Agenda Document Pack - Audit and Scrutiny Panel - 13/11/2025
North Lanarkshire Council · 13 November 2025
Back to Audit and Scrutiny Panel — 13 November 2025 and its agenda
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Clerk Name: Karen Swan Clerk Telephone: 07919 730272 Clerk Email: committee@northlan.gov.uk 4 November 2025 Members of the Audit and Scrutiny Panel Chief Executive’s Office Rachel Blair Chief Officer (Legal & Democratic) Civic Centre, Windmillhill Street, Motherwell ML1 1AB www.northlanarkshire.gov.uk Notice is given that a Meeting of the Audit and Scrutiny Panel is to be held in the Committee Room 1, Civic Centre, Windmillhill Street, Motherwell, ML1 1AB on Thursday, 13 November 2025 at 14:00 PM which you are requested to attend. The agenda of business is attached. Rachel Blair Chief Officer (Legal & Democratic) Members : S Watson, P Kelly, C Costello, M Hughes, J Hume, D Johnston, J Leckie, A McCrory, M McCulloch, J McLaren, G Robinson. Page 1 of 288
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Agenda 1 Declarations of Interest In Terms of the Ethical Standards In Public Life Etc. (Scotland) Act 2000 Scrutiny Related Items 2 Performance Reporting Schedule - Quarterly Performance Assurance Review Submit report by Chief Officer (Strategy and Engagement) bringing together a summary of the Council’s performance reports in one composite assurance overview to support the Panel in maintaining strategic oversight and awareness of the Council’s performance reporting arrangements in line with the Panel’s remit to provide “independent review of the council’s governance, risk management, performance, and control frameworks”. 5 - 42 3 Strategic Frameworks Annual Position Statement Submit report by Chief Officer (Strategy and Engagement) setting out the position statement for each Framework to provide a composite update in support of the Panel’s strategic oversight and governance role. 43 - 58 4 Performance in Complaints Handling Submit report by Chief Officer (Strategy and Engagement) providing an update on the performance of the Council complaints handling in line with the Panel’s role to provide an independent review of the Council’s governance, risk management, performance, and control frameworks. 59 - 76 Audit Related Items 5 Audit and Risk Related Items: Action Log Submit report by Chief Officer (Audit and Risk) allowing elected members to track implementation of outstanding requests and recommendations made by the Panel in respect of audit and risk-related items. 77 - 80 Page 3 of 288
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6 Internal Audit: Progress Report Submit report by Chief Officer (Audit and Risk) providing an overview of Internal Audit activity and audit reports issued since the last update to the Panel in August 2025 and an update on performance management. 81 - 116 7 Accounts Commission – Council Exit Packages Submit report by Chief Officer (Audit and Risk) providing contextual background to the issues identified at Glasgow City Council and outlining the work undertaken by Audit Scotland in reviewing recent exit packages for two Chief Officers at North Lanarkshire Council. 117 - 124 8 Referral from Housing Committee Submit report by Chief Officer (Audit and Risk) providing an update on the Internal Audit review of the award of a direct contract through an external procurement framework as part of the Council’s new build housing programme. 125 - 140 9 Internal Audit: Follow-up of Implementation of Audit Recommendations Submit report by the Chief Officer (Audit and Risk) updating the Panel on the progress made by management in the implementation of Internal and External Audit recommendations. 141 - 158 10 Risk Management Update Submit report by Chief Officer (Audit and Risk) seeking to support the Panel in the discharge of the aspect of its remit of monitoring the effective development and operation of risk management in the Council. 159 - 192 Remit 11 Remit - Adult Care and Social Work - Quality Assurance Annual Report Submit report by the Chief Officer (Planning, Performance and Quality Assurance) providing an update on the Quality Assurance activity over the period from 1 April 2024 to 31 March 2025 193 - 288 Page 4 of 288
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North Lanarkshire Council Report Audit and Scrutiny Panel Does this report require to be approved? ☒ Yes ☐ No Ref SP/SL Date 13/11/25 Performance reporting schedule - quarterly performance assurance review From Stephen Penman, Chief Officer (Strategy and Engagement) E-mail PenmanSte@northlan.gov.uk Telephone 07947 997750 Executive Summary The purpose of this report is to bring together a summary of the council’s performance reports in one composite assurance overview to support the Audit and Scrutiny Panel in maintaining strategic oversight and awareness of the council’s performance reporting arrangements in line with the Panel’s remit to provide “independent review of the council’s governance, risk management, performance, and control frameworks”. It also supports the Audit and Scrutiny Panel’s governance and accountability role in terms of ensuring the council can demonstrate Best Value through the existence of robust arrangements for performance reporting and scrutiny. This process monitors reports which have been submitted to council committees (in line with the Strategic Performance Framework - Performance Reporting Schedule) during the previous cycle. This process began in 2023 following the initial annual Performance Reporting Schedule at the Audit and Scrutiny Panel with implementation of a quarterly performance assurance review report thereafter. This report herewith provides the Panel with the outcome from the latest quarterly performance assurance review that has been undertaken on performance reports previously submitted to council committees during cycle 3 of 2025 (in line with the most recent Performance Reporting Schedule which was at the Panel in August 2025). Recommendations It is recommended that the Audit and Scrutiny Panel: (1) Review the composite overview of performance reporting provided in Appendices 1 and 2 to maintain an awareness of each report within the latest Performance Reporting Schedule, and (2) Identify whether there are any significant issues arising, from the composite performance overview presented in the attached Appendices, that the Panel considers requires additional scrutiny and a further report to be submitted from the respective Chief Officer to a future meeting of the Panel (following review through the Scrutiny Assessment and Prioritisation Process). The Plan for North Lanarkshire Item 2 Page 5 of 288
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1. Background 1.1 The quarterly performance assurance review report is now well established at the Audit and Scrutiny Panel, having been in place since May 2023. It aligns to the Performance Reporting Schedule which sets out the reporting, review, and scrutiny arrangements for a range of performance information to be considered at each cycle of committee meetings in support of the Strategic Performance Framework. 1.2 The Strategic Performance Framework comprises performance measurement at three levels. This aims to collectively provide an overview of performance to help understand the impact of council activities on improving services and outcomes for the people and communities of North Lanarkshire. The measures in this Framework allow for day-to- day activities, and progress towards achieving the long-term vision set out in The Plan for North Lanarkshire, to be regularly monitored, reported, assessed, and scrutinised. 1.3 The supporting Performance Reporting Schedule forms a key part of the Scrutiny Work Programme that underpins the Best Value governance and accountability theme by ensuring the council can demonstrate the existence of robust arrangements for scrutiny and performance reporting. It also aims to fulfil the Audit and Scrutiny Panel’s remit as per the Scheme of Administration to: • Review and monitor the performance of the council in delivering upon its priorities, outcomes, programme of work and targets in the council plan, specifically performance in improving local services and outcomes and in demonstrating Best Value. • Review performance to assess whether intended policy outcomes have been achieved. 1.4 The Strategic Performance Framework comprises a set of non-negotiable standards which Chief Officers are required to apply in all performance reporting that supports the Framework. These standards aim to ensure that performance reporting is: • Aligned - to The Plan for North Lanarkshire to give stakeholders an insight into the performance of council activities both in the short-term and against the long-term ambitions. • Consistent - to ensure a standard, easily recognisable, and well-established process across each different audience over time. This aims to help build credibility, reliability, and a common understanding. • Transparent - to allow stakeholders to understand what is being measured, what it means, what level of performance has actually been achieved, and what difference this means in reality for the people and communities of North Lanarkshire. • In context - to avoid the So What? question and provide a coherent narrative to ensure fully informed review, reporting, scrutiny, and decision-making processes. • Balanced - to ensure reporting contains areas in which performance has improved as well as areas where performance has not improvement or has declined. Any supporting narrative in this respect must add value and tell a balanced narrative. The narrative should include reasons for performance levels not in line with targets, standards, or original plans and the remedial action undertaken to address this. 1.5 The Performance Reporting Schedule shows there is a significant volume of Priority All priorities Ambition statement All ambition statements Programme of Work Statutory / corporate / service requirement Page 6 of 288
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performance information timetabled to be reported to various council committees in each cycle of the year. Cycle 3 2025 reports were reviewed by the Business Management Team in October 2025 to secure the relevant assurances - in line with the Best Value duty - that performance management arrangements promote effective use of council resources, that performance information is scrutinised at a senior management level, and that performance monitoring effectively addresses areas of underperformance by identifying the scope for improvement and agreeing the remedial action required. 1.6 The volume of performance information in the latest cycle has been reviewed and summarised further in Appendices 1 and 2 attached. It should be noted that the performance information within Appendices 1 and 2 has already been reviewed by Service Committees during cycle 3 of 2025. The purpose of the information presented herewith is therefore to provide Audit and Scrutiny Panel members with a composite, but easily digestible, overview for governance and assurance purposes in line with the specific scrutiny and strategic oversight role of the Panel. 1.7 Should the Panel consider there are any significant issues arising from the composite performance overview which require additional scrutiny, these matters will be reviewed through the Scrutiny Assessment and Prioritisation Process (updated and approved by the Panel in September 2022 and further endorsed in September 2023), prior to being added to the Scrutiny Work Programme for a further report to be submitted from the respective Chief Officer to a future meeting of the Panel. 2. Quarterly performance assurance review 2.1 The Strategic Performance Framework - Performance Reporting Schedule sets out several aspects of performance reporting. As part of this, paragraphs 2.2 to 2.6 itemise the performance reports submitted to cycle 3 2025 committees in accordance with the timetable set out in the Schedule. (1) Chief Officer’s individual Performance Review reports at Service Committees in line with the Strategic Performance Framework. (2) Chief Officer service specific performance reporting which takes place each year to meet business and/or statutory obligations. (1) Chief Officer’s individual Performance Review reports at Service Committees in line with the Strategic Performance Framework. 2.2 The Strategic Performance Framework comprises a range of performance indicators from each Chief Officer’s portfolio and the latest results in this respect are aligned to the respective ambition statements in The Plan for North Lanarkshire. The four reports previously submitted to the relevant committee in cycle 3 of 2025 are listed in Table 1 below, along with the corresponding hyperlink for ease of access. Table 1 Report title Committee Date Latest performance results - Active and Creative Communities link to report Communities Committee 18 August 2025 Latest performance results - Community Operations link to report Environment and Climate Change Committee 20 August 2025 Page 7 of 288
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Latest performance results - Housing link to report Housing Committee 27 August 2025 Adult social care performance - Quarter 4 (January to March 2025) link to report Adult Care and Social Work Committee 2 September 2025 2.3 Each council report was produced in line with a standard template and (a) provides the reader with the current context within which the service is operating, (b) highlights areas of good performance that can be evidenced in the accompanying data, and (c) provides a summary of areas of performance requiring improvement along with narrative that gives an explanation for the level of performance achieved and summarises the remedial action implemented (or to be implemented) to bring performance back on track. 2.4 A short summary analysis for each of the reports is set out in Appendix 1 against the five non-negotiable standards. (2) Chief Officer service specific performance reporting which takes place each year to meet business and/or statutory obligations. 2.5 This aspect relates to service specific reporting which is required to meet business and/or statutory obligations. This is included in the Performance Reporting Schedule to ensure all the council’s performance reporting arrangements are captured in the one place and the Schedule reflects a one council approach to performance reporting. 2.6 The 18 reports previously submitted to the relevant committee in cycle 1 of 2025 are listed in Table 2 below, along with the corresponding hyperlink for ease of access. A short summary for each of these reports is set out in Appendix 2. While this summary is set out against the five non-negotiable standards it recognises there may also be statutory specific approaches or standards which require to be adhered to. Table 2 Report title Committee Date Scottish Roadworks Commissioner - annual performance 2024/25 link to file Environment and Climate Change Committee 20 August 2025 Business regulation / food law - annual plan and performance link to file Environment and Climate Change Committee 20 August 2025 Scottish Housing Regulator - Annual Assurance Statement 2024/25 link to file Housing Committee 27 August 2025 Housing and corporate maintenance and investment services contract - interim report link to file Housing Committee 27 August 2025 Tackling poverty - annual report 2024/25 link to file Wellbeing and Tackling Poverty Committee 15 August 2025 Community Asset Transfer and Participation Requests - annual report 2024/25 link to file Communities Committee 18 August 2025 Page 8 of 288
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Report title Committee Date Local Outcome Improvement Plans (LOIPs) performance report - October 2024 to March 2025 link to file Communities Committee 18 August 2025 Procurement - annual report 2024/25 link to file Finance and Resources Committee 10 September 2025 Economic Regeneration Delivery Plan (ERDP) performance framework - annual update 2024/25 link to file Enterprise and Fair Work Committee 29 August 2025 Social work - quality assurance report 2024/25 link to file Adult Care and Social Work Committee 2 September 2025 Registration service - 2023 performance review link to file Finance and Resources Committee 10 September 2025 Improving educational outcomes - session 2024-25 link to file Education, Children, and Families Committee 9 September 2025 Lanarkshire Business Gateway - performance report link to file Enterprise and Fair Work Committee 29 August 2025 Treasury management - annual activity report 2024/25 link to file Finance and Resources Committee 10 September 2025 Revenue and benefits update link to file Finance and Resources Committee 10 September 2025 Financial monitoring report - council summary (revenue) link to file Finance and Resources Committee 10 September 2025 Financial monitoring report - council summary (capital) link to file Finance and Resources Committee 10 September 2025 Financial monitoring - savings link to file Finance and Resources Committee 10 September 2025 Next steps 2.7 Assurance reviews will continue to be undertaken and reported to the Audit and Scrutiny Panel on a quarterly basis in order to maintain the measures of success set out in paragraph 3.1. The content of the quarterly assurance review reports will continue to be informed by the Performance Reporting Schedule for which an update was presented to the Audit and Scrutiny Panel meeting in August 2025. 2.8 Reports submitted to the respective committee (in line with the Schedule) will continue to be kept under review by the senior management team of the council so that adherence to the timetable is maintained. This will also seek to secure the relevant assurances in terms of the efficient and effective operation of the council and that the ongoing delivery of the long-term ambition set out in The Plan for North Lanarkshire is underpinned with good corporate governance. 3. Measures of success Page 9 of 288
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3.1 Measures of success include: • Regular oversight and monitoring of performance across the organisation to gain assurances in terms of governance and accountability. • Regular review and challenge processes to scrutinise the performance of the council to ensure effective use of resources and that resources are directed in accordance with agreed policy and according to priorities, while ensuring sound decision making and clear accountability for the use of resources in achieving improved outcomes for service users and the local community. • Performance monitoring, management, and reporting arrangements that support the demonstration of improved performance in local services and outcomes, and the delivery of Best Value. 4. Supporting documentation Appendix (1) Chief Officer’s individual Performance Review reports at Service Committees in line with the Strategic Performance Framework. Appendix (2) Chief Officer service specific performance reporting which takes place each year to meet business and/or statutory obligations. Stephen Penman Chief Officer (Strategy and Engagement) 5. Impacts 5.1 Public Sector Equality Duty and Fairer Scotland Duty Does the report contain information that has an impact as a result of the Public Sector Equality Duty and/or Fairer Scotland Duty? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? If Yes, has an assessment been carried out and published on the council’s website? https://www.northlanarkshire.gov.uk/your-community/equalities/equality- and-fairer-scotland-duty-impact-assessments Yes ☐ No ☐ 5.2 Financial impact Does the report contain any financial impacts? Yes ☐ No ☒ If Yes, have all relevant financial impacts been discussed and agreed with Finance? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact? 5.3 HR policy impact Does the report contain any HR policy or procedure impacts? Yes ☐ No ☒ If Yes, have all relevant HR impacts been discussed and agreed with People Resources? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact? 5.4 Legal impact Does the report contain any legal impacts (such as general legal matters, statutory considerations (including employment law considerations), or new legislation)? Page 10 of 288
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Yes ☒ No ☐ If Yes, have all relevant legal impacts been discussed and agreed with Legal and Democratic? Yes ☒ No ☐ If Yes, please provide a brief summary of the impact? The Local Government Act 1992 established the role of the Statutory Direction to direct councils in terms of the “publication of information as to standards of performance”. The Local Government in Scotland Act 2003 introduced the duty of Best Value; this requires that councils “make arrangements to secure continuous improvement in performance”. 5.5 Data protection impact Does the report / project / practice contain or involve the processing of personal data? Yes ☐ No ☒ If Yes, is the processing of this personal data likely to result in a high risk to the data subject? Yes ☐ No ☐ If Yes, has a Data Protection Impact Assessment (DPIA) been carried out and e- mailed to dataprotection@northlan.gov.uk Yes ☐ No ☐ 5.6 Technology / Digital impact Does the report contain information that has an impact on either technology, digital transformation, service redesign / business change processes, data management, or connectivity / broadband / Wi-Fi? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? Where the impact identifies a requirement for significant technology change, has an assessment been carried out (or is scheduled to be carried out) by the Enterprise Architecture Governance Group (EAGG)? Yes ☐ No ☐ 5.7 Environmental / Carbon impact Does the report / project / practice contain information that has an impact on any environmental or carbon matters? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? 5.8 Communications impact Does the report contain any information that has an impact on the council’s communications activities? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? 5.9 Risk impact Is there a risk impact? Yes ☒ No ☐ If Yes, please provide a brief summary of the key risks and potential impacts, highlighting where the risk(s) are assessed and recorded (e.g. Corporate or Service or Project Risk Registers), and how they are managed? Implementation of the Schedule, which aims to facilitate regular review and scrutiny processes, contributes to the mitigation of the risk on the Corporate Risk Register for governance, leadership, and decision making. 5.10 Armed Forces Covenant Duty Does the report require to take due regard of the Armed Forces Covenant Duty (i.e. does it relate to healthcare, housing, or education services for in-Service or ex- Page 11 of 288
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Service personnel, or their families, or widow(er)s)? Yes ☐ No ☒ If Yes, please provide a brief summary of the provision which has been made to ensure there has been appropriate consideration of the particular needs of the Armed Forces community to make sure that they do not face disadvantage compared to other citizens in the provision of public services. 5.11 Children’s rights and wellbeing impact Does the report contain any information regarding any council activity, service delivery, policy, or plan that has an impact on children and young people up to the age of 18, or on a specific group of these? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact and the provision that has been made to ensure there has been appropriate consideration of the relevant Articles from the United Nations Convention on the Rights of the Child (UNCRC). If Yes, has a Children’s Rights and Wellbeing Impact Assessment (CRWIA) been carried out? Yes ☐ No ☐ Page 12 of 288
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Appendix 1 (1) Chief Officer’s individual Performance Review reports at Service Committees in line with the Strategic Performance Framework. Report title Summary Latest performance results - Active and Creative Communities August 2025 Active and Creative Communities is made up of a range of services providing cultural and leisure services to the communities of North Lanarkshire. There are six key service areas: • Active NL - operating from 18 leisure centres, the service provides a range of physical activity services including leisure centres and gyms, sports development, and health and wellbeing support through links with NHS Lanarkshire and the Volunteer NL programme. • Community libraries - delivered through 19 static libraries and an outreach delivery service. Records, archives, and local studies services are also provided, contributing to a range of national and local projects and providing protection to council and other public service records. • Museums and collections - operating from Summerlee Industrial Heritage Park and North Lanarkshire Heritage Centre, the service also supports local schools, colleges, and community groups to display art exhibitions and deliver a range of collections. A range of visual arts programmes are also delivered to the community (including photo media and ceramic workshops). • Creative resources - working from Airdrie Town Hall, Bellshill Cultural Centre, and Cumbernauld Theatre, the service delivers over 200 performances every year. Responsibilities include a range of community performing arts classes and the council’s Arts Strategy. • Active schools - funded partly by sportscotland, active schools operate from across all council secondary schools, supporting extracurricular activity for primary, secondary, and additional support needs for young people. • Outdoor education - from Palacerigg Country Park, all primary 7 pupils are given the opportunity to take part in one week of outdoor education as a key element of the curriculum. Subject to availability, this is also offered to secondary and additional support needs schools where possible. Aligned Priority: • Enhance participation, capacity, and empowerment across our communities. Ambition statement: 15. Encourage the health and wellbeing of people through a range of social, cultural, and leisure activities. Consistent The pre-defined template was used to ensure a standard, easily recognisable, and well established process across each different audience over time. The use of this template aims to help build credibility, reliability, and a common understanding. Transparent RAG indicators: Benchmarking indicators: https://www.improvementservice.org.uk/benchmarking /explore-the-data • Libraries - cost per visit • Satisfaction - % of adults satisfied with library services • Museums - cost per visit • Satisfaction - % of adults satisfied with museums • Sports facilities - cost per attendance • Satisfaction - % of adults satisfied with sport and leisure facilities In context • The context set out in the report recognises that there is a clear distinction in some areas of performance before and after the pandemic where it is clear that behavioural change impacted on some elements of how services are accessed and used. For example, while overall use of library services has continued to grow since the services re-opened following lockdown in 2021, a significant drop is still being experienced in the overall number of people accessing services. This has led to a review of how libraries are used and the services provided from these sites. Page 13 of 288
