordance with the regulations laid down by the Secretary of State The appointment of Board members to the committees and sub-committees of the Trust comes to an end on the termination of their term of office as Board members. 6.7 Committee Structure The committees established by the Board are: a) Audit Committee In line with the requirements of the NHS Audit Committee Handbook, NHS Codes of Conduct and Accountability and the Higgs report, an Audit Committee will be established and constituted to provide the Board with an independent and objective review on its financial systems, financial information and compliance with laws, guidance, and regulations governing the NHS. The Terms of Reference will be approved by the Board and reviewed on a periodic basis. The Higgs report recommends a minimum of three non-executive directors be appointed, unless the Board decides otherwise, of which one must have significant, recent and relevant financial experience. b) Remuneration and Nominations Committee In line with the requirements of the NHS Codes of Conduct and Accountability and the Higgs report a Remuneration and Nominations Committee will be established and constituted. The Higgs report recommends the committee be comprised exclusively of Non- Page 20 of 150