Code of Financial Procedures
Name of responsible (ratifying) committee / Audit Committee
Date ratified / 08 January 2015
Document Manager (job title) / Head of Financial Accounting
Date issued / 03 February 2015
Review date / 01 November 2015
Electronic location / Management Policies
Related Procedural Documents / Standing Orders, Standing Financial Instructions, Reservation of Powers, Detailed scheme of delegation.
Key Words (to aid with searching) / Standing Financial Instructions; SFIs; Financial management; Financial policy; Director of Finance and Investment ; Budgetary control; Asset management; Gifts; Charitable funds, Funds held on Trust.
Version Tracking
Version / Date Ratified / Brief Summary of Changes / Author3.1 / 08/01/2015 / Minimal terminology changes. Full Review Due November 2015 / Head of Financial Accounting
CONTENTS / Page
QUICK REFERENCE GUIDE
1 / INTRODUCTION / 1
2 / PURPOSE / 1
3 / SCOPE / 1
4 / DEFINITIONS / 1
5 / DUTIES & RESPONSIBILITIES / 2
6 / PROCESS / 3
7 / MANPOWER / 4
7.1 / Appointment Procedure / 4
7.2 / Relocation Expenses / 4
7.3 / Time Sheets and Salary Claims / 5
7.4 / Amendments to Staff Contracts / 6
7.5 / Travelling and Subsistence Expenses / 6
7.6 / Performance Schemes / 6
7.7 / Sick Pay following an Accident / 7
7.8 / Other Information / 7
7.9 / Termination Procedures / 8
7.10 / Seconded Staff / 8
7.11 / Private Interests / 8
8 / OTHER EXPENDITURE / 9
8.1 / Introduction / 9
8.2 / Purchasing goods & services / 9
8.3 / Ordering of goods and services / 10
8.4 / Payment for Supplies and Services / 11
8.5 / Petty Cash / 13
8.6 / Contract Management / 14
8.7 / Patients Travelling Expenses / 14
9 / INCOME / 15
9.1 / Cash Income / 15
9.2 / Cash Security, Banking and Bank Accounts / 16
9.3 / Credit Income / 17
9.4 / Income for Clinical Services / 17
9.5 / Non-contractual activity / 17
9.6 / Private and Overseas Patients / 18
9.7 / Road Traffic Accidents / 20
9.8 / Prescription Charges / 20
9.9 / Renting of Trust Property / 21
9.10 / Private Telephone Calls and Photocopying / 21
9.11 / Sales of Equipment and Waste / 22
9.12 / Other Charges / 23
10 / FINANCIAL ADMINISTRATION AND MANAGEMENT / 23
10.1 / Financial Planning and Programming / 23
10.2 / Budgetary Control / 23
10.3 / Cash Management / 25
10.4 / Project Appraisal / 26
10.5 / Capital Finance and Capital Charges / 27
10.6 / Trading Activities and Income Generation / 28
10.7 / Control and Holding Accounts / 29
10.8 / Controlled Stationery / 29
10.9 / Value Added Tax (VAT) / 30
10.10 / Funds held on Trust (Charitable Funds) / 30
10.11 / Lotteries / 31
10.12 / Insurance / 32
10.13 / Construction Industry Scheme / 32
10.14 / Leasing / 32
11 / MANAGEMENT OF ASSETS / 33
11.1 / Land and Property / 33
11.2 / Inventories / 34
11.3 / Loans of Equipment (including Laptop Computers & Mobile Phones) / 35
11.4 / Stock Control / 36
12 / PATIENTS MONIES AND VALUABLES / 36
12.1 / Short Term Patients / 36
12.2 / Out of hours access / 38
12.3 / Patients who die in hospital / 38
12.4 / Brought in Dead / 40
13 / LOSSES AND SPECIAL PAYMENTS / 40
13.1 / Trust Property / 40
13.2 / Lost Property / 41
13.3 / Compensation Payments / 42
14 / DATA PROTECTION / 43
15 / RETENTION OF FINANCIAL RECORDS / 44
15.1 / Introduction / 44
15.2 / Financial Records / 44
15.3 / Property Records / 45
15.4 / Contract Records / 45
15.5 / Capital Works Records / 45
15.6 / Stores Records / 45
15.7 / Charitable Fund Records / 45
15.8 / Patients Records / 45
15.9 / Destruction of Confidential Records / 46
16 / BACK UPS OF PERSONAL COMPUTERS / 46
QUICK REFERENCE GUIDE
1. The Code of Financial Procedures set out the basic standards for financial management and financial control to be followed within the Trust.
2. The Code should be read in conjunction with Standing Orders, Standing Financial Instructions, Reservation of Powers, Detailed scheme of delegation and other Trust policies and procedures.
3. All managers and staff working directly or indirectly for the Trust must comply with the provisions of this code.
Code of Financial Procedures : Issue Number 3.1 Issue Date 03/02/2015. Review Date: 01/112015
(Unless circumstances change)
1 INTRODUCTION
1.1 The Code of Financial Procedures set out the basic standards for financial management and financial control to be followed within the Trust. The Code should be read in conjunction with Standing Orders, Standing Financial Instructions, Reservation of Powers and detailed scheme of delegation and all other official policies and procedures issued by the Trust.
2. PURPOSE
2.1 The Code of financial procedures provides a more detailed guide for managers on the financial processes to be followed within the Trust.
3. SCOPE
3.1 All managers and staff working directly or indirectly for the Trust must comply with the provisions of this code.
3.2 ‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’
4. DEFINITIONS
4.1 In this Code the word “must” means the section of the Code is mandatory and all staff are expected to comply with that part of the Code. Failure to comply with the mandatory parts of this Code could result in the dismissal of the staff involved. The word “should” means that it is considered to be best practice and the staff should aim to comply with the provision if at all possible.