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Balanced Performance highlights • Digital users of library services - this shows an increase in performance from 2023/24 to 2024/25 which is, in part, due to a growing focus on improving access to digital services across the library service. This is reflected in achievement of a Programme of Work ambition to deliver Digital Zones for use by communities. Two new Digital Zones have recently been launched in Coatbridge Library and Chryston Library. Digital access to services has also been boosted by growing access to digital resources and an improved range of titles, including newspapers, which library members are able to access. • Community arts activities - this shows an increase in performance from the previous year which is, in part, due to delivery of a new focused service, as set out in the Arts Strategy. The Arts Strategy seeks to use the arts to support vulnerable groups and support learning across all areas of North Lanarkshire. • Indoor sports activities - the highest number of Active NL members has been recorded (37,412 members) since the organisation was established under North Lanarkshire Leisure. This, combined with pay as you go members and focused programmes for all participants, sees this figure continue to grow with an ongoing commitment to increase it further. • Outdoor sports activities - while showing a slight decrease in performance in 2024/25, the service continues to operate above target. Recent investment in the council’s outdoor spaces - at Moodiesburn, Harthill, and Cleland pitches, as well as Airdrie Leisure Centre, Ravenscraig Regional Sports Facility, and Bothwellhaugh Sports Fields have contributed to increased usage. Areas of performance requiring improvement: • Libraries: number of visits - this indicator is one of the most significantly impacted following the pandemic, with a national picture which also shows a significant drop in the number of people attending libraries. In North Lanarkshire, the number of visits to the library are monitored on a monthly basis, reporting these figures quarterly to the Communities Committee. While the nine town centre libraries continue to show healthy growth in attendance, the smaller libraries are less well used and contribute to an overall picture of falling attendance. In recognition of this change in habits, the town centre libraries are moving towards a position where the public can use libraries to access a range of different services. This might include access to Routes to Work advice and support, information on a range of public service, access to digital services, or the use of the Immersive Experience rooms (in Motherwell and Airdrie), or using the maker space services (in Motherwell and soon to open in Cumbernauld). It is recognised that this is more challenging in smaller branches, but work is ongoing to provide additional service, where appropriate, including Bookbug and support for clubs and groups. • Museum learning experiences - while showing an improvement in performance in 2024/25, the target has not yet been achieved for this indicator. Progress has been made in terms of a more focused programme of learning, linking in with schools both on site and within schools, to deliver a range of educational programmes. The Immersive Room, which opened with Summerlee during 2024/25, has been very popular with groups and schools and it is hoped that this indicator will see continued growth through access to the immersive experience. The proposed project at Summerlee, subject to agreed funding, will also improve specifically in the learning offer with a new learning landscape and increased opportunities for visitors to participate in the range of programmes. • Museum visits - similarly, while showing an increase in performance there is scope for more significant improvement in this indicator. The planned project at Summerlee will transform the attraction into one of the most important and impressive in Scotland, which it is hoped will impact positively on this indicator. Report title Summary Latest performance results - Community Operations August 2025 Community Operations has 36 indicators in the Strategic Performance Framework which assess efficiency and effectiveness in terms of delivery on a day-to-day basis. A suite of statutory indicators also enables performance, costs, and satisfaction to be assessed and compared nationally. Following the structural realignments in the One Place One Plan - Governance update report approved at Policy and Strategy Committee in December 2022, a single Community Operations service was created to strengthen the council’s delivery of community operations and put people and communities at the heart of the change that The Plan for North Lanarkshire aims to achieve. This realignment brought a wide range of community facing services in relation to the council’s environmental assets (i.e. Street Cleaning, Grounds Maintenance, Cemetery Services, Roads Maintenance Operations, and Country Parks for the Future) together with regulatory services (i.e. Environmental Health and Trading Standards), and services in respect of Waste Solutions, Fleet Resources, and the Built Environment. A subsequent realignment of specific service functions across the council (which was approved at the Policy and Strategy Committee in December 2023), added further services within the remit of Community Operations (i.e. Facility Support Services and School Transport which sit within the remit of the Education and Families Committee, and Active and Creative Communities which sits within the remit of the Communities Committee). Creation of a single community operation through the Chief Officer (Community Operations) has seen the integration of environmental services and enhancements to natural environments and green spaces to further support general wellbeing, social inclusion, physical and mental health, and Page 14 of 288
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connectivity with the local environment. The creation of a single front-line community operation that supports the day-to-day maintenance and management of the resources, services, and assets required to deliver a wide range of environmental services, as well as many culture, sport, and leisure pursuits, is key to bringing about environmental enhancements and the health benefits they bring. Aligned Priority: • Improve the health and wellbeing of our communities. • Enhance participation, capacity, and empowerment across our communities. Ambition statement: 14. Ensure the highest standards of public protection. 16. Transform our natural environment to support wellbeing and inward investment and enhance it for current and future generations. 17. Ensure we keep our environment clean, safe, and attractive. Consistent The pre-defined template was used to ensure a standard, easily recognisable, and well established process across each different audience over time. The use of this template aims to help build credibility, reliability, and a common understanding. Transparent Benchmarking indicators: https://www.improvementservice.org.uk/benchmarking/explore-the-data • Parks and open spaces - cost per 1,000 population • Satisfaction - % of adults satisfied with parks and open spaces • Street cleaning - net cost per 1,000 population • Satisfaction - % of adults satisfied with street cleaning services • Street cleanliness score - % areas assessed as clean • Satisfaction - % of adults satisfied with refuse collection • Roads - cost of maintenance per kilometre of roads • Road network - % A class roads that should be considered for maintenance treatment • Road network - % B class roads that should be considered for maintenance treatment • Road network - % C class roads that should be considered for maintenance treatment • Road network - % Unclassified roads that should be considered for maintenance treatment • Road casualties - number of fatal and serious casualties • Road casualties - number of fatal and serious casualties involving children • Environmental health - cost per 1,000 population • Street lamps - energy usage RAG indicators: Page 15 of 288
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In context As the service’s operating environment has changed significantly in recent years, performance should be considered within the context of the following: • A significant rationalisation exercise across the waste service has allowed consolidation of the service within key depot facilities and overall efficiencies for the service space being freed up for other service areas to consolidate their own facilities and ultimately provide a capital receipt for the council through the sale of any depot deemed surplus to requirements. • The extent to which the service has supported the council in terms of responding to and recovering from the pandemic over the three years from 2020 to 2022, while maintaining service delivery of critical areas of public health and safety in line with legislation. Resuming business as usual activities at pace thereafter involved dealing with significant volumes in terms of backlogs in particular areas of service - the latest results for these areas now show demand to be stabilising and performance levels back on track. • In resuming business as usual activities as noted above, the subsequent increase in the volume of business experienced by some areas of service added to caseloads which required to be dealt, e.g. in environmental health, while the food law recovery plan and related inspection regime implemented in the aftermath of the pandemic impacted on food business inspection visits and required changes to processes and ways of working. In addition, the report references the Internal Audit review reported to the Audit and Scrutiny Panel in May 2025), and notes that the performance report reflects implementation of one of the recommendations identified therein, i.e. reporting performance information to senior management and elected members. To address the second recommendation (in respect of improving compliance with corporate processes and procedures in relation to the description, calculation, and recording of performance indicators), a workshop was held with the Chief Officer and Service Managers in July 2025 to reiterate the corporate processes and procedures and service roles and responsibilities and deadlines therein, and review existing and potential future measures for Community Operations monitoring and reporting. In the meantime, data is being collated in respect of a new measure to support oversight of instances where residents’ bins are lost or damaged during collection (as agreed at the Council meeting in June 2025). This will be incorporated into the next six-monthly Community Operations performance report to the Environment and Climate Change Committee (i.e. cycle 1 of 2026). Balanced Performance highlights: • The council’s performance in respect of A class roads (i.e. major and strategic roads) and B class roads (i.e. roads serving a local purpose and connecting to strategic roads) which are considered to require maintenance treatment continues to remain lower than the averages for Scotland and the family group of similar councils: - Less than a quarter (24.7%) of A class roads in North Lanarkshire are considered to require maintenance treatment compared to the Scottish average (28.9%) and the family group of similar councils (26.1%). - 27.2% of B class roads in North Lanarkshire are considered to require maintenance treatment compared to the Scottish average (32.5%) and the family group of similar councils (26.9%). • Overall, the latest figures show that 32.6% of all of North Lanarkshire's roads are considered to require maintenance treatment; this is a small increase from previous years but still maintains the consistent trend over the years of less than a third of all roads requiring maintenance treatment. Performance also remains below (and therefore better than) target. • The latest costs in respect of cost of maintaining roads per kilometres of length show a decrease from the previous year and continue to remain lower than the family group of similar councils (which comprises the eight most densely populated council areas). The location of North Lanarkshire’s roads in central Scotland makes them very heavily used, with the heavier volume and density of traffic having a greater impact on wear and tear of the road network compared to a council in a rural area for example. • Performance for the council’s refuse service shows a positive picture in the round with refuse disposal costs remaining below target, satisfaction levels in terms of the refuse collection service showing improvement, and recycling rates increasing. • Previous performance reports to the Environment and Climate Change Committee had noted performance in completion certificates and building warrants continuing to remain below target, however both these service areas have experienced a significant improvement in recent years. This follows a prolonged period of high demand volumes combined with increased customer expectation around the completion of projects and extent of on-site activities as well as challenges around the recruitment process, long-term absences, support issues, and system outages all contributing to lower than target performance. It is anticipated this level of improved performance will continue, but it remains under review. Areas of performance requiring improvement: • Overall, performance results in relation to unit costs available through the Local Government Benchmarking Framework (LGBF) suite of indicators represent a mixed picture across all councils in Scotland. The latest LGBF overview publication recognises general trends across Scotland, for example, it notes that Page 16 of 288
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some nonprotected service areas have seen recent uplifts in their spend, after a long-term pattern of reducing budgets. This largely reflects the resumption in activity, which was deferred during the pandemic, including in relation to significant capital programmes. For example, culture and leisure, environmental services, roads, planning services, and corporate support services have all seen an increase in expenditure in recent years. However, unit costs should never be considered in isolation, and a full picture of performance should be reviewed, for example public satisfaction levels with environmental related services show a clear improvement in the latest results as does the level of performance achieved. Report title Summary Latest performance results - Housing August 2025 Housing has 22 indicators in the Strategic Performance Framework covering all aspects of the council’s social landlord role. This covers both housing management and housing property functions. The housing service covers the management of all housing provider related functions including housing repairs and investment, rent management, void management, tenancy management, tenant satisfaction, and homeless related services. Performance in each of these areas is monitored through various statutory returns, including the Annual Return on the Charter (ARC), the Scottish Government Housing Annual Statistical Return (HSAR), and the Scottish Government Homeless returns (HL1) as well as service and contractual performance indicators. As members of the Scottish Housing Network, the council regularly engages in benchmarking and practice sharing between other Scottish landlords. As set out in the council’s Local Housing Strategy 2021-26 (approved in November 2021), there are an estimated 157,625 dwellings in North Lanarkshire, with home ownership remaining the predominant tenure and 63% of households owning their own home. The council is the largest local authority landlord in Scotland and almost a third (29.5%) of households rent from a social landlord (23.3% from the council and 6.2% from other social landlords). The Local Housing Strategy 2021-26 recognises that an affordable, warm, and accessible home (that meets individual needs over the course of a person’s life) is the foundation for people to achieve their full potential in all aspects of life, including educational attainment and employment. Housing also plays a crucial role in addressing homelessness, tackling poverty, mitigating the impacts of climate change, improving health and wellbeing, and promoting inclusive growth. Aligned Priority: • Improve economic outcomes and opportunities. Ambition statement: 1. Ensure a housing mix that supports social inclusion and economic growth. Consistent The pre-defined template was used to ensure a standard, easily recognisable, and well established process across each different audience over time. The use of this template aims to help build credibility, reliability, and a common understanding. Transparent RAG indicators: Page 17 of 288
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In context • Financial pressures continue to be experienced by tenants due to the rise in the cost of living and is a priority for the service. The rent assistance fund, introduced in February 2023, continues to help tenants who may be on low incomes and others who may be on universal credit by helping maintain stable tenancies during challenging times. Dedicated Income Maximisers help support tenants and identify any additional financial assistance they might be entitled to. Last year the team secured over £20.4m in additional income for tenants. • Since 2024, several Scottish local authorities have declared a housing emergency in their area in response to the pressures through increased levels of homelessness, rising property prices, and high levels of temporary accommodation use. In May 2024, the Scottish Government formally acknowledged a housing crisis by declaring a national housing emergency. While North Lanarkshire had seen an increase in homeless presentations, council resources continue to be used effectively to deliver targeted support. As a result, there has been a notable reduction in presentation rates last year, an encouraging sign that interventions are having a meaningful impact. The council remains compliant with The Homeless Persons (Unsuitable Accommodation) (Scotland) Order 2014 and avoids the use of B&B-style placements, which are commonly relied upon by other authorities for temporary accommodation. • Despite the current housing climate the council’s overall performance and tenant satisfaction levels (reported to committee in November 2023) remain high and compare well with Scottish local authority averages. Balanced Performance highlights • Rent arrears continue to reduce, with a further drop from 7% to 6.6%, which is below the council target of 9% and Scottish local authority average (8.6%). • While overall numbers remain high, homeless presentation rates have reduced significantly in 2024/25. This marks a considerable deceleration compared to the 13% increase recorded between 2021/22 and 2022/23 and the 16% rise observed between 2022/23 and 2023/24. The average time taken to close a homeless case is below the 6 month target at 24 weeks. • The length of time taken to re-let empty properties continues to fall, improving by 5 days in the year, and good steady progress continues to be made towards meeting the Scottish Housing Quality Standard (SHQS) with a further increase in compliance. • Satisfaction with the repairs service has increased to 96.2%, comparing well with the Scottish local authority average of 85.7%. • Average time to complete emergency repairs stands at 2.67 hours, outperforming the Scottish local authority average of 3.77 hours. Year to date, a strong position is being maintained with an average of 3.02 hours, comfortably below the council target of 3.75 hours. • Non-emergency repairs are setting an average completion time of 5.7 days, below the Scottish local authority average of 10 days. Year to date performance remains on track, consistently meeting the target timescale of 7 days. Areas of performance requiring improvement • 95.9% of cases of anti-social behaviour reported in the last year were resolved at the year end and within the targets agreed locally. This compares favourably with the Scottish local authority average of 89%. Due to the nature and calculation method of this statutory indicator there will always be several cases outstanding at year end. Following a request to the Scottish Housing Regulator, this issue has been recognised and from 2025/26 the carry forward will be included in the calculation. • Satisfaction with the standard of home when moving in dropped slightly to 87.8% however, only 5.3% cited dissatisfaction, with the remaining 6.9% saying they were neither satisfied nor dissatisfied. Despite the lower level of dissatisfaction, this area remains a priority and focus of improvement for the service and, as such, a review of the reasons for dissatisfaction is ongoing. This information will be discussed with the various service forums as well as with contractors to ensure a high standard of lets is consistently achieved moving forward. Report title Summary Adult social care performance - Quarter 4 (January to March 2025) September 2025 The Chief Officer (Health and Social Care North Lanarkshire) has joint quarterly performance review meetings with the Chief Executives of NHS Lanarkshire and North Lanarkshire Council. These meetings are supported by a Chief Executive’s Performance Framework which comprises a range of performance measures taken from across both the health and social work systems, including relevant targets and trajectories for the measures presented. In each quarter there are areas for improvement identified within the performance framework; these are identified using a RAG rating and those measures that are flagged as Red or Amber are subject to improvement or corrective action. The performance review meetings are used as a means for jointly agreeing these actions. Aligned Priority: • Improve the health and wellbeing of our communities. Page 18 of 288
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Ambition statement: 12. Ensure our residents are able to achieve, maintain and recover their independence through appropriate supports at home and in their communities. 13. Improve preventative approaches including self-management and giving people information and choice over supports and services. 14. Ensure the highest standards of public protection. Consistent A pre-defined Health and Social Care Partnership template is in place to ensure a standard, easily recognisable, and well established process for quarterly reporting on areas for improvement. Transparent Based on a traffic-light system there are areas for improvement identified within the performance framework each quarter for those areas that are flagged as Red or Amber. The areas for improvement identified are progressed as a matter of priority, and progress updates are reported at future meetings of the Integrated Joint Board and/or the Integration Joint Board Performance, Finance, and Audit Committee as appropriate. In context • The joint performance review meetings (involving the Chief Officer for the Health and Social Care Partnership, the Chief Executive of NHS Lanarkshire, and the Chief Executive of North Lanarkshire Council) are used as a means for jointly agreeing corrective actions within the current operating environment. • Information from these performance reviews has been supplemented with additional information to offer a wider overview of performance across some key areas of adult social care delivery. Balanced The purpose of the report is to provide an update on the areas for improvement what have been identified as part of the quarterly performance review. The quarter 4 report (for January - March 2025) sets out corresponding narrative and corrective actions agreed for the areas identified for improvement; these are summarised below. • Reablement and rehabilitation - The indicators for reablement presented in the scorecard in an appendix to the report have not met the targeted level of performance. During 2023/24, the number of people completing the reablement process increased, however in 2024/25 there has been a reversal of this trend. The percentage of new or increased home support packages that are reablement is relatively stable in a range around, but below the targeted level of 70%. However, the percentage of people with no, or reduced home support at the end of the reablement process has not met the targeted level of performance. Additional data / information on reablement is available from other sources as summarised below. - The most recent home assessment team data covers a period to May 2025 and notes that since the start of the service, 3,496 referrals were accepted by the team. Since the start of the service, referrals that were not accepted grew in volume up to May 2024, this trend then reversed with very few referrals not accepted (21 in March 2025 and 12 in April). Over the last year, 369 referrals were not accepted, 66% of referrals not accepted were from Wishaw. - May 2025 was the thirteenth consecutive month where the volume of referrals exceeded 100. The average number of total monthly referrals over the past year was 127. The monthly referral distribution across the localities has been relatively stable over the past year and in terms of referral sources there is very little difference in percentage terms from previous reporting regarding the home assessment team referrals by hospital of origin. However, it is notable this is the first reporting period where UH Monklands has overtaken UH Wishaw (accepting 85 more referrals). - The average number of input services for home assessment team cases has increased over time, with the data continuing to reflect the expanding scope and complexity of support provided. Of the total referrals, only 1% (41 individuals) had no input services recorded, likely representing older cases, while 53% received one or two services. Notably, the proportion of individuals receiving three or more services has risen slightly and the average number of input services per referral has gradually increased; assuming that input services is a proxy of the intensity of support needs among service users, this may be an early indication that the service is dealing with more complexity over time. Home support remains the most frequently provided input service, involved in 87% of referrals, which is consistent with previous reporting. The volume of referrals where Occupational Therapy and Physiotherapy are input services has grown. Around 96% of all referrals, or 3,349 individuals have completed the home assessment team service since its inception. Of those who completed the process, 14% (466 people) were re-admitted to hospital and 37% (1,238 people) were identified as needing further services; these proportions appear to be consistent over time. At the point of completion, 63% of individuals required no further support, while 37% were recorded as needing at least one service. Of those, the majority (73%) required only one service, with the remainder needing two or more. The most frequently provided services were IRT (Physiotherapy) and Reablement, each accounting for 14% of completions, followed by IRT (Occupational Therapy) and mainstream Home Support each accounting for 10%. - The home support redesign programme is focussed on home support that achieves individual outcomes for people using the service and their families. The redesign is based on core principles that are aligned with B2B, self-directed support and developments in hospital flow. It is supported by several Page 19 of 288
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products that have been produced to progress the work, including service specifications, a workforce profile and an analysis of demand/capacity data. The proposal is for a Living Well service that provides home support to achieve individual outcomes for the people using the service and a distinct Assessment and Planning service, to include rehabilitation and reablement services, ensuring that people receive a holistic assessment of their need and are provided with the most appropriate services to meet individual outcomes. • Complaints - All council complaints are collated via one centralised, customer service portal, logged centrally and monitored through the relevant council governance processes. A detailed dashboard provides live management and performance information. As the cost of a licence for the system increased substantially from April 2023, the number of licences allocated to social work services has been reduced and consequently, only members of management support and complaint administrators have been granted a licence. The rationalisation of licence permissions ensures confidentiality for social work complaints. Within Adult Social Work services, in-house monitoring by the Quality Assurance team has been introduced to support improvements in managing complaints. While complaints processed within timescale have failed to meet the performance target, as a balancing measure University Health and Social Care North Lanarkshire (UHSCNL) receive significant volumes of feedback from service users through Care Opinion. UHSCNL had a total of 49 stories published on Care Opinion during February 2025; 90% of those were positive of their experience. • Sickness absence - The partnership continues to work towards reducing sickness absence rates as part of the Adult Social Care services and the Health Care Services savings delivery plan. Reviews, which began in April 2024 are running through 2024/25 and 2025/26 and, despite ongoing efforts, sickness absence remains an issue, with actions being taken to reduce the rate. Within the partnership, long and short-term sickness absence continues to be managed in accordance with the relevant organisational policies and monitored at service level. Attendance management reviews are taking place as required and local managers are complying with the requirements of the policy. Managers are focussing on cases that have breached sickness absence triggers and other long-term absences; there also remains a wider focus on staff health and wellbeing as a key contributing factor to levels of sickness absence. Page 20 of 288
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Appendix 2 (2) Chief Officer service specific performance reporting which takes place each year to meet business and/or statutory obligations. Report title Summary Scottish Roadworks Commissioner - annual performance 2024/25 August 2025 The Scottish Road Works Commissioner oversees improvements to the planning, co-ordination, and quality of road works by both local authorities and statutory undertakers in Scotland. The council has a duty, under section 118(1) of the New Roads and Street Works Act 1991, to co-ordinate the execution of works of all kinds in roads for which it is responsible. This report presents details of the Scottish Road Works Commissioner’s Performance Review in relation to road works undertaken by the council during 2024/25. Aligned Priority: • Enhance participation, capacity, and empowerment across our communities. Ambition statement: 17. Ensure we keep our environment clean, safe, and attractive. Consistent • The report is produced in line with the requirements of the Commissioner who monitors performance and promotes and encourages good practice across both utility companies and all roads’ authorities. The Commissioner also has powers to impose financial penalties on roads authorities who systematically fail in their duty to co-ordinate and upon statutory undertakers who systematically fail to co-operate when undertaking road works. Transparent • The Scottish Road Works Commissioner is an independent public official established under section 16 of the Transport (Scotland) Act 2005 and is accountable to the Scottish Ministers and ultimately the Scottish Parliament. The Commissioner's aim is to improve the planning, coordination, and quality of road works throughout Scotland. • The report sets out the requirement that all works undertaken within the Public Road in Scotland require to be noticed in accordance with the conditions and timescales as set out in the New Roads and Street Works Act 1991 and associated Codes of Practice. All works must be recorded on the Scottish Road Works Register (Aurora). Any proposed works entered onto the Aurora system without the requisite information, or outwith the prescribed timescales (both prior to and after the works are undertaken), will incur a noticing failure. • The report also notes that the Office of the Scottish Roadworks Commissioner issues annual performance review letters to all works promoters in Scotland. Any organisation that fails to meet the identified performance figures may be required to meet with representatives from the Commissioner’s office to discuss the figures in greater detail. - The aim is to balance the statutory rights of road works authorities and undertakers to carry out works, with the expectation of road users that disruption from works shall be kept to a minimum. - The Commissioner has the Power to issue a Penalty of up to £100,000 to organisations who persistently fail to comply with the requirements of the Act and / or secondary legislation. In context The report sets out the context in terms of the responsibility for the day-to-day management and co-ordination of works undertaken on roads which is as follows: • North Lanarkshire Council, as the roads authority, has a duty to co-ordinate all road works carried out on any road for which they are responsible. • The reinstatement of road surfaces remains the responsibility of the party undertaking the works. The roads authority has powers to inspect road works to ensure that statutory undertakers (typically utility companies) fulfil their obligations. • Traffic management at road works (cones, signs, and barriers) is the responsibility of the party undertaking the works. • The roads authority is responsible for any decisions related to the repair and maintenance of their roads. The report recognises that the provision of new utilities is fundamental to many regeneration and infrastructure projects that contribute to the success of The Plan for North Lanarkshire and advises of a continued increase in the number of requests for work, resulting in higher competition for road-space. In addition, the telecommunications sector has seen a significant increase in installation of new services. This includes the replacement of copper cables with fibre optic Page 21 of 288
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services and, within North Lanarkshire, the roll out of the digital infrastructure transformation project. Balanced • The report advises that performance levels in recent years have generally been to a high standard. In 2019/20 the Commissioners report stated that in relation to works planning and operational functions, “North Lanarkshire’s performance sets an example to other roads authorities”. • Performance in 2022/23 was summarised as “overall, the road works performance of North Lanarkshire Council was well-managed during 2022/23. This continues the good management from the 2021/22 reporting year and I acknowledge your continuing commitment.” • Performance in 2023/24 was summarised as “overall, the road works performance of North Lanarkshire Council was satisfactory during 2023/24. I expect to see increased efforts to deliver a well-managed performance in 2024/25”. • Performance in 2024/25 was summarised as “overall, I find North Lanarkshire Council’s performance to be satisfactory.” • The primary reason for the reduction in overall performance is due to the more stringent requirement in noticing regulations implemented through the Transport (Scotland) Act 2019 on 1st April 2023. - The Transport (Scotland) Act 2019 requires statutory compliance with Safety at Street Works and Road Works - a Code of Practice and a significant change in this respect is the statutory requirement to provide full pedestrian segregation at all road works. This initiated a change of standard practice at carriageway and footway resurfacing sites, where the provision of traffic management was previously based on risk. This has resulted in increased safety measures which required to be implemented to protect the public and workforce at additional costs. - The Commissioner introduced Compliance Officers in 2024 to ensure all organisations working on the Public Road network are fully compliant with the relevant legislation. Training was provided to council staff and the requirements were outlined to all contractors. However, a repeat (significant) failure by one contractor at a site in August 2024 resulted in the Commissioner issuing a Compliance Notice to the council. Action was taken to address the failure, resulting in the Commissioner highlighting: “I was reassured by the positive response to the compliance notice and would like to acknowledge the efforts made to significantly improve your management of road works sites in 2025”. - Overrunning works are identified as an area requiring improvement. These occur when the works take longer than anticipated due to unforeseen circumstances, and where the responsible officer fails to apply for a notice extension within the required timeframe. Performance issues in quarter 1 resulted in further training being undertaken with improvements noted in the second half of the year which are expected to continue. - The Commissioner introduced an additional indicator in 2024/25 to review the numbers of final inspections being recorded in relation to defects notified by an authority. Where roads inspectors find defective works, they notify the defect to the responsible utility, requiring a repair to be undertaken within a timescale defined by the risk that the defect presents. - The Commissioner noted 318 defects where the council had not recorded follow-up inspections to confirm that the remedial works were completed satisfactorily. This does not mean that the remedial works have not been completed or inspected, but an action plan is in place to ensure that the correct administrative processes are followed moving forward to address this. • The report contains an in-depth analysis of council performance in an appendix with data and graphs in relation to noticing failures, works stated and completed, overrunning works, fixed penalty notices issued to statutory undertakers, and sample inspections undertaken on statutory undertakers works. • The report also highlights the impact of changes in legislation including updated legislation from April 2024 which makes provision for the Commissioner to issue Compliance Notices where specific duties have been breached; figures in this respect are noted in the appendix to the report. • The report also highlights the council’s role in public utility works, along with information on the type and frequency of inspections as well as the performance in this respect. Report title Summary Business regulation/food law - annual plan and performance August 2025 All local authority regulators of food law and occupational health and safety law must plan their enforcement and advisory activities and, in accordance with independent auditor preference, present that plan before a relevant committee for its approval. The report provides a summary of the Service Plan for the council’s Business Regulation service which fulfils the council’s obligations relevant to food and health and safety law. Aligned Priority: • Improve the health and wellbeing of our communities. Page 22 of 288
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Ambition statement: 14. Ensure the highest standards of public protection. Consistent The service is required, in accordance with legislation, to prepare an annual plan which clearly maps out specific aims and objectives for the financial year. Transparent • Food Standards Scotland advocates that transparency is best achieved by seeking and obtaining the approval of elected members; this is achieved through due consideration of the annual report at a committee of the council each year. • Food Standards Scotland is independent of national government and has the primary objective of protecting the health and other interests of consumers in relation to all food issues. • The Health and Safety Executive’s National Local Authority Enforcement Code requires the council to be accountable to the public and businesses for their actions; this is achieved by publication of the annual Service Plan. In context • The report sets out the context within which the service operates in North Lanarkshire - in this respect the Business Regulation service is a subset of Protective Services and is responsible for the delivery of the statutory enforcement and advisory service for: - Food law in all food establishments within North Lanarkshire. - Occupational health and safety law in those premises within North Lanarkshire for which they have an enforcement role (health and safety enforcement) within premises being split between local authorities and the Health and Safety Executive depending on the nature of the business. • The report also notes that Food Standard Scotland granted dispensation to local authorities to deviate from their annual food inspection plans from 30/03/2020 due to the restrictions imposed during the pandemic, and to enable re-tasking of Environmental Health officers to undertake wider public health duties related to Coronavirus legislation. The dispensation ended on 31/08/2021, at which point local authorities commenced 5 year planned work recovery intervention programmes. During 2025/26, the council is continuing to implement the inspection recovery plan, from year 4 into year 5 of the final 5-year rolling plan. Extensive risk rating and forward planning has been undertaken to ensure that Food Standard Scotland remain satisfied that the council is adopting an appropriate recovery plan to ensure that all premises receive the required inspection visits within a practicable and programmed timeframe. Balanced • The report sets out the performance targets for the year and the Service Plan in the accompanying appendix details resources and targets for inspections and interventions in respect of food law, including: - Achieving a target of at least 85% of all programmed food law inspections within agreed timeframes. This is an increase on last years’ target which was set at 80%. - Ensuring at least 93% of food business operators’ premises achieve a Pass status in accordance with the national Food Hygiene Information Scheme (FHIS). This is an increase on last years’ target which was set at 90%. - Commencing investigation of at least 90% of high-risk food and food premises complaints within 2 working days of receipt, and commencing investigation of at least 90% of low-risk food and food premises complaints within 5 working days of receipt. This maintains the targets from last year, which was the first time the performance measure had distinguished between high-risk and low-risk. - Maintaining a target of at least 95% of infectious disease cases being responded to in accordance with the NHS Lanarkshire Epidemiological Investigation Protocol. This is an increase on last years’ target which was set at 94%. - Responding to at least 93% of high-risk and low-risk requests for assistance/advice within 2 and 5 working days of receipt respectively. • The annual Service Plan in the appendix in the report, sets out the detailed delivery aspects of the service as well as demand volumes and performance. • An important principle of the Food Law Rating Scheme is to allow local authorities to target resources on high-risk and non-compliant businesses. The food law intervention scheme rating is based upon a recent food business performance model that targets resources on high to medium risk and non-compliant businesses. This impacts upon the calculation used to determine the frequency of inspection of food business establishments for both the hygiene and standards components of a food law inspection. The Food Law Rating Scheme takes account of a food business operator’s track record of compliance and where this is good, the business will receive an earned recognition status influencing the risk rating to reduce the frequency of inspections. This assists the council by enabling resources to be targeted towards non-compliant businesses which are subjected to more frequent inspections and enforcement actions where required. • The report also includes information on occupational health and safety law - the Health and Safety Executive’s national Local Authority Enforcement Code sets out a risk-based approach to targeting health and safety interventions to be followed by local authority regulators. A key component is to ensure that appropriate interventions are focussed upon specified high-risk sectors. In accordance with the national enforcement code, the council will continue to Page 23 of 288
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respond to requests for advice, investigate complaints, accidents, dangerous occurrences, and other incidents reported and undertake appropriate interventions, particularly relevant to North Lanarkshire, wherever possible. The Service Plan details activities which are planned to be undertaken throughout the financial year in respect of the regulation of occupational health and safety matters. Additional projects may also be added where appropriate, having been highlighted by the Health and Safety Executive, regionally by the West of Scotland Health and Safety Liaison Group, or through local intelligence, complaint, notification or other direct referral to the council. • The Health and Safety Executive require local authorities to submit enforcement returns by the end of May each year, detailing the occupational health and safety works undertaken in the previous year, the report notes that the council’s return was submitted on 19th May 2025. Report title Summary Scottish Housing Regulator - Annual Assurance Statement 2024/25 August 2025 The Scottish Housing Regulator was empowered by the Housing Scotland Act 2010 and has, since April 2013, possessed statutory powers to monitor, assess, report, and intervene (as appropriate) based on the performance of any Social Landlord in Scotland. Since April 2019, Social Landlords in Scotland have a statutory annual obligation to produce an Annual Assurance Statement relating to the previous financial year (by 31 October each year). The council has adopted a process whereby the statement requires to be presented to Committee and is signed by the Convener of Housing prior to submission to the Regulator. These statements are published for each landlord making them readily available to all tenants. Aligned Priority: • Improve economic opportunities and outcomes. Ambition statement: 1. Ensure a housing mix that supports social inclusion and economic growth. Consistent The service requires to comply with the regulatory requirements set out in Chapters 3 and 5 of the Scottish Housing Regulator Framework. To ensure that compliance is met, the service has appropriate and effective mechanisms in place to support the signing of the Annual Assurance Statement each year. These processes and actions continue to be maintained, monitored, reviewed, and updated (if required) on a regular basis. Transparent • The full Annual Assurance Statement is attached to the report. To fulfil Scottish Housing Regulator requirements, the service manage and monitor a comprehensive portfolio of control checks and review mechanisms. In addition, an evidence base is held (including items such as base and formulated performance data (with full worked examples of performance measures), procedural guides, process maps, completed audit reports, and copies of reports submitted to council committees) - this evidence base is set out in the August 2025 report to the Housing Committee. In context The report advises that its purpose is to seek committee approval on the sign off relating to the sixth Annual Assurance Statement as shown in an appendix. The statement confirms that the North Lanarkshire Council Annual Assurance Statement for 2025 advises that the council: • Complies with all the regulatory requirements set out in section 3 of the Regulatory Framework. • Achieves all standards and outcomes in the Scottish Social Housing Charter for tenants, people who are homeless, and others who use council services. • Complies with all legal obligations relating to housing and homelessness, equality and human rights, and tenant and resident safety. Balanced • The Scottish Housing Regulator has advised that legally the council must notify them during the year of any material changes to the assurance in the Annual Assurance Statement, including any areas of non-compliance. The report to the Housing Committee in August 2025 advises there are no areas of non-compliance to report for 2024/25. • In line with Scottish Housing Regulator guidelines, landlords are asked to confirm whether they meet all duties in relation to tenant and resident safety, and in particular that they have obtained appropriate assurance about compliance with all relevant safety requirements including gas safety, electrical safety, water safety, fire safety, asbestos, damp and mould, and lift safety and the council’s assurance in this respect is set out in an appendix to the report. In addition, any landlords who have identified Reinforced Autoclave Aerated Concrete (RAAC) in their homes and don’t have a plan to manage the associated risks are required to highlight this in their Annual Assurance Statement. While the council has identified RAAC in a small number of properties, there is a plan in place to manage this (as reported to the Housing Committee in February 2025) and therefore information has not been included in the Annual Assurance Statement. Page 24 of 288
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Report title Summary Housing and corporate maintenance and investment services contract - interim report August 2025 Operational, since July 2024, the housing and corporate maintenance and investment services contract has allowed the council to access a range of maintenance, repair, and essential compliance services for its housing and corporate property portfolio, including gas servicing, planned maintenance on tenanted, corporate and empty properties, responsive repairs, essential compliance services (including fire safety, gas safety, electrical testing, water testing, and asbestos management), some related call handling services, investment projects/programmes, and ad-hoc minor works. This report provides the latest results against the contract through a set of performance measures, well as performance in relation to the Scottish Housing Regulator and measuring the charter outcomes. Aligned Priority: • All priorities. Ambition statement: • All ambition statements. Consistent • To support the approach to contract management, an Enterprise Contracts Performance and Assurance team has been established in respect of the governance arrangements. As part of the council’s approach to enhanced contract management, a suite of toolkits has also been developed to regularly and consistently support and monitor key aspects of the contract. A range of tools are operational to support this process, i.e. contractual spend tracker, service credit model calculator, social value tracker, obligation register, performance indicator monitoring dashboard with trend forecasts, contract risk register, change control register, core projects register, and an annual service delivery plan. • To ensure regular updates on the contract are reported to committee, an annual report is scheduled to be presented to the Housing Committee each year, providing an overview of the achievement of performance indicators and social value outcomes, contract spend, applicable service credits and strategic maturity monitoring for each contractual year. In addition, an operational performance report with interim updates on performance against operational indicators, contract spend, and social value outcomes is scheduled to be presented to the Housing Committee at cycle 1 for each contractual year. Transparent • The report sets out the governance arrangements for the contract which involves multiple layers to provide essential scrutiny and oversight (this is also depicted in a diagram). It also sets out clear roles and responsibilities for operational ownership, contract management, and contract development activity. A list of the governance groups, their roles, meeting frequencies, and council membership are contained within the report. In context • The report lists the services that are being delivered to the asset types which include but are not limited to, Housing - approximately 36,500 homes including mainstream housing for social rent, retirement housing and supported needs (including emergency homeless accommodation), and Corporate - approximately 1,200 buildings, which include public buildings, educational establishments, community facilities, and other miscellaneous buildings. • The report provides information in respect of the transition of contracts in scope. In addition, a summary of community benefits is reported to show the benefits at a local area which was a key aspect of the procurement along with the contractor’s social value commitments (e.g. including the creation of new jobs, craft and modern apprenticeship programmes, work placements, and employing locally, etc). Balanced • Social value highlights delivered during the first year of the contract include 51 new apprenticeships created across the contract and supply chain, 91% of workforce locally based, target exceeded for percentage of women hired on the contract, target exceeded for percentage of employees (BAME) hired on the contract, over £18m spent through local supply chain, over 2,000 hours of voluntary time provided to local groups and VCSE’s, and six local projects financially supported through the contractors Foundation. • The contract allows for an enhanced approach to performance monitoring through the use of strategic and operational performance indicators, including the introduction of a service credit model with financial deductions for failure to meet indicators. A small number of indicators do not yet have available data to allow for robust reporting or have not generated data during the operational period to produce an output. Where required, performance monitoring of these areas is carried out through the contract governance groups. • Latest results and further information on the suite of indicators are summarised in the covering report with more detail included within appendices to the report. This includes information on housing property performance, contract property performance, frontline resolutions, complaints, core projects, contractual spend, and risks. Page 25 of 288
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Report title Summary Tackling Poverty annual report 2024/25 August 2025 This report provides details of the income maximisation work carried out by tackling poverty, social work, and housing services during 2024/25 and additional benefit income for the residents of North Lanarkshire. It also highlights the activity of the external services commissioned by the council and the additional income generated for residents. The report also provides further information on operational activity while updating on the continued programme of welfare reform and its impact, and challenges - which the council, partners, and communities are predicted to face over the next three to four years. Aligned Priority: • Improve the health and wellbeing of our communities. Ambition statement: 11. Increase economic opportunities for adults by understanding, identifying, and addressing the causes of poverty and deprivation and barriers to financial inclusion. Consistent • The council is the largest local authority landlord in Scotland. In addition, the local Registered Social Landlord sector owns and manages approximately 9,000 properties. • The report estimates that around 58.5% of social tenants are in receipt of Housing Benefit (57.3% in the council housing sector). Early intervention with income maximisation assists in the prevention of rent arrears and the sustainability of tenancies. Housing advisors provide basic information and advice to vulnerable tenants and homeless people, concentrating on housing benefit to ensure people can pay their rent. They receive welfare rights training and are supported by council Welfare Rights Officers. Transparent • The report provides a very detailed overview of performance in all the key areas of service delivery - income maximisation, appeals, debt advice, training, external services, and the impact of legislative / policy changes. • The report also lists benefits which have now been devolved to Scotland and which the Scottish Social Security Agency are in the process of rolling out. • The report also outlines plans announced by the UK and Scottish Government for major changes to the benefits system initiated in, or planned, for 2025/26. In context • The report sets out the context in terms of 2024/25 being a time when inflation was less acute, but the cumulative effects of the cost-of-living crisis have continued to impact on communities, bringing the importance of income maximisation and wider work to tackle poverty into sharp focus, highlighting the impact of low paid and insecure work in particular as being a specific challenge. • The report also sets out the context in terms of local approaches to tackling poverty and reducing inequality in North Lanarkshire, which continue to be driven by the Towards a Fairer North Lanarkshire Tackling Poverty Strategy with activity focused on the key drivers of poverty and an integrated whole systems approach. Balanced The report lists a range of key highlights for 2024/25 which include the following: • Income maximisation - demand has increased in respect of the welfare rights service with the average number of referrals received per month rising 4.5% from 1,180 in 2023/24 to 1,233 in 2024/25. Benefits checks increased from 26,158 in 2023/24 to 29,819 in 2024/25. • Additional benefit income generated by the council increased by 14% from 2023/24 to 2024/25 with £55.3m of additional benefit income generated via claims, mandatory reconsiderations, and appeals for benefits. • As reflected in last year’s activity report the increase in referrals has had an impact on response times, with the normal call back of 3-5 working days, moving to 5-7 days to meet that demand. At times it has been necessary to move this to 7-10 days to meet the demand placed on the service. • MacMillan Lanarkshire advice service - this service (provided by the council) provides home visits, telephone interviews, office visits, and surgeries in local hospitals - reported 857 referrals. This is an increase of 157 from last year, of which 43% were for SR1/BASRiS cases (terminally ill). Income generated in 2024/25 was £3.4m residents referred affected by cancer. • Appeals - the council provides representation for residents at mandatory reconsideration stage and Social Security appeals and represented 286 individuals at mandatory reconsideration stage with a success rate of 66% and represented residents at 287 appeals. The overall success rate for Social Security Appeal Tribunals was 79.8%, which is the same as last year and above the national average of 63%. Page 26 of 288
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Report title Summary Community Asset Transfer and Participation Requests - annual report 2024/25 August 2025 This report provides an annual progress update regarding Community Asset Transfer (CAT) and Participation Requests (PR) in North Lanarkshire. This demonstrates the council’s compliance with the Community Empowerment (Scotland) Act 2015 which came into force in July 2015. The Act requires local authorities to engage with communities and the voluntary sector to deliver effective services in partnership to meet local need. Community Asset Transfers are covered under part 5 of the Act and Participation Requests are covered under Part 3 of the Act. Aligned Priority: • Enhance participation, capacity, and empowerment across our communities. Ambition statement: 19. Improve engagement with communities and develop their capacity to help themselves. Consistent The report has been prepared in line with the legislative requirements set out in Parts 3 and 5 of the Community Empowerment (Scotland) Act 2015, requiring relevant authorities to publish an annual report setting out the number of requests received and the outcome of these. The Scottish Government provides a template to use for this purpose. Transparent A summary of this report is published and made available online to communities ( https://www.northlanarkshire.gov.uk/your-community/working- communities/community-asset-transfer-and-participation-requests/community-asset-transfer ). In context • The report sets out the context within which the service is required to operate in relation to legislation. • The council’s corporate Community Ownership and Management working group oversees the development and implementation of processes relating to community ownership and management of assets. This group sets priorities, provides strategic guidance, and ensures consistency of practice across council services. • Debt advice - 2,367 referrals were received for money advice / debt advice from residents, elected members, CABx, health and social care services, education, housing services, NHS Lanarkshire, and other advice and information agencies. 53 Debt Payment Programmes (DPP) were dealt with and 42 bankruptcies were awarded. The cost-of-living crisis and people’s circumstances continuing to be unstable has impacted on the number of formal debt solutions being accessed. 2024/25 saw a further increase in the number of payment / crises breaks, variations, and revocations being dealt with by the council for current DPPs. The total debt dealt with was £5.3m. • Customers survey - following the introduction of the cost-of-living helpline, a text survey was introduced for residents referred to the council. While the number of returned text survey are very low (407) in relation to the number of referrals in 2024/25, work is continuing to increase returns during 2025/26. Headline results show that 84% of the referrals were self-referrals and the remaining 16% were NHS Lanarkshire, other council services, or elected members. The main reason for referrals was for benefit advice (income maximisation), followed by money advice, food and fuel poverty, mandatory reconsiderations, and representation at Social Security Appeals Tribunals. Overall, 90% of those responding were happy with the quality of advice provided, 90% were happy with the timescales of the response time, and 90% were happy with the ease of access to the service, with the main channel still by telephone and e-mail. Online self-referrals are available on the council website for money advice, but to date this has been low (8) during 2024/25. Of the 10% who completed the survey to say they were unhappy with the service, reasons for this were around the outcomes of appeals, e.g. unsuccessful, or the delay in the waiting time for the date of the appeal, both of which are outwith the control of the service. • Training - during 2024/25, over 100 training sessions have been provided to council services and external partners - using online video tools and face to face methods - covering tackling poverty awareness sessions, updates on benefits, welfare reforms and legislation, financial assessments, employment and support allowance, migrant workers, and other welfare benefits-related subjects. A range of online e-learning training packages continue to be maintained and made available, e.g. on the Scottish Welfare Fund, Personal Independence Payments, and Universal Credit. • External services - have seen 7,297 welfare rights enquiries, 3,216 housing advice enquiries with 4,631 referred to other agencies, 4,692 money advice enquiries with 2,780 referred to other agencies, and 5,356 benefit checks completed during the year. This helped to generate benefit income to local residents of £7,65m. In cost/benefit terms, every £1 invested by the council in external services during the year generated £20.83 for residents and the local economy. Page 27 of 288