“Trust Board” means the executive and non-executive Directors of the Trust.
“Employee” means any person employed by the Trust on either a temporary or permanent basis. Under some circumstances it includes contractors of the Trust.
“Manager” or “Budget Manager” means any member of staff who is responsible for either one or more budgets or one or more other members of staff.
“Budget” means the anticipated income and/or expenditure attributable to one or a group of accounting cost centres.
“Charitable Fund” or “Funds held on Trust” mean those funds which the Trust holds on the date of incorporation, receives on distribution by statutory instrument or chooses subsequently to accept under powers derived under S.90 of the NHS Act 1977, as amended.
“Legal Adviser” means the person or company appointed by the Trust to provide it with Legal advice or carry out Legal functions on behalf of the Trust.
“Trust” means the Portsmouth Hospitals NHS Trust.
“Chief Executive” means the chief officer of the Trust.
“Commissioning” means the process for determining the need for and obtaining the supply of healthcare and related services by the Trust within available resources.
“Committee” means a committee or sub-committee created and appointed by the Trust.
“Contracting and procuring” 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.
“Director of Finance and Investment ” means the Chief Financial Officer of the Trust.
“Member” means officer or non-officer member of the Board as the context permits. Member in relation to the Board does not include its Chairman.
“Officer” means employee of the Trust or any other person holding a paid appointment or office with the Trust.
“Secretary” means a person appointed to act independently of the Board to provide advice on corporate governance issues to the Board and the Chairman and monitor the Trust’s compliance with the law, Standing Orders, and Department of Health guidance.
“SFIs” means Standing Financial Instructions.
“SOs” means Standing Orders.
Words imparting the masculine gender include the feminine
5. DUTIES AND RESPONSIBILITIES
5.1 The code of financial procedures set out the basic standards of financial control and financial management which apply to the main financial processes of the Trust. The Code should be read in conjunction with the detailed procedures which will exist for systems.
5.2 The Trust as a public organisation expects high standards of financial control and regulation, and in particular::-
a) that all financial procedures should be subject to adequate internal check, that is, the actions of one person are scrutinised in some way by another;
b) that staff recognise that the Trust is funded primarily by public money and that high standards apply to the control and use of public funds.
c) it is in the interest of all staff that adequate controls operate within the Trust.
Internal control is an essential requirement of any system and can be defined as the whole system of controls and methods of working which are established to safeguard assets, ensure reliability of records, promote operational efficiency and ensure compliance with Trust policies and directives.
6. PROCESS
6.1 It is the responsibility of each manager to ensure that every financial system for which he/she is responsible is secure and based on sound principles of financial control. If managers and staff are in any doubt as to the interpretation of any part of this Code, the advice of the Director of Finance and Investment should be sought before any action is taken.6.2 Staff must take reasonable precautions to safeguard Trust cash and property and they must act as diligently in this regard as they would if the cash or property was their own.
6.3 No new financial or administrative system (impacting upon the financial processes of the Trust) should be introduced until the Director of Finance and Investment has appraised its impact and the adequacy of its internal control.
6.4 It is the responsibility of managers to ensure that all financial systems (and administrative systems having an impact upon the finances of the Trust) should have detailed “desk top” procedures to enable adequate control to be exercised in the absence of management or other key staff and also to assist in the training of new users of those systems. These procedures will be required for review by Audit.
Code of Financial Procedures : Issue Number 3.1 Issue Date 03/02/15. Review Date: 01/11/2015
(Unless circumstances change)
Page 12 of 47
7. MANPOWER
7.1. / Appointment Procedures7.1.1 / The Trust should establish and keep under review a manpower establishment which will comprise all Trust posts.
7.1.2 / The responsibility for the appointment of staff will rest with the appropriate Budget Manager in consultation with their Workforce and Finance Managers. The hours and grades of all permanent staff appointed to an established post should be within the grade and hours set for that post, with all new permanent posts approved by a Trust Board Director via the appropriate approval process in place at that time i.e. Workforce Strategy Committee (WSC).
7.1.3 / If advertising is to be used to recruit staff, this should be arranged through the Workforce Manager following the Workforce Strategy Committee (WSC) approval process. The advert request form (PHT1 form) advert, job description, person specification and job plan must be fully completed by the line manager, authorised by the Clinical Service Centre management team and forwarded to the Clinical Service Centre Workforce Manager.
7.1.4 / Recruitment and employment checks will be undertaken in line with the Trust’s Recruitment and Selection, pre employment and employment checks policies.
The details of all new employees should be entered onto a PHT2 Starter form which should be completed and signed by the Budget Manager and forwarded to the HR – Employee Resourcing ( Adverts and Forms ) inbox before the new employee takes up his/her post.
7.1.5 / A written Statement of Main Terms and Conditions of Employment (Contract of Employment) should be provided for all staff before they take up their appointment, and MUST be provided to staff within eight weeks of their appointment.
7.1.6 / The Terms of the , “Main Terms and Conditions of Employment” must comply with either the requirements of the ,”Agenda for Change”, Terms and Conditions of Employment, or the appropriate Whitley Council where these conditions apply, as well as any others prescribed by the Trust.
7.1.7 / The Statement of , “Main Terms and Conditions of Employment” must be signed by both the employee and a Human Resources Manager acting for the Trust and the appropriate details forwarded to the payroll provider.
7.1.8 / The HR Department will provide details to new employees of their options with regard to pension provision when they take up the post. Eligible staff may join the NHS Superannuation Scheme. If an employee wishes to make or continue their own pension arrangements, the HR department should be informed of this.
7.1.9 / Employees are paid via the Electronic Staff Record System (ESR)