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• During 2024/25, the working group has delivered improvements aligned to the Community Ownership and Management of Council-Owned Assets Policy (approved at Policy and Strategy Committee in June 2024) which implemented a broader and more community focused approach to ensure a more co- ordinated corporate approach and response to promoting, raising awareness, and responding to any requests for community use or the management or ownership of assets. This has strengthened the council’s commitment to supporting community bodies and maximising benefits from local assets. Key areas of focus have included: - Empowering community bodies to secure ownership or leases of land and buildings, giving them a stronger voice and a stake in decision-making. - Improving community participation and planning through clearer processes, early engagement, and better information sharing. - Reviewing and updating the council’s Community Asset Transfer and Participation Request policies to align with The Plan for North Lanarkshire and national best practice. • While the report refers to the formal Community Asset Transfer and Participatory Budgeting process, it notes that alternative mechanisms, such as negotiated leases and management agreements, may often provide the best route for community use. The recent policy updates and strengthens governance structures to ensure these opportunities continue to grow and deliver lasting benefits for communities across North Lanarkshire. Balanced Community Asset Transfers • The report provides an update on Community Asset Transfers, including in relation to the volume of enquiries and submissions as well as engagement and support to organisations and groups at the different stages of the process. It also sets out the key highlights since the last annual report. • During 2024/25 there was a total of 42 new enquiries relating to Community Asset Transfers. Combined with 37 ongoing enquiries from the previous year, the council has been engaging and supporting 79 organisations and groups, each at different stages of the Community Asset Transfer process. • Key highlights from the last annual report include: - An increasing number of enquiries year on year. - Successful implementation of the one-point-of-contact system. - More officer time invested in early-stage support, with clear guidance provided upfront to organisations about the process, eligibility criteria, and available funding or technical advice. - Ongoing strong demand from sports clubs and associations, particularly in relation to sports pitches and community facilities, indicating the importance of local assets for sports participation and community wellbeing. - Increased referrals to Voluntary Action North Lanarkshire for advice around governance and funding. - Strengthened relationships with the Community Ownership Support Service, operated by the Development Trust Association Scotland, to draw on national best practice and community wellbeing. - Reinforcing the council’s commitment to maximising community benefit from its assets through the Policy, ensuring fairness, consistency and transparency in how requests are assessed, and safeguarding assets where appropriate. The Policy confirms that each request is assessed against robust criteria including, where appropriate, that discounted leases and other flexible options may be agreed to enable community groups to deliver tangible local outcomes. - Strengthened cross-service co-ordination and early-stage discussions to explore all feasible options with groups, helping to manage expectations and ensure sustainable outcomes for communities and the council alike. - The most recent batch of applications where processed, assessed, and scored were presented to committee in record time, cutting the normal allocated 6-month timeline by 50%. Participation Requests • The report provides an update on Participation Requests, including in relation to the volume of enquiries and requests. It also sets out the key highlights since the last annual report. • During 2024/25 there was a total of 2 new enquiries relating to Participation Requests. Combined with 2 ongoing enquiry from the previous year, the council has been engaging and supporting 4 cases. • Key highlights from the last annual report include: - While the number of community organisations submitting formal Participation Request applications remains relatively modest at this stage, the council continues to provide comprehensive pre-application support to the majority of groups who express an early interest or submit an initial enquiry. This early-stage support is essential to ensure that community organisations fully understand the statutory processes. Page 28 of 288
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- In many cases, organisations benefit from ongoing, more intensive capacity-building support delivered by the council. This support goes beyond simple signposting and frequently includes bespoke advice on organisational planning, financial management, governance arrangements, volunteer and staffing requirements, policies and procedures, marketing and communications, project planning, community engagement and consultation approaches, and the collation of supporting evidence required to strengthen formal applications. • Information is also provided in the report in terms of the council’s commitment to strengthening the visibility and understanding of both Community Asset Transfers and Participation Requests and this will include developing, testing, and embedding a range of practical measures over the next three years. These measures will include refreshed communications materials, tailored community information sessions and roadshows, success stories and the provision of technical advice surgeries along with the continued integration within wider community engagement and partnership activity. Officers will also review opportunities to work more closely with local anchor organisations, such as Voluntary Action North Lanarkshire (VANL), and other key intermediaries such as Community Ownership Support Service, and the Scottish Land Fund. • The report also highlights improvement actions for the year ahead which includes a review and refresh of the Community Asset Transfer application form and the assessment and scoring process, a new suite of documents to be used by the working group assessment process, widening the reach to ensure that seldom-heard groups are fully aware, and delivering three events by spring of 2026 that focus on showcasing the legislation in practice. Report title Summary Local Outcome Improvement Plans performance report - October 2024 to March 2025 August 2025 This report provides a snapshot of progress linked to key priorities for each of the nine Local Outcome Improvement Plans (LOIPs) for the period from 1st October 2024 to 31st March 2025. This aims to demonstrate progress in delivering the LOIP priorities and implementing the supporting partnership delivery approaches. The report also provides an overview of progress with implementation of the Management and Monitoring Framework and work to develop the role of the Local Partnership Teams. Aligned Priority: • Enhance participation, capacity, and empowerment across our communities. Ambition statement: 19. Improve engagement with communities and develop their capacity to help themselves. Consistent • The report advises that the LOIP Management and Monitoring Framework is a tool for partners to highlight and report on progress with local action linked to LOIP priorities. The tool also aims to assist with reporting progress and outcomes around LOIP priorities to a range of audiences including the Community Boards, the Communities Committee, the North Lanarkshire Partnership Strategic Leadership Board, and individual partnership agency leadership teams as appropriate. • The Framework is intended to streamline reporting, ensure consistency, and allow partners to focus on critical issues or significant developments. Local Partnership Team members share a collective responsibility for ensuring action at a local level to drive forward the LOIP priorities, and to ensure that progress is regularly updated through the Framework. • Local Partnership Teams meet six-weekly with the purpose of ensuring oversight for delivery of LOIP priorities. With a few exceptions, priorities for each area have a clear delivery mechanism in place through the creation of operational subgroups or pre-existing partnership groups or processes. • Local Partnership Teams use the Framework and continue to refine the approach to reporting on progress to the Communities Committee. Transparent • The report advises that the LOIP Management and Monitoring Framework underpins quarterly reporting to individual Community Boards, six monthly reporting to Committee, and statutory annual reporting in line with the Framework for Demonstrating Improved Outcomes for Communities. • The six monthly performance outcomes, attached in appendices to the report, provide a summary of key highlights across the priorities identified in each LOIP. Planned future actions for the forthcoming six months (i.e. April to September 2025) are also included. In context • The report sets out the context within which the Management and Monitoring Framework was developed, i.e. in support of the North Lanarkshire Partnership Strategic Leadership Board’s Framework for Demonstrating Improved Outcomes for Communities - to ensure effective management, oversight, and reporting of progress on LOIP priorities by Community Planning Partners through the Local Partnership Teams. Page 29 of 288
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• Local Partnership Teams were established to drive and embed delivery of the LOIPs across the Community Planning Partnership and ensure effective monitoring and management of progress. Balanced • The report is accompanied by two appendices which set out an update on progress in delivering the LOIP improvement plans between October 2024 and March 2025, and an update in relation to the online LOIP webpages showcasing the work being undertaken by the North Lanarkshire Partnership. The latter contains hyperlinks to the council’s website which summarises these highlights. • Work has been undertaken with partners to ensure accountability and ownership for delivery of actions, participation in Local Partnership Teams and use of the framework to inform monitoring. Examples include: - Consultation with Local Partnership Team members and a review of the Management and Monitoring Framework to streamline and improve the reporting process for LOIP priority leads. This informed amendments to the system implemented from September 2024 onwards. - Accountability meetings introduced with senior officers to ensure that quality of information fed into the Framework and reports reflect progress with local action. Senior managers are also responsible for finalising the information that is appended to reports to the Strategic Leadership Board, Communities Committee, and Community Boards. - The four Local Partnership Teams have development plans in place to ensure a focus on continuous improvement actions for their operation. - Online LOIP webpages have been created to showcase the work undertaken across all nine localities to deliver the LOIP priorities. - Maintaining resources to ensure consistency of approach where there are organisational changes and higher levels of staff turnover. - Continuing to address any potential disconnect between strategic approaches and how local priorities are driven and led. - Continuing to strive to increase levels of community engagement, participation and ownership for action in delivery mechanisms to ensure a local focus, and involvement of the community and voluntary sector key delivery partners. • The report updates on Community Board Chairs and improvement activity (which follows on from the self-assessment activity that took place in 2023/24). This references that the nine Community Board Chairs continue to meet quarterly with the council officers to consider matters relevant to all boards, share good practice, and explore any challenges collectively. To date the chairs have assisted with the Community Board Conference in May 2025 and development of a Community Board induction process with video content. Each of the Boards will agree their own improvement actions at the autumn 2025 series of meetings and will continue to be involved in the implementation of these actions throughout 2025/26. • The report also references the LOIP review which is taking place from 2025 to 2027 as per the report to the Communities Committee in August 2025. Report title Summary Procurement - annual report 2024/25 September 2025 As per the Procurement Reform (Scotland) Act 2014, the council is required to prepare an Annual Procurement Report on all regulated procurement activity as soon as reasonably practicable after the end of each financial year. The latest report to Committee in September 2025, provides the Annual Procurement Report which covers the council’s procurement activity during the financial year 2024/25. The Annual Procurement Report also provides a summary of performance against the council’s Procurement Strategy 2024/25, which was approved at Committee in February 2024. The report is published on the council’s website: https://www.northlanarkshire.gov.uk/business/procurement/key-procurement-documents. Aligned Priority: • All priorities. Ambition statement: • All ambition statements. Consistent The Annual Procurement Report is required to be produced in accordance with legislation and specific guidance. The report specifically specifies the areas which the legislation requires the council to report on: • As legislated through the Procurement Reform (Scotland) Act 2014, the council is required to prepare an annual procurement report on all regulated procurement activity as soon as reasonably practicable after the end of that financial year. Regulated procurements refer to any procurement above £50,000 for supplies or services and above £2,000,000 for works. • The Act requires the council’s annual procurement report to include: - A summary of the regulated procurements that have been completed in the previous financial year. Page 30 of 288
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- A review of whether those procurements complied with the council’s procurement strategy, and, where any regulated procurements did not comply a statement of how the council intends to ensure that future regulated procurements do comply. - A summary of any community benefits fulfilled from regulated procurements. - A summary of any steps taken to facilitate the involvement of supported businesses in regulated procurements. - A summary of the regulated procurements the council expects to commence in the next two financial years. - Such other information as the Scottish Ministers may by order specify. Transparent • The Act requires the council to publish the annual procurement report online and to share a copy with Scottish Ministers. • Scottish Ministers must prepare a report on procurement activity in Scotland; this is generated from the annual procurement reports submitted by relevant public bodies. • Scottish Ministers are required to publish their report and lay a copy before the Scottish Parliament. • The Act requires Scottish Ministers to publish guidance for the consistent data gathering and preparation of annual procurement reports and procurement strategies; this is provided in the Scottish Procurement Policy Note, SPPN 2/2025. In context • The introduction in the appendix to the annual report sets the context in that the council: - Is responsible for the delivery of a wide and diverse range of statutory and discretionary public services. - Delivers services through a mixed economy acting as both a provider, through direct provision of services using its own workforce and assets, and an enabler with services delivered through private contractors, the third sector, and supported businesses. - Spent £706m during 2024/25 (excluding VAT) on goods, services, and works to carry out operations and delivery of public services. Balanced • The appendix to the report provides a detailed account of the council’s procurement activities for 2024/25 in line with the national guidance. It provides a summary in terms of regulated procurement activity for 2024/25, compliance with the procurement strategy, community benefits, supported businesses, and regulated procurements expected in 2025/26 and 2026/27. • It also sets out the procurement outcomes in detail for the year; these are articulated through a large suite of performance indicators which clearly identify the outcome for the year. • Two additional annexes to the report provide detailed information on regulated procurements completed and planned. Report title Summary Economic Regeneration Delivery Plan (ERDP) performance framework - annual update 2024/25 August 2025 This report provides an update on the progress being made towards the implementation and delivery of North Lanarkshire’s Economic Regeneration Delivery Plan (ERDP) and associated Action Plan. The Economic Regeneration Delivery Plan (ERDP) was initially approved at Committee in August 2019, covering the period 2019-23. A light-touch refreshed ERDP, covering the period 2023-28, was then approved at Committee in February 2023. The Action Plan is updated annually, and the progress report details activity as at the 2024/25 year end. The report also presents the latest ERDP Performance Framework update which is used to monitor wider ERDP performance over the short, medium, and longer term (through to 2035). Unlike the ERDP Action Plan, figures within the Performance Framework are reported on a cumulative basis to show the progress against the longer-term ambitions of the ERDP. Aligned Priority: • Improve economic opportunities and outcomes. Ambition statement: 1. Ensure a housing mix that supports social inclusion and economic growth. 2. Refocus our town centres and communities to be multi-functional connected places which maximise social, economic, and environmental opportunities. 3. Maximise the use of our marketable land and assets through improved development in business and industrial infrastructure. 4. Market and promote North Lanarkshire as the place to live, learn, work, invest, and visit. Page 31 of 288
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5. Grow and improve the sustainability and diversity of North Lanarkshire’s economy. Consistent • Since 2019, an Action Plan to support the delivery of the ERDP through a range of key measures and investment programmes has been produced and approved each year by Committee. The Action Plan sets the priorities for the financial year ahead, reflecting progress made to date and the evolving priorities of the council. • The 2024/25 Action Plan was approved at Committee in February 2024 and the 2025/26 Action Plan was approved in February 2025. • An accompanying ERDP Performance Framework was approved at Committee in February 2021. Transparent • The report has a dedicated section that summarises the performance review undertaken on the latest data and highlights recent achievements. • An appendix to the report provides an update on all ERDP Action Plan objectives and targets achieved during 2024/25. In context • The Economic Regeneration Delivery Plan (ERDP) aims to help co-ordinate physical and economic regeneration activity across North Lanarkshire, increase economic output, and address social and economic inequality. • The ERDP Performance Framework sets out the context within which it operates in that it comprises a set of performance indicators at three levels. • These indicators aim to collectively provide an overview of performance that helps the council to understand the impact of its work on improving economic opportunities and outcomes for all. It also enables performance issues against the ERDPs key priorities to be identified and addressed, mitigating the risk of delivery failure. • Given the shared ambition set out within The Plan for North Lanarkshire, the ERDP Performance Framework is closely aligned to the corporate Strategic Performance Framework. • The ERDP Performance Framework is kept under regular review to ensure arrangements remain effective and aligned to future versions of the ERDP and The Plan for North Lanarkshire. Balanced The report advises that good progress continues to be made against the ERDPs key objectives with highlights during 2024/25 including: • Delivery of an additional 278 new build homes via the new supply programme, as well as a further 92 open market / empty homes purchase scheme completions, taking total completions to 2,474 by March 2025. • Committee approval of Town Action Plans for Bellshill, Kilsyth, and Shotts. • Formation of a Coatbridge Neighbourhood Board to deliver the UK Government’s £19.5m Plan for Neighbourhoods funding as well as a series of public engagement across the summer of 2024 to kickstart the development of the decade long Regeneration Plan for the town. • A six-week public consultation held at Cumbernauld Library, showcasing initial timescales and early exemplar images of the reimagined Cumbernauld town centre, attracted more than 440 in-person engagements and 1,600 website views during the consultation period. • 105 new affordable homes delivered across North Lanarkshire’s town centres, including edge of town sites. This includes council developments as well as Registered Social Landlords (RSLs). • Construction of building 3 at Link Park, Newhouse began in February 2025. This project is scheduled to complete in December 2025 and will deliver 19,375 square feet of new industrial workspace. • Establishing an Invest in North Lanarkshire team and formal multi-disciplinary pre-application service to support delivery of a Programme of Work priority. • As part of the Ravenscraig Access Infrastructure project, demolition works were completed to properties at Manse Road (former Cook and Indis and Yesss Electrical), the former Evans Halshaw dealership, and the adjacent vacant commercial unit at Windmillhill Street. • Outline Business Case approval was secured for the East Airdrie Link Road (EALR) project from Glasgow City Region City Deal Cabinet in August 2024. The report also highlights significant progress in improving economic opportunities and outcomes for North Lanarkshire’s residents and businesses. Highlights achieved as at 31st March 2025 include: • 1,629 new build council homes complete. • 845 homes brought into council ownership via the open market purchase scheme, including some homes previously sold under the Right to Buy. • £119.7m invested in town centre (including edge of town) developments, of which more than £56m was secured via external funding sources. • Town Action Plans approved for Airdrie, Bellshill, Kilsyth, Motherwell, Shotts and Wishaw. • 1,797 new affordable town centre homes completed (including edge of town sites) by the council and housing associations. This includes developments across most towns with completed sites including the former Orrs building, South Bridge Street (Airdrie), Brandon Street (Motherwell), the former Page 32 of 288
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Kingfisher Building, Dowanfield Road (Motherwell), Caledonian Avenue (Bellshill), 95 Main Street (Kilsyth), and Roberts Street (Wishaw) among others. • 169,733 square feet of business and industrial workspace created or refurbished as a result of investment by the council, Fusion Assets, and North Lanarkshire Properties (NLP). • £62.3m invested in key road infrastructure projects funded via the council and the Glasgow City Region City Deal. Report title Summary Social work - quality assurance report 2024/25 September 2025 The role of quality assurance includes a broad spectrum of activity both internally across social work services, and, in partnership with commissioned services. Assurance and governance underpin key service functions while aligning work to The Plan for North Lanarkshire and Programme of Work. Throughout 2024/2025, the Quality Assurance team have participated in strategic planning meetings, influencing and shaping future priorities and approaches aligned with the University Health and Social Care (UHSCNL) Strategic Commissioning Plan 2023-26 and the priorities outlined within the associated Programme of Work. This report updates on the service’s quality assurance activity over the period from April 2024 to March 2025. Aligned Priority: • Improve the health and wellbeing of our communities. Ambition statement: 12. Ensure our residents are able to achieve, maintain, and recover their independence through appropriate supports at home and in their communities. Consistent • A commitment is in place to provide an annual report on activity carried out in the preceding year; this reflects ongoing improvement and work to ensure people can influence and shape decision making. Transparent • The report outlines how work has progressed in areas which includes contracts and contract management, procurement, back to basics - getting it right for everyone, safe staffing, market facilitation, review of registered social landlords, duty of candour, in-house monitoring, social work risk management, adult social work governance subgroup for registered managers, participation and engagement, and carers. • The bigger part of the work focuses on social work procurement and contract monitoring. The range of contracts that have been procured, and further development of the contract management framework, are detailed within an appendix to the report. In context • The report notes that the health and social care environment in which the service operates remains challenging and sharing of best practice and solution focused ideas are integral to ensure the people of North Lanarkshire receive good quality support to help meet their outcomes. Balanced • The report comprises the detailed annual report in the appendix which provides the context within which quality assurance operates in social work. This recognises that quality assurance has a wide and varied function including monitoring and evaluating key aspects of social work practice and performance. A central activity is the ongoing contract monitoring of external social care providers. • The appendix includes data and information to support the quality assurance process and performance update and highlights areas of good practice as well as areas requiring improvement and remedial action implemented. • The Contract Management Framework was the focus of a recent internal audit of quality assurance. Findings were positive, with only minor recommendations for improvement. As a result of the audit, feedback from stakeholders, and new legislation, further enhancements have been made: - The Contract Management Framework process has been made clearer with roles and responsibilities outlined for quality assurance staff and providers. - The monitoring prioritisation assessment has been modified to more clearly identify service-related risk. - An analysis of quarterly return submission is documented, and feedback is now given to providers. - A closure date has been introduced for acceptance of quarterly and annual return submissions to enhance compliance. - Information has been added to capture the principles of safe staffing legislation. Report title Summary Page 33 of 288
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Registration service - 2023 performance review September 2025 This report provides an overview of the performance of the council’s Registration Service during 2023, together with an update on the ongoing review of operational arrangements and service delivery model. The Registration Service manages high levels of demand, delivering statutory functions relating to births, deaths and marriages, as well as civil ceremonies and citizenship services, on behalf of the Registrar General for Scotland. Aligned Priority: • Enhance participation, capacity, and empowerment across our communities. Ambition statement: 20. Improve the involvement of communities in the decisions, and development of services and supports, that affect them. Consistent • Performance is routinely monitored through internal performance management arrangements and independently assessed annually by District Examiners from National Records of Scotland (NRS). Transparent • The most recent NRS audit, summarised in an appendix to the report 1, demonstrates that the Registration Service continues to perform at a consistently high level, achieving accuracy rates in excess of 97% across all three districts (North, Central, and South). In context • The report notes that significant transformation of service delivery has taken place since the pandemic, including the introduction and formalisation of remote registration methods under the Coronavirus (Recovery and Reform) (Scotland) Act 2022. The review of Registration Services has identified opportunities to centralise staffing at the Dalziel Building in Motherwell, while continuing to provide face-to-face appointments in the three key locality areas of Cumbernauld, Airdrie, and Coatbridge to maintain community accessibility. This approach aligns with the strategic direction set out in the council’s Programme of Work and office rationalisation commitments. • The Registration Service employs 12 staff (10.5FTE), designated as static workers, with eight staff holding the nationally recognised Certificate of Proficiency in the Law and Practice of Registration. These staff ensure compliance with all statutory obligations and best practice guidance issued by the NRS. • The Registration Service currently operates from three primary offices: Airdrie, Cumbernauld, and Motherwell. In line with the council’s office rationalisation policy, all registration staff have now been centralised at the Dalziel Building in Motherwell. This centralisation does not reduce accessibility for residents. Face-to-face appointments continue to be delivered at both Airdrie and Cumbernauld offices, supported by a managed appointment system to ensure efficient use of resources while maintaining local provision. Looking forward, a review will be undertaken to explore additional opportunities for in-person appointments across other locality venues. Balanced • The report highlights that in 2023, a total of 8,100 life events were registered, comprising 3,033 births, 4,399 deaths, and 650 marriages, alongside civil partnerships and stillbirth registrations. • Error rates remained low, with an overall 2.02% error rate across all registrations. The South district recorded the highest volume of events (3,433) and also achieved the lowest error rate (1.63%), highlighting both the scale and quality of work being delivered within that area. • While the data confirms consistently strong performance, it also reflects variations in demand across localities, with Central and South handling notably higher volumes of deaths and marriages compared to North. These trends are informing workforce deployment and the design of the blended delivery model, ensuring that resources are aligned to patterns of demand while maintaining service quality across all localities. • The ability to sustain such accuracy levels through this period of change reinforces confidence in the robustness of service delivery and the effectiveness of ongoing quality assurance processes. • The covering report summarises the latest data in respect of births, deaths, and marriages with two appendices to the report providing further data in respect of registration service performance and registration service demand and delivery trends. Report title Summary Improving educational outcomes - session 2024- 25 Removing barriers to achievement and promoting excellence and equity for all learners is a strategic priority for the council. Local education authorities are required to submit a standards and quality report and improvement plan to comply with statutory duties and to ensure transparency, accountability, and continuous improvement in the education system. Page 34 of 288
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September 2025 The Education, Children and Families Service Improvement Report covers the period from August 2024 to August 2025. It highlights key improvements and progress across the service, specifically related to the priorities identified within the Service Improvement Plan for session 2024-25 which was approved in November 2024 at Committee. The Education and Families Service Improvement Plan for 2025-26, is the first iteration of a longer-term five-year plan and identifies key priorities for driving continuous improvement across local education services. It is informed by robust self-evaluation and aligns with national policy and legislative duties. The report and plan include specific attainment data linked to national measures and local authority stretch aims. In conclusion, the Service Improvement Report and Plan reflect progress to date and outline future plans for driving forward continuous improvement, strengthening accountability, and ensuring that children, young people, and families across the authority benefit from high-quality education and support. Aligned Priority: • Support all children and young people to realise their full potential. Ambition statement: 6. Raise attainment and skills for learning, life, and work to enhance opportunities and choices. Consistent • Education, Children and Families service improvement report is designed to serve three purposes: - To provide all stakeholders and residents with performance information across the six National Improvement Framework (NIF) drivers and against improvement priorities to measure how well educational outcomes are being improved for children, young people and their families. - In line with external grant funding, the service is required to summarise the outcomes and performance of the Pupil Equity Fund programme, at authority level. The Scottish Government have acknowledged that to reduce bureaucracy and duplication, the report can link to the existing statutory reporting requirements under the Standards in Schools etc. Act 2000 as amended by the Education (Scotland) Act 2016. There is a requirement to prepare an annual report describing local authority activity to: (a) reduce inequalities of educational outcome experienced by pupils as a result of socio- economic disadvantage and (b) achieve the strategic priorities of the National Improvement Framework (NIF). The Service Improvement Report allows the local authority to meet those requirements, and it will be shared with all stakeholders and forwarded to the Scottish Government. - Submission and publication of the service improvement report will ensure the local authority complies with the duties imposed on it by section 3B(3) - to seek and have regard to the views of the persons listed in section 3B(4) and to provide any advice and support the authority thinks appropriate to those persons in relation to its consideration of decisions of a strategic nature about the carrying out of its functions relating to school education. Transparent • The report notes that the attainment data for session 2024-25 included in the plan and report is provisional. It is subject to minor changes following Scottish Government data cleansing processes and SQA appeals decisions. In context • The report notes that the service improvement plan and report reflect the reality of delivering services within the challenging context of the ongoing cost of living crisis and sustained reductions in public funding. The plan reflects the commitment to strategic prioritisation, evidence-based decision-making, and collaborative working to ensure that resources are targeted where they will have the greatest impact. It also demonstrates how the council will continue to innovate and adapt processes and practice to uphold high standards, ensuring equity and inclusion. • The report also references the context when setting North Lanarkshire’s core and core plus aims in that evaluative evidence gathered through the first year of the target setting process was used, alongside guidance presented by the Scottish Government. At the point of establishing baseline data, it was noted that North Lanarkshire were performing particularly well within the primary sector, due to the allocation of additional teachers to support pandemic recovery. However, the council reflected on the potential tension between setting more cautious targets that are easier to achieve or setting more aspirational and challenging targets. Based on research evidencing that setting more challenging targets leads to better outcomes, more ambitious and aspirational targets were set, accepting the risk that these may be difficult to achieve. Balanced • The Service Improvement Report and Plan provide detailed evaluations of key performance indicators, encompassing both nationally recognised attainment measures and local authority core and core plus stretch aims. In line with original Scottish Government guidance and the Scottish Attainment Challenge reporting period, the council’s ambitious stretch aims will remain in place until session 2025-26. • The core stretch aims elements are part of a requisite package of measures identified by the Scottish Government and the report appendix includes the latest results in this respect. Broadly, core aims focus on achievement in literacy and numeracy at key stages (P1, P4, P7), school leavers attaining SCQF Page 35 of 288
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Level 5 and Level 6 qualifications, participation of 16-19-year-olds in education, employment, or training, and attendance data. • The core plus element enables local authorities to identify further aims, measurable by either local or national data. The council’s four aims in this respect - for which the appendix to the report provides the latest results - are the % of P4 learners achieving expected levels for writing (Curriculum of Excellence first level), % of S3 pupils achieving third level or better in combined literacy (based on reading, writing and talking, and listening), % of S3 pupils achieving third level or better in numeracy, and % of leavers achieving S5 1+ Highers (A-C passes based on all candidates / based on S4 roll figures from Insight). • The performance information in the report helps to track progress over time, understand where further improvements are needed, and assess how well specific actions and resources are making a difference for children and young people. The performance data, along with the ambitious targets set, reflects the commitment to improving outcomes for all children and families, with a focus on ensuring equity and tackling the poverty related attainment gap. Report title Summary Lanarkshire Business Gateway - performance report August 2025 This report provides an overview of the activities and performance achieved during the first year of an in-house delivery model of the Business Gateway Lanarkshire service. It provides an update on the activity and performance during 2024/25 and sets out the targets that the service is working towards in 2025/26. Business Gateway is a national service which is delivered by individual local authorities to provide free, impartial advice and support to pre-start, new start, and existing businesses. In Lanarkshire the service was delivered through a series of outsourced contracts but was insourced with effect from 1st March 2024, with North Lanarkshire Council delivering the service on behalf of both North and South Lanarkshire Councils. Aligned Priority: • Improve economic opportunities and outcomes. Ambition statement: 5. Grow and improve the sustainability and diversity of North Lanarkshire’s economy. Consistent • The report is presented within the context of the following core service objectives for Business Gateway which are to: - Support more people with their ambitions to start a business. - Support more businesses to survive and achieve their growth ambitions. - Support more people with their aspirations for high business growth. - Support more people from underrepresented groups to access mainstream business support. • Underpinning the service objectives there is a commitment to providing support across a number of themes such as carbon reduction, fair work, innovation, internationalisation, digital upskilling, community wealth building, and job creation. Transparent • The quality of the Business Gateway service delivery in each local authority area is monitored by Business Gateway nationally via an independent research organisation which surveys clients that have interacted with the service. This approach seeks feedback in respect of the level of satisfaction related to six criteria - general satisfaction with the Business Gateway service, were expectations met/exceeded, was the service provided of benefit to the business, would they recommend the Business Gateway service to others, would they continue using the Business Gateway service, and satisfaction with staff. Based on the feedback, a score is generated based on the number of very satisfied/satisfied responses received and compared against the national target of an 80% positive response in each measured area. • Positive responses for 2024/25 are noted in the table on the right, although the response rate is less than 10% of customers using the service. Both North and South Lanarkshire based customers have secured strong and consistent performance across all service areas, with high satisfaction, growing client loyalty, and positive staff interactions. Notably, North Lanarkshire saw good performance in relation to satisfaction with staff. In context • The report sets out the following context: - Coinciding with the move to in-house delivery, Business Gateway National implemented a new service specification which introduced new client classifications to support customer engagement (commencing June 2024). This allows an adviser to provide an intense level of support to a customer when required - determined by client needs, ambitions, and the potential for economic impact. The expectation being that businesses offering higher Page 36 of 288
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growth potential would typically receive more support. - The in-housing of the service and the change noted above meant that 2024/25 was a year of transition as staff faced the various challenges of integrating with a new employer and operating in a new environment to provide a service which had a new delivery focus and service specification. - In addition to the national objectives, local priorities and objectives were also agreed for 2024/25 to align to the plans for both North and South Lanarkshire Councils, these aim to: - Increase the reach of the service across all communities including a renewed focus and take-up of services from residents from rural communities and priority SIMD areas - Increase take-up of services from under-represented groups including long-term unemployed, economically inactive residents, carers, young people, BAME, disabled people, restorative justice/offenders. - Increase focus and take-up of Lanarkshire Business Gateway services from social enterprises, employee-owned businesses and co-operatives. - Inspire and increase engagement and take-up of services by young people focussing on enterprise pathways in schools, college (New College Lanarkshire/South Lanarkshire College), University of the West of Scotland, and youth groups. - Work alongside sectoral plans, and provide services to key sectors including construction, food and drink, creative industries, energy sector, manufacturing/engineering services, tourism, transport, and logistics. - Deliver support to town centre businesses to support North Lanarkshire/South Lanarkshire town centre action plans. - Increase engagement with non-engaged businesses and businesses who require additional support to survive. • The report notes that 2024/25 was a period of transition, with marketing activity evolving to keep pace with operational changes and priorities. Despite challenges, work continued to raise awareness of the support, connect with communities, and lay the foundations for a more strategic approach going forward in 2025/26. Balanced • The report summarises the 2024/25 full year performance in respect of: - Enquiries - clients typically access the service by making an initial enquiry via multiple channels and approximately 3,000 enquiries are received per year, of which 2,000 relate to pre-start/new start business enquiries with the balance of 1,000 enquiries being from established businesses. - Business start-up service - 1,157 reviews were handled in 2024/25 (628 in North and 529 in South Lanarkshire). 50% of these were new to the service or had a new business idea. Performance was lower than target and the previous year with a range of factors contributing to this including the impact of the transitional period from the previous contact to the in-house delivery model, setting up new systems and processes, and the impact of the introduction of a new service specification by Business Gateway nationally. External factors will also have had an impact in relation to the economy. For existing business services, it is recognised this is a demand led service and economic conditions remain challenging for businesses. - Workshops / events - saw 1,686 Lanarkshire clients attend a range of 435 workshops with almost a 50/50 split of those based in North and South Lanarkshire areas attending respectively. - Community engagement - over 120 events were supported across Lanarkshire in 2024/25. This allowed the profile of the service to be raised and enabled networking with potential clients. Report title Summary Treasury Management - annual activity report 2024/25 September 2025 This report fulfils the key requirements of the council’s reporting procedures for Treasury Management in accordance with the CIPFA Code of Practice on Treasury Management and the CIPFA Prudential Code for Capital Finance in Local Authorities in that it: • Outlines the treasury management activity undertaken during 2024/25 and the impact on the council’s borrowing and investment strategy. • Reports on the council’s performance in complying with the mandatory prudential indicators. • Provides a detailed summary of the council’s performance, making reference to those targets and prudential indicators set at the start of the year within the approved strategy. Aligned Priority: • Improve North Lanarkshire's resource base. Ambition statement: 24. Ensure intelligent use of data and information to support fully evidence based decision making and future planning. Page 37 of 288
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Consistent • The council has adopted the CIPFA Code of Practice in Treasury Management and operates its treasury services to mitigate the effect of possible risk in this function, while undertaking borrowing and investment activities that are prudent, affordable, and sustainable. • The council’s treasury activities are strictly regulated by statutory requirements and a professional code of practice. Revised editions of the CIPFA Prudential Code and CIPFA Treasury Management Code of Practice were issued in December 2021. In accordance with the council’s financial regulations, the council adopts the fully revised CIPFA Treasury Management in the Public Services Code of Practice including the key principles and the Treasury Management Policy statement. Transparent • The Treasury Management Strategy statement 2024/25, approved by committee in February 2024, sets out the Treasury Management policies, practices and activities to be undertaken by the treasury management function during 2024/25. • Within the council, the Audit and Scrutiny Panel ensures the effective scrutiny of the treasury management strategy and policies, while the Finance and Resources Committee remains responsible for the development of the Strategy, as well as its implementation and monitoring. The council also promotes Elected Members’ responsibility in this area, requiring greater member scrutiny of treasury management activity. • The Code of Practice requires the council to produce reports on its Treasury Management policies, practices, and activities, including (as a minimum) an annual strategic plan at the beginning of the financial year, a mid-year review, followed by an annual report on the measurement of success at the year- end. To ensure compliance with the Code of Practice, Treasury Management procedures are continually reviewed with any amendments reported to Committee as appropriate. • Prudential arrangements and treasury management performance information is also submitted to the Finance and Resources Committee quarterly. In context • The covering report states that Treasury Management activity continues to be managed in the light of the market conditions. This ensures advantage of lower interest rates is taken for borrowing where possible, while minimising the level of investment balances held. The council’s average loans pool rate increased from 4.45% to 4.87% due to increasing market interest rates throughout 2024/25. • Further context is set out in the detailed annual activity report in the appendix; this advises that Treasury Management deals with the borrowing and investment activity of the council and is an integral part of the council’s Financial Strategy. It seeks to ensure that both capital borrowing requirements and day to day revenue transactions are fully funded. Its importance has increased as a result of the additional freedoms provided by the Prudential Code. Balanced • The report advises that the council has adopted the CIPFA Code of Practice in Treasury Management and operates its treasury services to mitigate the effect of possible risk in this function, while undertaking borrowing and investment activities that are prudent, affordable, and sustainable. • The Code of Practice requires the council to produce reports on its Treasury Management policies, practices, and activities on a regular and ongoing basis. This includes the preparation of an annual activity report providing a detailed summary of the council’s performance, making reference to those targets, limits, and indicators set at the start of the year within the approved strategy. • In accordance with the council’s Treasury Management policy, the report focuses on activities undertaken during the year in the following key areas - external borrowing, interest rates and payments, debt maturity profile, investment performance, sources of borrowing, leasing, and the regulatory framework, risk, and performance. • An appendix to the report provides a detailed summary of the council’s performance, referencing those targets and prudential indicators set at the start of the year within the approved strategy. Report title Summary Revenues and benefits update September 2025 This report provides a regular update on the payment performance for council tax and non-domestic rates, the administration of a range of welfare benefits, and the council tax reduction scheme. It provides an update on performance as at 30th June 2025. Aligned Priority: • Improve North Lanarkshire's resource base. Ambition statement: 21. Continue to identify and access opportunities to leverage additional resources to support our ambitions. Page 38 of 288
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Consistent • Produced quarterly, this report provides detailed in-year performance figures which can be compared to the same period in previous years. Transparent • The year to date performance set out in the report covers a wide range of service activities as well as the amount of funding paid out to help households in need in order to provide a safety net for local people on low incomes. • The report also allows for comparisons of performance with the same period in previous years. In context • The council is responsible for the administration and collection of all local taxation in North Lanarkshire in the form of council tax and non-domestic rates. In addition, the council administers a number of benefits for residents of North Lanarkshire including housing benefit, council tax reduction, Scottish welfare fund, discretionary housing payment, free school meals, clothing grants, and blue badges. • The report includes the latest context within which the service is operating; this is of particular relevance given the aforementioned administration of grants and support payments required for low income households. The report also advises of any new national grants when they are introduced, or will cease, and the qualifying conditions for receipt of such. • The report advises that the service undertakes an ongoing programme of discount and exemption reviews to ensure that everyone receives the discounts they are entitled to and that discounts are awarded to the appropriate people. A review of all customers currently receiving single person discount is about to commence. This review was last completed during 2023 by outsourcing this to an external third party to match and review council tax single person discount records to credit reference data. This yielded positive results, and, as such an external third-party is being used to undertake the 2025 review. Where initial data matching indicates a potential risk of fraud or error, residents will receive a letter requesting they update their details in respect of their entitlement by using the either the text facility noted on the letter, completing an online review form, or returning the letter to the address noted on it with the relevant information. This will also discharge the requirement to review any matches for single person discount identified via the National Fraud Initiative (NFI), as the NFI report will be matched to the outcome of this review. The results will be reported to a future meeting of the Audit and Scrutiny Panel, in accordance with established practice. Balanced The report provides a high-level summary of the highlights which include: • As at 30th June 2025, 29.10% of council tax due for 2025/26 had been collected. This is a marginal increase of 0.8 percentage points from the same period last financial year. • Non-domestic rates collection at 30th June 2025 is 20.90% of the total annual charge which is slightly higher than the same period in the previous financial year (20.63%). • The service continues to meet statutory timescales for administering benefits applications and changes of circumstance. Report title Summary Financial monitoring report - council summary (revenue) September 2025 This report presents the council’s revenue monitoring position for the General Fund Account, Housing Revenue Account, and Adult Health and Social Care. (Note, the Council set its Revenue Budget and Council Tax for 2025/26 and provided a forecast Revenue Budget position for financial years 2026/27 and 2027/28 at the committee meeting in February 2025.) Aligned Priority: • Improve North Lanarkshire’s resource base. Ambition statement: 21. Continue to identify and access opportunities to leverage additional resources to support our ambitions. 25. Ensure intelligent use of data and information to support fully evidence-based decision making and future planning. Consistent • The report at each financial period end consolidates the budget monitoring position of all council services into one council summary, highlighting and explaining major variances as per the council’s approved Financial Regulations. • The September 2025 report presents the council’s revenue monitoring position for the financial year to 31st March 2026 as at the end of period 4 (18/07/25). Transparent • The report highlights and explains major variances as per the council’s approved Financial Regulations. The Financial Regulations require services to Page 39 of 288
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remain within their approved budgeting provision, and to report all significant deviations - defined as the higher of £100,000 or 5% - within their budget monitoring reports. • Following Committee agreement, it is noted this report will provide financial performance information in relation to the council’s Arm’s Length External Organisations (ALEOs) moving forward. This will be included in line with each organisation’s own governance and reporting arrangements and timetables. In context • All activities undertaken by the council are subject to risk, and in acknowledging the council’s approved Risk Management Strategy, services manage these as part of their overall corporate and service planning processes. The September 2025 report states that the current economic climate and pay and non-pay inflation, continuing at historically high levels, are some of the key factors that have the potential to impact on the council’s ability to provide quality services within approved budget levels. Balanced • Where significant deviations are identified, services must provide explanatory commentary, outline the action required to rectify such deviations and, where relevant, highlight the impact this has on other budget headings. This information is captured by Finance and summarised in the overall council report. • A summary by division for the period ending 18/07/25 (P4) is included in an appendix to the report, as is a note of anticipated commitments against earmarked reserves, and availability of general fund balances. Report title Summary Financial monitoring report - council summary (capital) September 2025 This report provides an update on the 2024/25 resources and expenditure for the council's Strategic Capital Investment Programme. The report also shows the 2024/25 projected outturn position and the resultant variances. (Note, the Strategic Capital Investment Programme for 2024/25 to 2028/29 was approved by Policy and Strategy Committee in March 2024 and an annual update was provided in March 2025.) Aligned Priority: • Improve North Lanarkshire’s resource base. Ambition statement: 21. Continue to identify and access opportunities to leverage additional resources to support our ambitions. 25. Ensure intelligent use of data and information to support fully evidence-based decision making and future planning. Consistent • The report at each financial period end consolidates the capital monitoring position of all council services into one council summary. • The September 2025 report summarises the overall council Strategic Capital Investment Programme for 2025/26 in relation to resources and expenditure and the 2025/26 projected outturn position and resultant variances. Transparent • The report notes that Strategic Capital Investment Programme 2024/25 to 2028/29 was approved at Policy and Strategy Committee in March 2024 with an annual update provided in March 2025. It represents the total Community Investment Programme incorporating the General Services Capital Programme and HRA Capital Programmes. • The programme was developed in conjunction with services and led by the Strategic Capital Delivery Group (SCDG) using the principles established by the council’s Capital Strategy. In context • The report states that the General Services Capital Programme supported by General Services resources demonstrates to communities that the place making vision for towns remains a priority, and that the approved 5-year capital investment plan supports delivery of The Plan for North Lanarkshire. • The programme includes additional investment in Town and Community Hubs, the City Deal programme, and external grant funding. In addition, the Housing Revenue Account (HRA) resources support several HRA Capital Investment Programmes including the mainstream programme for investment in the council’s existing estate and delivery of the ambition for additional supply through the new build and council buyback programmes. Balanced • The report notes the current financial position in respect of the 2025/26 General Services Capital Programme and the Housing Revenue Account. This reflects the approved budget and subsequent decisions made at the Strategic Capital Delivery Group (SCDG) in accordance with the SCDG terms of reference, and where appropriate either by the individual service committees, Finance and Resources Committee, or the Policy and Strategy Committee Page 40 of 288
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(as per the Scheme of Administration). • A breakdown of the overall 2025/26 budget by service programme and associated approved budget movements is included in an appendix to the report. • In acknowledging the risks, the report recognises that the capital programme continues to face challenges in relation to the wider economic climate, linked to availability of materials, contractors, and inflationary pressures. These are managed by services and Project Boards associated with specific programme delivery and will continue to be monitored throughout the year in accordance with the Strategic Capital Delivery Group (SCDG) Terms of Reference. Report title Summary Financial monitoring - savings September 2025 This report provides an update on the achievement of the three-year financial savings targets and progress. Aligned Priority: • Improve North Lanarkshire's resource base. Ambition statement: 21. Continue to identify and access opportunities to leverage additional resources to support our ambitions. Consistent • This regular report ensures ongoing oversight by Elected Members of the Finance and Resources Committee in terms of the progress in implementing savings. Transparent • This report provides an update on the achievement of the three-year financial savings total of £8.326m approved as part of the 2025/26 budget setting process and advises it is projected that 89% of the 2025/26 savings will be delivered within the financial year, with replacement savings identified to fully address the shortfall. In addition, it is currently anticipated that there will be no recurring savings gap arising from the 2025/26 to 2027/28 approved savings. In context • The report presents the up-to-date savings position within the context of the overall budget position for the council. Balanced • Each service report that supports this composite report, sets out the context for savings in that services are required to monitor the delivery of their target savings to ensure they remain within their approved budgets. Periodic progress updates are required within individual service revenue monitoring reports, identifying alternative solutions to any in-year shortfall envisaged. In addition, services are required to monitor whether the original approved saving has been implemented and if not, provide an explanation along with alternative action required to ensure the recurring financial saving will be achieved going forward. This information is captured by Finance and summarised in the overall council report. Key to RAG status green Performance is on target and/or within acceptable thresholds red Performance does not meet target and is outwith acceptable thresholds blue Performance surpasses the target and exceeds expectations Page 41 of 288
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North Lanarkshire Council Report Audit and Scrutiny Panel Does this report require to be approved? ☐ Yes ☒ No Ref SP/SL Date 13/11/25 Strategic frameworks annual position statement From Stephen Penman, Chief Officer (Strategy and Engagement) E-mail PenmanSte@northlan.gov.uk Telephone 07947 997750 Executive Summary The Audit and Scrutiny Panel are aware of the inter-related strategic frameworks that focus on ensuring a corporate one council approach in respect of Policy, Governance, Performance, Self-Evaluation, Project Management, and Demonstrating Improved Outcomes for Communities. These frameworks are key to assessing the success of The Plan for North Lanarkshire and ensuring its delivery through the Programme of Work is appropriately aligned, planned, guided, implemented, monitored, and governed. To ensure these frameworks remain aligned to The Plan for North Lanarkshire, and support delivery of the Programme of Work, each is on a schedule to undergo a regular review and refresh exercise. Since 2020, an annual position statement has been presented to the Audit and Scrutiny Panel to support their role in terms of providing an independent review of the council’s governance, risk management, performance, and control frameworks. Various reports in respect of these Frameworks have been considered by the Audit and Scrutiny Panel during the last year; this composite annual position statement aims to provide a high-level summary by setting out the background, current position, and next steps for each Framework. Recommendations It is recommended that the Audit and Scrutiny Panel: (1) Acknowledge the position statement for each Framework and the next steps to ensure each remains aligned to The Plan for North Lanarkshire and that delivery through the Programme of Work is appropriately aligned, planned, guided, implemented, governed, and monitored, and (2) Are aware that a corresponding Review Programme supports each Framework which ensures that all relevant matters are kept under review, updated as required, and reported to the relevant committee for Elected Member oversight and scrutiny. Item 3 Page 43 of 288
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1. Background 1.1 The Plan for North Lanarkshire is well established as the long-term strategic direction for the council and North Lanarkshire. It outlines the shared ambition to make North Lanarkshire the place to live, learn, work, invest, and visit. 1.2 With a vision of inclusive growth and prosperity for all set out therein, The Plan for North Lanarkshire aims to bring equal benefits and a fairer distribution of wealth to North Lanarkshire’s people and communities. This long-term vision provides a very clear focus and compelling narrative in terms of what the council is working towards. 1.3 This narrative has become embedded consistently throughout all policy statements agreed by the council, as well as all strategic management, financial management, strategy development, service delivery, and corporate governance approaches. As such, it has been the constant basis to enable the Programme of Work to bring together strategic planning and community investment in a cohesive manner and establish solid foundations for the place based approach. 1.4 As the delivery vehicle for The Plan for North Lanarkshire, the Programme of Work translates the vision into priorities for action. In place since 2019, this affords a dynamic strategic planning process that provides a stable direction for delivering The Plan for North Lanarkshire, while allowing for appropriate flexibility in the operational delivery of many complex inter-connected programmes, projects, and activities. 1.5 The context within which the Programme of Work is being delivered is kept under consideration to ensure it remains current, relevant, and deliverable. The latest Programme of Work to 2028 (approved at Policy and Strategy Committee in March 2023) changed from an annual to a five year programme to ensure a greater focus on scale and purpose in order to escalate significant place based transformation across local communities and deliver positive and sustainable change that improves the lives of the people of North Lanarkshire. 1.6 Supporting the council’s strategic planning process is a range of inter-related frameworks which are key to assessing the success of The Plan for North Lanarkshire and ensuring a corporate one council approach. They are also key to assessing delivery towards achieving the overall vision and ensuring each stage is appropriately aligned, planned, guided, implemented, monitored, and governed: • Strategic Policy Framework. • Strategic Governance Framework. • Strategic Performance Framework. • Strategic Self-Evaluation Framework (including Options Appraisal). • Project Management Framework. • Framework for Demonstrating Improved Outcomes for Communities. 1.7 To ensure these frameworks continue to align to The Plan for North Lanarkshire, and support delivery of the Programme of Work, all are on a schedule to undergo a regular The Plan for North Lanarkshire Priority All priorities Ambition statement All ambition statements Programme of Work Statutory / corporate / service requirement Page 44 of 288
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review and refresh exercise. As all frameworks are now well established and embedded into everyday activities with all relevant interconnections made therein, future updates focus on any significant enhancements needed, for example, due to legislative or internal governance changes, or to further support the council in delivering the Programme of Work and achieving the vision set out in The Plan for North Lanarkshire. 1.8 This report herewith follows on from the annual update of the Frameworks presented to the Audit and Scrutiny Panel in October 2024. It sets out the current position statement for each Framework to provide a composite update in support of the Audit and Scrutiny Panel’s strategic oversight and governance role. 2. Update 1. Strategic Policy Framework Background 2.1 Initially approved in September 2018, the Strategic Policy Framework aims to ensure that strategies, policies, and plans supporting delivery of The Plan for North Lanarkshire are formulated, developed, implemented, monitored, and reviewed in a consistent and transparent manner across the council. 2.2 The Strategic Policy Framework has supported this process by providing corporate Guidance to ensure that the development of new strategies, policies, and plans (and updates to existing documents) remain aligned to the one plan direction and one council approach, as well as relevant local and/or national strategy, policy, and legislative contexts. It also comprises a Review Programme to ensure the ongoing maintenance and monitoring of strategies, policies, and plans within a standardised approach and pre-defined timescales. 2.3 The role of the Strategic Policy Framework in supporting The Plan for North Lanarkshire and its delivery was recognised by Audit Scotland in their Best Value thematic work which reviewed the leadership of the development of new local strategic priorities (as reported to the Policy and Strategy Committee in December 2023): • “Sitting alongside the Programme of Work, the council has a Strategic Policy Framework in place which ensures the council’s strategies, policies and plans remain aligned to its vision and support its shared ambition. This framework details Elected Member and officer responsibilities for strategic planning and includes details of Elected Member approval of individual strategies, policies, and plans.” • “This framework sets out the formal review process and timetable to ensure all strategies and plans remain aligned to overall council strategy and are fit for purpose.” Current position 2.4 The Strategic Policy Framework has undergone various updates since initially approved. The 2022 annual review process represented the outcome of a significant refresh exercise undertaken at the time. This has enabled subsequent reviews to be more light touch and focussed on specific areas of improvement, thus ensuring council developments in this respect continue to comply with the requirements of Best Value and the principles of good corporate governance (as set out in CIPFAs national Delivering Good Governance in Local Government: Framework (2016)). 2.5 As such, changes implemented following the 2025 review were able to focus on an Page 45 of 288
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update to the Review Programme to reflect new (or updates to existing) strategies, policies, and plans and also the timescales indicating when updates are expected to ensure all documents are kept under review, updated as required, and reported to the relevant committee. This also supports forward planning and an indication of when consultation with stakeholders can be expected. 2.6 Since the strategic frameworks annual position statement report to the Panel in October 2024, new (or updated) strategies, policies, and plans have been approved at committee during the year in respect of the following: • Procurement Strategy 2025/26 - February 2025. • Community Safety Strategy 2025-30 - February 2025 • Developing the Young Workforce Delivery Plan 2025-28 - September 2025. • Eat Well, Be Well Policy 2025-30 - September 2025. 2.7 To provide ongoing assurance and demonstrate compliance with the elements in the Strategic Policy Framework Guidance that relate to the council’s governance obligations - e.g. specifying the intended impact on, or changes for, stakeholders (including citizens and service users), ensuring that communication methods are effective, and ensuring openness and comprehensive stakeholder engagement - an annual light touch assessment is undertaken on strategies, policies, and plans updated during the year. The 2025 assessment found no significant issues in relation to ensuring compliance with the Strategic Policy Framework Guidance in this respect. Specific areas of good practice were found in the following documents: • The Community Safety Strategy - which was co-produced with local communities and community safety partners and includes a specific section in the document that refers to the consultation process and the information derived from this which was used to inform the development of the strategy. • The Eat Well, Be Well Policy - which states that work to implement the policy and the actions therein will progress in conjunction with partnership activities across NHS Lanarkshire, the voluntary and private sectors, and local communities. Next steps 2.8 The Strategic Policy Framework and its accompanying Review Programme will continue to undergo a regular review and update process as outlined in paragraph 1.7. 2.9 The Guidance supporting the Strategic Policy Framework includes various decision making roles and responsibilities in respect of strategies, policies, and plans. As such, future changes required to the Guidance will be considered, where appropriate, as the review progresses in respect of the council’s democratic, committee, and decision- making governance procedures for which a phased review approach was approved by Policy and Strategy Committee in September 2025. 2. Strategic Governance Framework Background 2.10 The Strategic Governance Framework brings the principles of good governance together with legislative requirements and management processes by which the council is directed and controlled and through which it is accountable to, engages with, and leads the local community. It sets out the council’s local code of governance in line with the national Delivering Good Governance in Local Government: Framework (2016). Page 46 of 288
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2.11 The Strategic Governance Framework recognises the importance of good governance in terms of meeting statutory Best Value obligations and ensuring the council is able to effectively pursue the long-term ambition set out in The Plan for North Lanarkshire, while ensuring this is underpinned with control and the management of risk, and: • Resources are directed in accordance with agreed policies and according to priorities, and in line with corporate Project Management procedures. • There is sound and inclusive decision making. • There is clear accountability for the use of those resources in achieving defined outcomes for service users and local communities. 2.12 More specifically, the Strategic Governance Framework outlines the list of elements and mechanisms that demonstrate the council’s compliance with the 7 principles, 21 sub principles, and 91 behaviours and actions contained within the national Delivering Good Governance in Local Government: Framework (2016). It should be noted that the list of elements and mechanisms does not aim to introduce new items of governance to the council, rather its purpose is to collate all existing items (produced by the respective Chief Officer) into the one local code for annual review, assessment, assurance, and reporting purposes. 2.13 Initially approved in 2020, the Strategic Governance Framework went through a substantial review and update process in 2021 which was thereafter approved by the Audit and Scrutiny Panel. A review and refresh process has subsequently been undertaken annually thereafter, and an updated Strategic Governance Framework is approved by the Audit and Scrutiny Panel each year as part of the evidence used to inform the development of the Annual Governance Statement. 2.14 The Strategic Governance Framework, and its accompanying review programme, have been recognised as an area of good practice in recent years’ corporate governance audits undertaken by Internal Audit. As reported to the Panel in August 2025, the most recent Internal Audit considered that the “council’s corporate governance arrangements in relation to self-assessment are adequate and operating effectively” and therefore this audit was assessed as providing “substantial assurance”. No areas for improvement were recommended through this audit, however the importance of the council continuing to monitor changes in the legal, risk, and control environment is noted in the audit report as is the council being able to adapt its governance arrangements accordingly to ensure that the current level of compliance is maintained. Current position 2.15 Chief Officers and Elected Members are responsible for determining and implementing the council’s governance arrangements and ensuring the local code is assessed on an annual basis to ensure ongoing effectiveness and compliance. The Corporate Management Team also have a role to play in terms of identifying any improvement actions and/or future planned developments in relation to key governance arrangements and continuous improvement activity, and the annual evaluation aspect of this role was carried out at their meeting on 13th June 2025. 2.16 The updated Strategic Governance Framework was subsequently approved by the Audit and Scrutiny Panel on 26th June 2025. Of note was the latest RAG status for each of the elements and mechanisms within the Framework’s annual Review Programme. This process provides a method by which to identify and prioritise items requiring to be reviewed and updated further. The latest position identified no Red elements or mechanisms, one Amber, and the rest were Green. For the one assessed as Amber (i.e. employee engagement and wellbeing), there is a commitment by the Page 47 of 288
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respective Chief Officer to ensure an update is undertaken during 2025/26. 2.17 As noted in the Strategic Governance Framework in June 2025, the national Delivering Good Governance in Local Government: Framework (2016) requires councils to report on how the governance arrangements have been monitored for effectiveness in the year and to highlight any changes, this includes demonstrating continuous improvement which has recently included the following: • Fulfilling recommendations made following the 2023 internal audit review of corporate governance through: - An update to the year-end Assurance Certificate and Checklist documents to ensure information is appropriately captured regarding the implementation of improvement activity within each Chief Officer’s area of responsibility. - Improving how each source of assurance that supports the council’s year-end governance process is reflected in the Annual Governance Statement. - Ensuring improvement actions and/or future planned developments in relation to the council’s governance arrangements and systems of internal control are more clearly identified and thereafter stated in the Annual Governance Statement (to better allow key stakeholders to monitor performance and continuous improvement from one year to the next). - Enhancing the structure of the council’s Annual Governance Statement to take on board practices following research with all other local authorities in Scotland. With no adverse feedback received on the approaches noted above which were implemented for 2023/24, this approach continued for 2024/25. • Fulfilling recommendations made following the 2024 internal audit review of corporate governance by: - Adding a step into the year-end Assurance Certificate and Checklist process for Chief Officers to ensure that any omissions in completing the documents are reported to the Business Management Team. This allows for appropriate action to be taken, where needed, in respect of the assurances required to support the evidence for the Annual Governance Statement. Next steps 2.18 Moving forward, the Strategic Governance Framework and its Review Programme will remain on a formal annual review process to demonstrate the council’s compliance with the national Good Governance in Local Government: Framework (2016) and provide evidence to inform the Annual Governance Statement. This approach will also support the council in continuing to monitor changes in the legal, risk, and control environment and adapting its governance arrangements accordingly to ensure that the current level of compliance is maintained - as noted in paragraph 2.14. 3. Strategic Performance Framework Background 2.19 The Strategic Performance Framework comprises performance measurement at three levels which aim to collectively provide an overview of performance to help understand the impact of council activities on improving services and outcomes for the people and communities of North Lanarkshire. The measures in this Framework allow for day-to- day activities, and progress towards achieving the long-term vision set out in The Plan for North Lanarkshire, to be regularly monitored, reported, assessed, and scrutinised. Page 48 of 288
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2.20 To ensure compliance with the requirements of Best Value and good governance, the Strategic Performance Framework remains aligned to the Accounts Commission’s Statutory Direction which directs the council in respect of the “publication of information as to standards of performance”. 2.21 The Audit Scotland Best Value thematic report for 2022/23 (reported to the Panel in October 2023) acknowledged the approach to performance reporting which has been implemented by the council and concluded that “the council now has a Performance Reporting Schedule in place which includes Chief Officer reviews at service committees, corporate reporting, and service specific reporting”. 2.22 As reported to the Panel in August 2024, the most recent Internal Audit of performance management was categorised as offering “reasonable assurance” and considered there had been “a significant improvement in the current arrangements for performance management, with regular and meaningful reports and data being submitted to committee in line with the reporting schedule, and the implementation of an assurance review and reporting process.” Current position 2.23 A report submitted to the Audit and Scrutiny Panel in August 2025 outlined the latest Strategic Performance Framework Performance Reporting Schedule. This schedule aims to support the timely submission of a range of performance information to committee which enables Elected Members to undertake regular performance reviews in support of the council’s scrutiny obligations. 2.24 The Performance Reporting Schedule shows there is a significant volume of performance information timetabled to be reported to various council committees in each cycle of the year in line with the two aspects noted below. (1) Chief Officer’s individual Performance Reviews at service committees in line with the Strategic Performance Framework. (2) Chief Officer service specific performance reporting which takes place each year to meet business and/or statutory obligations. 2.25 Chief Officers performance reports are also reviewed by the council’s Business Management Team, Corporate Management Team, and service Senior Management Teams to secure the relevant assurances - in line with the Best Value duty - that performance management arrangements promote effective use of council resources, that performance information is scrutinised at a senior management level, and that performance monitoring effectively addresses areas of underperformance by identifying the scope for improvement and agreeing the remedial action required. 2.26 Throughout each committee cycle of 2024/25, Chief Officers have ensured that a wide range of performance has been reported to the respective service committee (in line with the Performance Reporting Schedule) for scrutiny by Elected Members. In addition: • Each of the performance reports submitted to the respective service committee has thereafter been summarised into a composite quarterly assurance review report for scrutiny by the Audit and Scrutiny Panel in line with their role to “review and monitor the performance of the council in delivering upon its priorities, outcomes, programme of work and targets in the council plan, specifically performance in improving services and outcomes and in demonstrating Best Value”. • By bringing together a summary of council performance, this approach provides a Page 49 of 288
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composite (but easily digestible) overview that also supports the Audit and Scrutiny Panel’s governance and accountability role in terms of ensuring the council can demonstrate Best Value through the existence of robust arrangements for performance reporting and scrutiny. • In carrying out the scrutiny role through the quarterly performance assurance review reports (and through Elected Member led scrutiny in line with the assessment and prioritisation process), one area of service (in respect of school IT assets age and maintenance) was scrutinised during 2025. 2.27 Additional activities undertaken during 2024/25, to support the council’s Best Value duties in relation to performance management, include the undernoted. • An annual update to the 28 health check indicators continues to be reported to the Policy and Strategy Committee, with the most recent in March 2025. • The suite of health check indicators play an important role in informing the council’s strategic planning process through the Programme of Work to 2028. This continues with a quarterly review of Programme of Work delivery at the Corporate Management Team along with a six monthly progress report to the Policy and Strategy Committee (the latest of which was in September 2025). • Reporting of Local Government Benchmarking Framework (LGBF) measures are integrated into the Strategic Performance Framework alongside the wider suite of measures within each Chief Officers’ area of responsibility. This approach ensures that reports contain a suite of performance indicators that collectively provide a more complete picture of performance. • The council’s website hosts the LGBF dashboard launched by the Improvement Service in 2023. This provides the most up-to-date performance for a benchmarking measure as at a point in time and enables comparisons with other local authorities and the national average. The use of this dashboard is signposted in performance reports to service committees. • As noted in paragraph 2.23, the Strategic Performance Framework is supported by a Performance Reporting Schedule which sets out corporate performance reporting, monitoring, review, and scrutiny arrangements. During the year, information regarding items on the Performance Reporting Schedule was made available to the Audit and Scrutiny Panel through quarterly performance assurance reports in order to support the Panel’s scrutiny and strategic oversight role. • Chief Officers’ six-monthly reports in line with the Strategic Performance Framework followed the standard template. This ensured that all reports consistently (a) set out the current context within which the service is operating, (b) highlighted areas of good performance that could be evidenced in the accompanying data, (c) provided a summary of areas of performance requiring improvement along with narrative that gives an explanation for the level of performance achieved and summarises the remedial action implemented (or to be implemented) to bring performance back on track, and (d) demonstrated that the loop has been closed in terms of implementing and monitoring improvement actions and subsequent performance levels. • Previously, the extent of the action undertaken by each audience when reviewing and scrutinising the performance information before them has been varied. The ask of the audience reading the report is now specifically (and appropriately) referenced in performance reports to service committees. • In line with the Local Authority Model Complaints Handling Procedure which defines the two-stage process the council is required to implement when handling all complaints received, complaints performance reports are produced to fulfil the governance arrangements. The next complaints performance report is scheduled to be presented to the Audit and Scrutiny Panel in cycle 4 of 2025. Page 50 of 288
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Next steps 2.28 As noted in the statutory performance reporting requirements report considered by the Audit and Scrutiny Panel in August 2025, a key aspect of the Accounts Commission’s Statutory Direction is public performance reporting. To demonstrate compliance, processes are already in place that includes service specific annual performance reports (as highlighted to the Panel through the quarterly assurance review reports), regular news articles and updates on delivery and performance of the Programme of Work which are reported to the public through the council’s website following each committee cycle, and a dedicated performance section on the council’s website. 2.29 Following recommendations identified through recent Best Value thematic audits, further work will be undertaken during 2025/26 to review and re-develop the approach to public performance reporting to enhance the public’s ability to determine how the council is performing and ensure that reporting of progress against the 28 health check indicators is more accessible to the public. 4. Strategic Self-Evaluation Framework Background 2.30 Initially approved in 2018, the Strategic Self-Evaluation Framework asks the questions How well are we doing? How do we know? and How can we do better? to ensure the council has a way of regularly assessing practices, recognising strengths, and identifying areas for improvement. 2.31 Aligned to the national Best Value guidance, the Strategic Self-Evaluation Framework is supported by a rolling review programme. This provides a mechanism to assess the council’s functions and activities and identify areas for improvement through a single strategy for improvement that (a) is in line with the Best Value duty to secure continuous improvement, and (b) ensures self-evaluation is undertaken within the context of fulfilling the vision set out in The Plan for North Lanarkshire. 2.32 A single strategy for improvement is in place through the Strategic Self-Evaluation Framework and rolling Review Programme. This was initially endorsed by the Corporate Management Team in July 2021 and approved by the Audit and Scrutiny Panel in September 2021 with subsequent updates reported thereafter. • The update to the Strategic Self-Evaluation Framework in October 2022 introduced a corporate approach to Options Appraisal to formalise the guidance and procedures and ensure that the outcomes from such exercises continue to provide assurances that service provision is efficient and effective and represent value for money, and that decisions made remain consistent with the strategic direction for the council, as set out in The Plan for North Lanarkshire. • Minor changes to the Strategic Self-Evaluation Framework in February 2024 were made to ensure ongoing alignment with the national approach to auditing Best Value through thematic audit work, as well as ongoing compliance in terms of councils continuing to use self-evaluation to identify areas for improvement. 2.33 The council’s commitment to self-evaluation was recognised in the Audit Scotland Best Value 2022/23 thematic report on the council’s leadership of the development of new strategic priorities (reported to the Panel in October 2023) which acknowledged that “the council has a well-established self-evaluation framework in place which supports continuous improvement”. Page 51 of 288
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Current position 2.34 As reported to the Panel in June 2025, through the Annual Governance Statement 2024/25, since the Strategic Self-Evaluation Framework and rolling Review Programme was formally established, ten self-evaluation exercises have been undertaken. A summary of each exercise has been included in previous years’ Annual Governance Statements, and an annual monitoring process is in place to capture the status of implementing the improvement actions arising from each exercise: • The ten self-evaluation exercises resulted in areas for improvement being identified and captured in supporting improvement plans. In general, these aimed to further strengthen existing arrangements, rather than address any significant issue in terms of gaps or effectiveness. • The most recent self-evaluation exercises in 2025 comprised the following: - A self-evaluation of Audit and Scrutiny Panel to ensure the Panel continues to demonstrate it is effective in discharging its role (which followed on from the initial self-evaluation undertaken in 2023). Findings were reported to the Audit and Scrutiny Panel in August 2025 with the Panel being given the opportunity to identify any further developments and next steps actions required to inform the improvement plan. No further actions were identified. - A self-evaluation in relation to the council’s compliance with the CIPFA Financial Management (FM) Code; this followed on from the initial evaluation undertaken in 2022. This concluded that the council’s financial management practices comply with all aspects of the CIPFA FM Code with an average overall rating of 99.6% strongly agreeing or agreeing the extent of compliance across all the 17 financial management standards (an improvement from 98% in the 2022 assessment). There were no disagree or strongly disagree assessments assigned by the assessment team (an improvement from 2% disagreeing in the 2022 assessment). However, existing arrangements where it was considered the council could improve / further strengthen were identified and, as such, an improvement plan is in place around three FM Code principles. Next steps 2.35 The Strategic Self-Evaluation Framework and its Review Programme will continue to undergo a regular review and update process as outlined in paragraph 1.7. 2.36 As the Panel are aware from the update report in February 2025 in respect of auditing Best Value in local government, a new approach was implemented nationally with effect from 2022/23 onwards. This approach comprises the following: • The external auditors Annual Audit Report (AAR) - the 2024/25 AAR was presented for the Panel’s consideration at the meeting in September 2025. • Best Value thematic audits - the outcome following the Best Value thematic audit on transformation (specifically how the council is redesigning services and delivering more efficient services to achieve planned outcomes) was reported to the Audit and Scrutiny Panel and the Policy and Strategy Committee in September 2025. • Details of the theme for the 2026 Best Value audit are expected to be made available by the end of 2025. 2.37 The council has maintained a dedicated page on the website that provides a central location for reporting on findings and recommendations from national audits and inspections. This is updated as and when new reports become available nationally. 5. Project Management Framework Page 52 of 288
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Background 2.38 Following an extensive review, the council’s Project Management Framework was re- launched in December 2022. The review followed recommendations arising from Internal Audit reports on the governance of capital projects and managing strategic change but was also considered necessary in light of the changes in the council’s operating environment since the introduction of the Model in 2018. 2.39 The Project Management Framework provides a corporate approach that outlines the processes and techniques to help scope and manage a project, meet agreed milestones, fulfil appropriate reporting and assurance requirements, involve the right people at the right time, implement each stage of delivery from start to finish, and achieve the expected benefits or improved outcomes of each project. It aims to provide support and guidance for all employees involved in project management regardless of their role and previous experience, and it recognises that project management is something that is becoming common practice in the workplace and more prevalent across many operational roles. 2.40 As reported to the Panel in February 2023, the Project Management Framework does not attempt to set out all the complexities of project management - or say there is only one way to manage a project - or define which methodology a particular project should use. The flexibility set out therein is intentional to allow each Senior Responsible Officer and Project Manager the ability to identify the approaches that best suit the requirements of a particular project and will most effectively support the delivery of the expected benefits and outcomes to cost, time, and quality - but will do so within the fundamentals of good project management and good governance. 2.41 During 2024, the Project Management Framework was subject to a light touch review to ensure it continued to remain fit for purpose. This took account of feedback arising from the training programme, reiterated the requirement to undertake a post project evaluation, incorporated the gateway check process from the Invest in North Lanarkshire Programme of Work, reiterated the importance of Data Protection Impact Assessments being considered at the start of a project, and raised awareness that project management and change management need to complement each other and work in tandem to support delivery of the Programme of Work. Current position 2.42 Project Management training was rolled out across the organisation from February 2023 and has continued each year since. This now comprises a programme of full day training sessions for which Chief Officers identify the employees to undergo training. Feedback from these sessions continues to be positive and a refresher programme is under development for roll out during 2026/27. Ongoing support continues to be available through 1:1 sessions and materials on InsideNL and LearnNL. 2.43 As reported to the Audit and Scrutiny Panel in February 2024, quality assurance arrangements have been established and aligned to the governance supporting the Programme of Work to ensure the council can demonstrate compliance with the Project Management Framework. Following implementation of the quality assurance review programme, an overview of the results and findings from the baseline assessment was reported to the Audit and Scrutiny Panel in February 2025. This advised the areas for improvement identified through the review were being progressed through improvement plans developed for each respective Chief Officer. Page 53 of 288
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2.44 Implementation of these improvement plans during 2025 has been assessed through business as usual arrangements already in place to ensure ongoing maintenance, tracking, and monitoring. As the review programme is a rolling programme, the improvement plans have remained as live documents which are reviewed and updated quarterly. In addition, an annual check is scheduled to be completed prior to the annual quality assurance report scheduled to be submitted to the Audit and Scrutiny Panel in cycle 1 of 2026 to ensure that plans and monitoring processes remain fit for purpose. This fulfils the recommendation in respect of monitoring and tracking the improvement plans and, ensuring these plans include the “as at” status date as well as a “status column”, which arose from the Internal Audit review of project management quality assurance (which was reported to the Panel in May 2025). Next steps 2.45 While the role of overseeing various components of major programmes and projects sits with the respective Service Committee, good practice recommends that a council's audit and scrutiny committee have an important oversight and assurance role to play in respect of the implementation of the Project Management Framework. As such, the role of the Audit and Scrutiny Panel is to be assured that suitable review procedures have been adopted so that the council can gain the relevant assurances about the value of independent reviews that are undertaken during the life cycle of a project. 2.46 As such, and in line with the Project Management Framework quality assurance report to the Audit and Scrutiny Panel in February 2025, an annual report is next scheduled to be presented to the Panel in cycle 1 of 2026. This will include an update on implementation of the improvement actions referenced in paragraphs 2.43 and 2.44. 6. Framework for Demonstrating Improved Outcomes for Communities Background 2.47 As the public spending watchdog for local government in Scotland, the Accounts Commission aim to ensure their work (a) helps provide assurance to the public on the performance of each Scottish council, and (b) reflects councils’ responsibilities to deliver high quality services to the public. 2.48 These assurances are provided through a range of audit activity that is set out in the Accounts Commission’s programme of work; this includes setting a Statutory Direction that directs local authorities on the publication of performance information relating to their activities that allows for comparisons over time and with other local authorities. 2.49 An update to the Accounts Commission’s Statutory Direction in November 2021 made specific revisions to areas regarding community engagement and empowerment. In this respect, the emphasis is on evidencing that the council is carrying out community planning for the “improvement in the achievement of outcomes” and councils (in agreeing outcomes with partners and communities) reporting on how they have engaged with, responded to, and helped to empower their communities, including those who require greater support. 2.50 For this reason, and in line with the focus of the Statutory Direction set out in paragraph 2.49, a Demonstrating Improved Outcomes for Communities Framework was established to ensure the evidence is in place to formally fulfil this aspect. Current position Page 54 of 288
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2.51 Approved by the North Lanarkshire Partnership Strategic Leadership Board in June 2022, the Framework for Demonstrating Improved Outcomes for Communities sets out the model which the North Lanarkshire Partnership use to assess progress and performance in terms of delivering upon priorities and plans and ensuring that partnership activities can demonstrate improved outcomes that make a real difference for local people and local communities. 2.52 A regular oversight and outcome report supports the council’s requirements to report publicly on progress including where outcomes have been improved through joint planning, collaboration, and partnership working. In this respect, the latest report to the Communities Committee in February 2025 highlighted where community planning in North Lanarkshire is making a positive impact in strengthening partnership working and improving outcomes in line with The Plan for North Lanarkshire’s shared ambition. Next steps 2.53 As reported to the Audit and Scrutiny Panel in August 2025, the Accounts Commission has published a new Statutory Direction for 2025/26 to 2027/28. While this places additional requirements on councils, the Panel will recall changes have been able to be incorporated into existing council performance management, progress monitoring, and performance reporting arrangements to minimise the impact on resources and ensure processes remain aligned and practicable. 2.54 A key aspect of the Statutory Direction remains the requirement for the council to publish information that shows how well is it improving local outcomes with community planning partners in the area. Within the council, delivery of local priorities in association with community planning partners is co-ordinated through nine Local Outcome Improvement Plans (LOIPs) and, as reported to the Communities Committee in August 2025, these plans are due for review and relaunch from 2027. Established in line with the Community Empowerment (Scotland) Act 2015, the LOIPs set out an approach to working with and empowering local communities, enabling them to contribute to, and influence local priorities that contribute to achieving the vision set out in the Plan for North Lanarkshire through community led action. 2.55 Given the alignment between the strategic level Framework for Demonstrating Improved Outcomes for Communities and the associated operational delivery through the LOIPs, next steps development for this Framework will be considered in line with the LOIP review timeline and process which is set out in the report to the Communities Committee in August 2025. 3. Measures of success 3.1 Regular scrutiny of the council’s performance and governance arrangements supports the council to efficiently and effectively deliver on the long-term vision set out in The Plan for North Lanarkshire, while ensuring this is underpinned with the relevant controls as set out in the national Delivering Good Governance in Local Government: Framework (2016) and the Best Value Guidance (2020). 3.2 Regular oversight and scrutiny by the Audit and Scrutiny Panel aims to ensure there is effective use of council resources, and resources are directed in accordance with agreed policy and according to priorities, while ensuring sound decision making and clear accountability for the use of resources in achieving improved outcomes for service users and the local community. 4. Supporting documentation Page 55 of 288
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None Stephen Penman Chief Officer (Strategy and Engagement) 5. Impacts 5.1 Public Sector Equality Duty and Fairer Scotland Duty Does the report contain information that has an impact as a result of the Public Sector Equality Duty and/or Fairer Scotland Duty? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? If Yes, has an assessment been carried out and published on the council’s website? https://www.northlanarkshire.gov.uk/your-community/equalities/equality- and-fairer-scotland-duty-impact-assessments Yes ☐ No ☐ 5.2 Financial impact Does the report contain any financial impacts? Yes ☐ No ☒ If Yes, have all relevant financial impacts been discussed and agreed with Finance? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact? 5.3 HR policy impact Does the report contain any HR policy or procedure impacts? Yes ☐ No ☒ If Yes, have all relevant HR impacts been discussed and agreed with People Resources? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact? 5.4 Legal impact Does the report contain any legal impacts (such as general legal matters, statutory considerations (including employment law considerations), or new legislation)? Yes ☒ No ☐ If Yes, have all relevant legal impacts been discussed and agreed with Legal and Democratic? Yes ☒ No ☐ If Yes, please provide a brief summary of the impact? The Local Government Act 1992 established the role of the Statutory Direction to direct the “publication of information as to standards of performance”. The Local Government in Scotland Act 2003 introduced Best Value which requires that councils “make arrangements to secure continuous improvement in performance”. 5.5 Data protection impact Does the report / project / practice contain or involve the processing of personal data? Yes ☐ No ☒ If Yes, is the processing of this personal data likely to result in a high risk to the data subject? Yes ☐ No ☐ If Yes, has a Data Protection Impact Assessment (DPIA) been carried out and e- mailed to dataprotection@northlan.gov.uk Page 56 of 288
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Yes ☐ No ☐ 5.6 Technology / Digital impact Does the report contain information that has an impact on either technology, digital transformation, service redesign / business change processes, data management, or connectivity / broadband / Wi-Fi? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? Where the impact identifies a requirement for significant technology change, has an assessment been carried out (or is scheduled to be carried out) by the Enterprise Architecture Governance Group (EAGG)? Yes ☐ No ☐ 5.7 Environmental / Carbon impact Does the report / project / practice contain information that has an impact on any environmental or carbon matters? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? 5.8 Communications impact Does the report contain any information that has an impact on the council’s communications activities? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? 5.9 Risk impact Is there a risk impact? Yes ☒ No ☐ If Yes, please provide a brief summary of the key risks and potential impacts, highlighting where the risk(s) are assessed and recorded (e.g. Corporate or Service or Project Risk Registers), and how they are managed? Ensuring the inter-connected strategic frameworks are reviewed regularly ensures the council complies with Best Value and the principles set out within the Delivering Good Governance in Local Government: Framework (2016). This contributes to the mitigation of Corporate Risk Register risks for governance, leadership, and decision making and the programme of work. 5.10 Armed Forces Covenant Duty Does the report require to take due regard of the Armed Forces Covenant Duty (i.e. does it relate to healthcare, housing, or education services for in-Service or ex- Service personnel, or their families, or widow(er)s)? Yes ☐ No ☒ If Yes, please provide a brief summary of the provision which has been made to ensure there has been appropriate consideration of the particular needs of the Armed Forces community to make sure that they do not face disadvantage compared to other citizens in the provision of public services. 5.11 Children’s rights and wellbeing impact Does the report contain any information regarding any council activity, service delivery, policy, or plan that has an impact on children and young people up to the age of 18, or on a specific group of these? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact and the provision that has been made to ensure there has been appropriate consideration of the relevant Articles from the United Nations Convention on the Rights of the Child (UNCRC). If Yes, has a Children’s Rights and Wellbeing Impact Assessment (CRWIA) been carried out? Yes ☐ No ☐ Page 57 of 288
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North Lanarkshire Council Report Audit and Scrutiny Panel Does this report require to be approved? ☐ Yes ☒ No Ref SP/SL Date 13/11/25 Performance in complaints handling From Stephen Penman, Chief Officer (Strategy and Engagement) E-mail PenmanSte@northlan.gov.uk Telephone 07947 997750 Executive Summary The council has a well-established complaints handling procedure which has been in place for many years. Over this time, this has remained aligned to the requirements of the Scottish Public Services Ombudsman (SPSO) whose remit includes specific powers and responsibilities to publish complaints handling procedures and monitor and support best practice in complaints handling, as well as administering the final stage for complaints about most devolved public services in Scotland (including councils). Across the council, implementation of this procedure is supported by a range of processes that have been developed in line with SPSO guidance and best practice. To support continuous improvement, the council has always considered complaints to be a valuable source of information as they offer direct insight into service quality, help to identify underlying systemic problems, and provide opportunities for service improvement and innovation by highlighting patterns or recurring issues. The Scottish Public Services Ombudsman (SPSO) have established a Local Authority Model Complaints Handling Procedure which defines the two-stage process that the council is required to implement when handling all complaints received. A key aspect of this procedure is the supporting complaints governance arrangements in terms of reporting and publicising complaints information that includes performance statistics, trends and outcomes, as well as improvements and lessons learned. This report provides the Audit and Scrutiny Panel with an update on the performance of the council in complaints handling in line with the Panel’s role to provide independent review of the council’s governance, risk management, performance, and control frameworks. Recommendations It is recommended that the Audit and Scrutiny Panel: (1) Are aware of the Local Authority Model Complaints Handling Procedure in place across the council and the corresponding complaints governance requirements in terms of performance reporting, and (2) Note the latest performance results for complaints handling through the suite of SPSO indicators. Item 4 Page 59 of 288
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1. Background 1.1 The process for handling complaints made to public bodies is defined by various sector specific Model Complaints Handling Procedures. These were developed by the Scottish Public Services Ombudsman (SPSO) in partnership with the respective body and in line with legislative requirements which arose from the Scottish Public Services Ombudsman Act 2002. 1.2 The SPSO has a wide remit, covering a variety of functions and services. The Ombudsman’s powers and duties come (predominantly) from the Scottish Public Services Ombudsman Act 2002, within which there are four distinct statutory functions; this includes: • The final stage for complaints about most devolved public services in Scotland - including councils, the health service, prisons, water and sewerage providers, Scottish Government, and universities and colleges. • Specific powers and responsibilities to publish complaints handling procedures and monitor and support best practice in complaints handling. • Independent review service for the Scottish Welfare Fund with the power to overturn and substitute decisions made by councils on community care and crisis grant applications. • Independent National Whistleblowing Officer (INWO) for the NHS in Scotland, final stage for complaints about how the NHS considers whistleblowing disclosures and the treatment of individuals concerned (from April 2021). 1.3 The SPSO responsibility in terms of the final stage for complaints means they can investigate complaints at stage three if a complainant remains dissatisfied with the outcome of their complaint with the council (i.e. if they remain dissatisfied with the decision or the way the complaint was dealt with). However, the SPSO will not consider (a) any complaint that hasn’t been through the council’s formal two stage process in the first instance, (b) events that happened (or that the complainant became aware of) more than a year ago, or (c) a matter that has been, or is being, considered in court. 1.4 The two stage Local Authority Model Complaints Handling Procedure came into effect in April 2013; this comprises: • Stage one - which is classed as frontline resolution which seeks to resolve complaints at the initial point of contact, or as close to the point of service delivery, as possible. • Stage two - for complaints unable to be resolved at the frontline or for those that are complex, serious, or high-risk and require more in-depth investigation. 1.5 The most recent version of the Local Authority Model Complaints Handling Procedure was published by the SPSO for implementation from April 2021. This applies to all local authorities and all local authority services. It also applies to all services provided by a health and social care partnership on behalf of a local authority. At this time the council adopted the revised Local Authority Model Complaints Handling Procedure and The Plan for North Lanarkshire Priority All priorities Ambition statement All ambition statements Programme of Work Statutory / corporate / service requirement Page 60 of 288
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developed both customer-facing and internal guidance to align with the SPSO model. 1.6 In accordance with the Scottish Public Services Ombudsman Act 2002, the SPSO must also publish a Statement of Principles concerning the complaint handling procedures of public bodies. These Principles are considered the foundation for the SPSOs Model Complaints Handling Procedures. The most up to date version of the Statement of Principles was shared with the Policy and Strategy Committee in September 2025. 1.7 A key aspect to the Local Authority Model Complaints Handling Procedure is complaints governance in terms of reporting and publicising complaints information that includes performance statistics, trends and outcomes, as well as improvements and lessons learned. In this respect, the Statement of Principles sets out the principle of learn and improve as it specifically relates to performance data, changes or improvements implemented as a result of complaints received, or for action to be taken to reduce the risk of recurrence. Extract from the SPSO Statement of Principles, September 2025 1.8 Within the council, complaints are dealt with at a service level and there are designated officers from each service across the council with responsibility for administering complaints through the council’s Customer Relationship Management system (Dynamics). Key to this process is ensuring that information (such as the outcome of the complaint) is recorded accurately and appropriately when each case is closed. Implementation of the Dynamics system, operational from April 2021, followed a digital transformation that sought to achieve a more efficient and automated approach to processing, managing, reporting, and analysing complaints and was required when the previous system (Lagan) reached the end of its life. 1.9 In line with the complaints governance requirements set out in the Local Authority Model Complaints Handling Procedure, and also to support the council in demonstrating Best Value (in terms of continuous improvement in performance) and in complying with the CIPFA Delivering Good Governance in Local Government: Framework (2016) (in terms of corporate governance), this report provides the Audit and Scrutiny Panel with an update of the council’s performance in complaints handling. Page 61 of 288
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2. Complaints performance 2.1 A key aspect of the Local Authority Model Complaints Handling Procedure is the supporting complaints governance arrangements in terms of reporting and publicising complaints information that includes performance statistics, trends and outcomes, as well as improvements and lessons learned. As part of the governance arrangements, the SPSO established a suite of performance indicators which the council have collected and reported on from the outset. The council’s previous performance in respect of complaints handling was considered by the Audit and Scrutiny Panel in 2024. 2.2 An update of the council’s performance in handling complaints is set out in Appendix 2 for complaints closed at (a) stage one and (b) stage two. This analysis focuses on performance in complaints handling at a council wide level, with an initial deeper dive into areas of service where there are clear trends in the data. Key points of note are: • The analysis of the council’s performance in complaints handling is an initial deep dive that seeks to use the findings to identify trends and patterns in the data. These findings will be further examined through the cross council Corporate Complaints Group to ensure that processes are working as efficiently as they can be and/or to identify areas for improvement. • The analysis covered by this report covers the years from 2013/14 (when the new two stage procedure came into place) up to the end of the 2024/25 financial year. However, as noted in Appendix 2 implementation of the new system in 2021/22 expanded the services captured and enhanced functionality meaning that care should be taken when comparing the data for 2021/22 onwards with previous years as calculations within the two systems have differed. • For this reason, and to focus the analysis further on recent trends, future reporting to the Audit and Scrutiny Panel from 2026 will only reflect data from 2021/22 onwards. 2.3 In line with the learn and improve principle referred to in paragraph 1.7, various changes and improvements have been made over the years to ways of working and to ensure complaints of a similar nature do not recur. These are captured through the following processes: • Lessons learned - the recent examples are included at Appendix 1. • Improvements to ways of working - an end-to-end review of the council’s complaints handling process in 2024/25 resulted in an improvement action plan which was reported to the Policy and Strategy Committee in September 2025. 2.4 Learning and improving remains an ongoing activity of the cross council Corporate Complaints Group which comprises representatives from each service. This supports ongoing sharing of good practice, data cleansing, and quality control, as well as the identification of common issues in complaints handling and training needs, and any learning from stage three outcomes. Continued attendance at the national Complaints Handlers Network also ensures ongoing learning and benchmarking. Next steps 2.5 To ensure complaints continue to support efficient ways of working and inform improvements to services, the current work programme includes the following to support ongoing improvements in performance in complaints handling. • Further developments to improve the visualisation and analysis of the performance information arising from complaints to provide a high-level overview, allow key Page 62 of 288
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results and trends to be viewed at a glance, and support data driven action to identifying areas of improvement. This will also support more automatic processes in terms of monitoring and analysing the suite of indicators established by the SPSO, and subsequent reporting to each respective audience. This work seeks to improve and enhance the original series of dashboards created when the new Dynamics system was originally implemented. • More in-depth analysis on the findings set out in Appendix 2 to identify if there are further improvements required in terms of complaints handling or service delivery, and/or to support more efficient ways of working. • Ensuring ongoing learning and identification of areas for improvement arising from complaints handling through reviewing best practice, analysing supporting statistics for patterns or trends, identifying any recurring issues in those complaints escalated from a stage 2 (and submitted to the SPSO to be dealt with at stage three), and ensuring changes / improvements required as a result of complaints received are being acted upon. • Development work on the performance reporting system to identify Child Friendly Complaints following a functionality update to the recording system (Dynamics). This will ensure the council can further demonstrate its commitment to supporting the rights of children and young people to express concerns and participate in decisions affecting them in all areas of complaints handling (in line with the United Nations Convention on the Rights of a Child (UNCRC). 3. Measures of success 3.1 General measures of success include improvements in complaints handling, implementing positive changes as a result of learning from complaints (including improvements to service delivery and more efficient ways of working), and a reduction in the reoccurrence of complaints of a similar nature. 4. Supporting documentation 4.1 Appendix 1: Examples of lessons learned. Appendix 2: Summary of complaints performance at stage one and stage two. Stephen Penman Chief Officer (Strategy and Engagement) 5. Impacts 5.1 Public Sector Equality Duty and Fairer Scotland Duty Does the report contain information that has an impact as a result of the Public Sector Equality Duty and/or Fairer Scotland Duty? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? If Yes, has an assessment been carried out and published on the council’s website? https://www.northlanarkshire.gov.uk/your-community/equalities/equality- and-fairer-scotland-duty-impact-assessments Yes ☐ No ☐ 5.2 Financial impact Page 63 of 288
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Does the report contain any financial impacts? Yes ☐ No ☒ If Yes, have all relevant financial impacts been discussed and agreed with Finance? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact? 5.3 HR policy impact Does the report contain any HR policy or procedure impacts? Yes ☐ No ☒ If Yes, have all relevant HR impacts been discussed and agreed with People Resources? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact? 5.4 Legal impact Does the report contain any legal impacts (such as general legal matters, statutory considerations (including employment law considerations), or new legislation)? Yes ☒ No ☐ If Yes, have all relevant legal impacts been discussed and agreed with Legal and Democratic? Yes ☒ No ☐ If Yes, please provide a brief summary of the impact? The Scottish Public Services Ombudsman Act 2002 provides the legislative basis for the SPSO to publish Model Complaints Handling Procedures for bodies under its jurisdiction. The Chartered Institute of Public Finance and Accountancy (CIPFA) Delivering Good Governance in Local Government Framework (2016) requires that councils demonstrate compliance with seven principles and 21 sub-principles. This includes principle A in terms of “Behaving with integrity, demonstrating strong commitment to ethical values, and respecting the rule of law” and its sub-principle in relation to “Demonstrating, communicating and embedding the standard operating principles or values through appropriate policies and processes which are reviewed on a regular basis to ensure that they are operating effectively.” These principles cite complaints policies, responding to complaints about behaviour, and changes / improvements as a result of complaints received being acted upon as examples of systems, processes, documentation, and other evidence that demonstrate compliance with the CIPFA Framework. The Local Government in Scotland Act 2003 introduced the duty of Best Value; this requires that councils “make arrangements to secure continuous improvement in performance”. The Local Government Act 1992 established the role of the Statutory Direction to direct the “publication of information as to standards of performance”. 5.5 Data protection impact Does the report / project / practice contain or involve the processing of personal data? Yes ☐ No ☒ If Yes, is the processing of this personal data likely to result in a high risk to the data subject? Yes ☐ No ☐ If Yes, has a Data Protection Impact Assessment (DPIA) been carried out and e- mailed to dataprotection@northlan.gov.uk Yes ☐ No ☐ 5.6 Technology / Digital impact Page 64 of 288
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Does the report contain information that has an impact on either technology, digital transformation, service redesign / business change processes, data management, or connectivity / broadband / Wi-Fi? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? Where the impact identifies a requirement for significant technology change, has an assessment been carried out (or is scheduled to be carried out) by the Enterprise Architecture Governance Group (EAGG)? Yes ☐ No ☐ 5.7 Environmental / Carbon impact Does the report / project / practice contain information that has an impact on any environmental or carbon matters? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? 5.8 Communications impact Does the report contain any information that has an impact on the council’s communications activities? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? 5.9 Risk impact Is there a risk impact? Yes ☒ No ☐ If Yes, please provide a brief summary of the key risks and potential impacts, highlighting where the risk(s) are assessed and recorded (e.g. Corporate or Service or Project Risk Registers), and how they are managed? Ensuring complaints performance reporting that supports the council in ensuring compliance with the requirements of the SPSO, the CIPFA Delivering Good Governance in Local Government Framework, and the Best Value duty to secure continuous improvement contributes to the mitigation of the risk on the Corporate Risk Register for governance, leadership, and decision making. 5.10 Armed Forces Covenant Duty Does the report require to take due regard of the Armed Forces Covenant Duty (i.e. does it relate to healthcare, housing, or education services for in-Service or ex- Service personnel, or their families, or widow(er)s)? Yes ☐ No ☒ If Yes, please provide a brief summary of the provision which has been made to ensure there has been appropriate consideration of the particular needs of the Armed Forces community to make sure that they do not face disadvantage compared to other citizens in the provision of public services. 5.11 Children’s rights and wellbeing impact Does the report contain any information regarding any council activity, service delivery, policy, or plan that has an impact on children and young people up to the age of 18, or on a specific group of these? Yes ☒ No ☐ If Yes, please provide a brief summary of the impact and the provision that has been made to ensure there has been appropriate consideration of the relevant Articles from the United Nations Convention on the Rights of the Child (UNCRC). Child Friendly Complaints - The UNCRC (Incorporation) (Scotland) Act 2024 makes Scotland the first country in the UK and the first devolved nation globally to directly incorporate the United Nations Convention on the Rights of the Child (UNCRC) into domestic law. This ensures that children’s rights are central to policy and decision-making, Page 65 of 288
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particularly in public service complaints procedures. The SPSO has developed a child friendly complaints approach, including principles and guidance for handling complaints. The council are adopting and incorporating these principles and guidance into internal complaint handling procedures. If Yes, has a Children’s Rights and Wellbeing Impact Assessment (CRWIA) been carried out? Work to undertake a CRWIA is currently underway. Yes ☐ No ☒ Page 66 of 288
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Appendix 1 Examples of lessons learned from complaints 2024 - 2025 The complaint said … The council … The wifi cables were cut when the grass was cut. Ensured that toolbox talks will be given to staff to avoid this happening again. There was no notification of roadworks in an area where residents were directly affected which did not allow residents time to make suitable arrangements to avoid being cut off during the event. Putting up signs is not enough. Has reminded staff to advise anyone who is closing a road to send notification letters to residents who stay within the affected area. The assessment undertaken was poor and incomplete and breached adult protection procedures. Will ensure improvements to ongoing assessment and discharge planning with effective joint working, responsiveness, and communication. They were unable to register online to make a formal objection to a planning application. Is reviewing information available on the website on how to log a comment online to identify improvements required. They had visited Strathclyde Country Park for the first time and were appalled at the amount of rubbish by the loch side and the pathways. There were also many instances of dog excrement on the grassy areas and most of the bins had graffiti daubed on them. “This was altogether not an appealing experience, and I won’t be back and will pass on this unpleasant visit to family and friends.” Has instigated more loch patrols and a meeting has been arranged with street scene regarding adding more scheduled litter picking to their routes. Discussions are underway to identify any futures measures required to address dog fouling issues. There are two links to primary school menus on the council’s website. This is confusing when trying to make lunch choices for the following week with my children on a Sunday. Has improved lines of communication to ensure that updates are populated correctly on the council’s website. Page 67 of 288
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Complaints: Stage One Volume % change in volume year to year 2013/14 2014/15 +52% 2015/16 +8% 2016/17 -10% 2017/18 +39% 2018/19 -5% 2019/20 -21% 2020/21 -12% 2021/22 +77% 2022/23 -5% 2023/24 +16% 2024/25 +2% • The volume of complaints closed at stage 1 in 2024/25 shows a small increase to 2,948 from 2,879 in the previous year. • The digital transformation of the complaints handling process has provided the public with more, and easier, ways in which to engage with the council when it comes to making a complaint. It is therefore expected this will have had an impact on the increase in the volume of stage one complaints closed from 2021/22 onwards. • In addition, prior to 2021/22 the data in Figure 1 excludes complaints for sports and leisure, libraries and culture, adult health and social care, and the arm's length external organisations. Data for complaints for these services was not recorded in the previous system and was only incorporated into the new system from 2021/22 onwards. • It is expected that the data for 2020/21 will have been impacted by prioritisation processes and resourcing decisions required in services in order to for them to proactively respond to the demands of the pandemic. At the time it was recognised by the SPSO that “resource implications may impact on a council’s ability to continue to deliver services to the standards they normally would, including complaints handling and providing the SPSO with information within the required timescales”. • Spikes in the volume of complaints prior to implementation of the new system in 2021/22 have been recorded in previous performance reports. • By way of comparison the council closed 10.3 complaints per 1,000 population in the year compared to a national average across Scotland of 11.5 per 1,000 population. • The aim of the Local Authority Model Complaints Handling Procedure (LAMCHP) is to resolve as many complaints at the initial point of contact, or as close to the point of service delivery, as possible (i.e. at stage one) - to get it right first time. • Since the LAMCHP was introduced in 2013/14, the council has consistently dealt with 9 out of 10 complaints at the initial point of contact (see Figure 2). • The new system introduced in 2021/22 contains a built-in function which automatically escalates complaints from stage one to stage two which breach their service level agreement (i.e. when a stage one complaint has exceeded its 5 working day deadline). For this reason, care should be taken when comparing the data for 2021/22 onwards with previous years as calculations within the two systems differ. Outcome • When complaints are concluded they are required to be assigned one of four outcomes - upheld, partially upheld, not upheld, or resolved. • Over the years, the volume of complaints combined for upheld + partially upheld has, in the main, exceeded 50% of all complaints closed at stage one. This means that the proportion of complaints upheld and/or partially upheld has in the main therefore exceeded those not upheld. • Figures for 2024/25 show a reversal in this respect with an increase in the proportion not upheld (from 33% to 40%) compared to a decrease in the proportion upheld and partially upheld combined (from 56% to 48%). • The outcome of resolved was introduced into the LAMCHP by the SPSO in 2021/22, this means “a complaint is resolved when both [the organisation] and the customer agree what action (if any) will be taken to provide full and final resolution for the customer, without making a decision about whether the complaint is upheld or not upheld”. Appendix 2 Page 68 of 288
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Responsiveness • The LAMCHP timescales specify that stage one complaints should be closed within 5 working days. • The volume of complaints for specific issues, as shown in the narrative Figure 1, will have had an impact on the average response time for these years. For example, in 2017/18 when the statistics associated with the spike in waste management complaints are removed from calculations, the average response time for all other complaints was 5.2 days. • The implementation of the new system in 2021/22 has impacted on the comparability of figures for 2021/22, 2022/23, and 2023/24, and 2024/25 with previous years. This is because at the point when a complaint has breached the 5 working day deadline for stage one, the new system automatically escalates that complaint to be dealt with at stage two and therefore it is no longer included in the counts at stage one. For this reason, care should be taken when comparing the data for 2021/22 onwards with previous years. Timeliness • The LAMCHP allows for an extension to be applied to the time allowed to respond to stage one complaints. The maximum extension that can be granted is five working days (that is, no more than ten working days in total from the date of receipt of the original complaint). • Figure 5a shows the proportion of complaints closed within the service level agreement irrespective of whether the extension option was applied or not. This shows a varying picture over time which will have been impacted by the spikes in the volume of complaints regarding specific issues noted against Figure 1. • The implementation of the new system in 2021/22 has impacted on the comparability of figures for 2021/22, 2022/23, 2023/24, and 2024/25 with previous years for the same reason as noted in the narrative above in relation to Figure 4 for the average days taken. • Figure 5b shows the number of stage one complaints that were closed with an authorised extension. Prior to 2021/22 the volume of complaints to which the extension option was applied remained relatively low. The notable increase in the volume of complaints to which the extension option applies from 2021/22 onwards which is due to the automated escalation process in the new system, however further analysis is underway to review the route of these complaints through the system in order to ensure complaints handling remains efficient and the use of the extension option is consistently understood and applied. Page 69 of 288
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Root cause • Figure 6a shows the category of all complaints closed at stage one over the four-year period from 2021/22 to 2024/25. While the previous system also included a breakdown by category, the new system has a wider and more specific range of categories (i.e. service areas) which enables better identification of the root cause. The analysis on this page has therefore only been undertaken on the last four years' worth of data. • Figure 6a shows that the top 6 categories of complaints have consistently been: - bins and recycling - education, schools, learning - housing repairs and investment - housing general - council tax, benefits, money advice - parks, open and green spaces, trees • Excluding the top 6 categories, Figure 6b on the next page shows that the majority of the other categories of complaints (service areas) receive very few complaints in a year. • Taken in context with the extent of services that the council provides, the volume of complaints received in terms of bins and recycling equates to 0.01% - this is less than one complaint per household in a year. • Given that no other service within the council interacts with all of North Lanarkshire’s properties to anywhere near the same frequency as the waste service does - and that there are 12 million household bin collections in a year - it is not surprising that the most complaints received are about bins and recycling, • Similarly with housing repairs, the volume of complaints received equates to less than 1 complaint per 100 repairs in a year. Page 70 of 288
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• As noted on the previous page - excluding the top 6 categories, the majority of the other categories of complaints (service areas) receive very few complaints in a year. Figure 6b also shows that there are no trends or patterns that are of significant concern, although there has been an increase in volume in adult health and social care compared to the previous year. • The new complaints system and supporting online process, introduced in 2021/22, enables complainants to select from one of six options to determine the reason why the complaint is being made. • Figure 6c shows that over the last four years the most prevalent reasons why the public complain have been associated with the quality of service and whether a service was provided. • Figure 6d below for 2024/25 shows that these 2 reasons account for over 50% of stage one complaints. • The previous system had similar reasons - with quality of service and service provision being among the top categories in previous years as well - but as not reasons all are directly comparable with the new system, the analysis below only looks at the last four years. Root cause Page 71 of 288
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• Not all complaints received are actually a complaint but are a request for service. The LAMCHP clearly identifies what is, and what is not, a complaint, e.g. “a complaint is not a routine first-time request for a service”. • The volume across the years, as shown in Figure 7a, shows that the complaints process continues to be used by the public for routine requests for services. • Previous analysis had identified the most common reasons for requests for services that are often received as complaints and signposting was set up on the council’s website to assist the public direct their request for service accordingly. However, given that the volume to be processed continues this is being revisited to see if further improvements can be made to avoid double handling these enquiries. Other outcomes • Analysis undertaken in previous years to identify the reason why a complaint was recorded as withdrawn or not resolved found several complaints recorded as such because the complaint was not about a council service. • When the new system was introduced in 2021/22 a specific outcome was introduced to record the volume of complaints received by the council that are not about a council service. • While Figure 7b shows this has been a relatively small number over the past three years, this still has a resource implication for council staff, and this is being reviewed further to identify if other signposting on the council’s website would help to alleviate this in the future. • Some complaints are withdrawn due to the complainant changing their mind or the issue being resolved outwith the formal complaints process or, on occasions, the matter is not within the entire gift of the council to resolve. • Figure 7c shows traditionally low volumes in this respect, however there has been an increase in volume that has coincided with the introduction of the new system from 2021/22 onwards and this is currently being examined in more detail. • Not all complaints are able to be resolved. This may be, for example, due to insufficient information provided by the complainant in the first instance or a service being unable to make further contact to clarify matters in more detail. • Figure 7d shows traditionally low volumes in this respect. The spikes in 2018/19 and 2019/20 coincide with enhancements to the online process introduced at the time which enabled complaints to be made anonymously. Without any details for the council to send a response to - or obtain further information from if required - this meant these complaints were unable to be responded to and were, as such, marked as unresolved. • However, given there is an increase in the latest figures in respect of complaints not being resolved, this is currently being examined in more detail to ascertain if there are any recurring reasons why. When complaints are concluded satisfactorily, they are required to be assigned one of four outcomes - upheld, partially upheld, not upheld, or resolved. However, not all complaints that require to be processed by the council reach a satisfactory conclusion. Complaints can be withdrawn or not resolved, or on occasion complaints are received that do not refer to a council service at all. In addition, the public can often log a request for service as a complaint. Page 72 of 288
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Complaints: Stage two Volume • There are two types of complaints handled at stage two: (i) Those that are an appeal - this is where the complainant is not happy with the response they have received to their stage one complaint and they have come back to complaint again. (ii) Those that are not an appeal - this is where a complaint has been escalated from stage one to stage two for one of three reasons - for investigator assessment where more time is required for staff to gather information (where the complaint is perhaps complex or cross service, or has legal implications), the complainant has requested that their complaint be dealt with straight from the outset at stage two, or because the complaint logged at stage one has not been responded to within the 5 working day deadline and it has therefore breached the service level agreement and been automatically escalated. • Figure 8a shows the total volume of complaints closed at stage two irrespective of the type. Overall, this shows that a relatively low proportion of all complaints received by the council have reached stage two (as depicted in Figure 8b). • It should be noted that because of the automatic escalation in the new system, the data in Figure 8a from 2021/22 onwards includes those stage 1 complaints that were automatically escalated from stage one to stage two when they breached their service level agreement (i.e. when a stage one complaint has exceeded its 5 working day deadline). • A breakdown of complaints closed at stage two by type is shown in Figure 8c. This shows that, in the main, more than two thirds of stage two complaints are an appeal. Appeals • However, this needs to be considered within the context of the volume of stage one complaints which are appealed and re-processed at stage two. Figure 8d shows this is relatively low, often less than 10%. Not an appeal • A further breakdown of the stage two complaints which are not an appeal shows that prior to the implementation of the new system in 2021/22 investigator assessment was the main reason for a complaint being processed at stage two - see Figure 8e. • The automated function in the new system from 2012/22 onwards - first noted against stage one volumes in Figure 2 - means that the automatic escalation is now the main reason. This is currently being reviewed further. Page 73 of 288
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Outcome • When complaints are concluded at stage two they are required to be assigned one of the same four outcomes as for stage one complaints, i.e. upheld, partially upheld, not upheld, or resolved. • Over the years, the volume of complaints for not upheld has, in the main, been greater than those upheld, or even those for upheld and partially upheld combined - as shown in Figure 9a. • The introduction of resolved as an outcome in 2021/22 has seen the proportion of not upheld drop and the proportion of upheld increase, this has also coincided with the introduction of the new system. Appeal • More in-depth analysis on the stage two complaints that were an appeal - Figure 9b - shows an even greater volume were not upheld, but again the introduction of the new system in 2021/22 has also increased the volume of stage two complaints that were appealed that were subsequently upheld. Not an appeal • More in-depth analysis on the stage two complaints that were not an appeal - Figure 9c - shows much more variation across the years and across the four possible outcomes. • The use of resolved as an outcome is more prevalent for those complaints that are not an appeal (Figure 9c), compared to those that are an appeal (Figure 9b). • In general, the proportion of complaints closed that are not upheld is greater at stage two (for complaints that are appealed) than at stage two for complaints that are not an appeal or at stage one. This suggests a level of effectiveness in ensuring an accurate and full response is provided the first time (at stage one) that is not then overturned during the stage two appeals process. • However, this assessment is based on the handling of the complaint, not the quality of the response and therefore more in-depth analysis is underway to identify any further trends or patterns in the data in terms of the outcome for stage two complaints to identify any areas for improvement in this respect. Page 74 of 288
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Responsiveness • The LAMCHP timescales specify that stage two complaints should be closed within 20 working days. • The implementation of the new system in 2021/22 has impacted on the comparability of figures for 2021/22, 2022/23, 2023/24, and 2024/25 with previous years. This is because at the point when a complaint has breached the 5 working day deadline for stage one, the new system automatically escalates that complaint to be dealt with at stage two and therefore it is no longer included in the counts at stage one. For this reason, care should be taken when comparing the data for 2021/22 onwards with previous years. • Notwithstanding these caveats, the trends in Figure 10 shows that the council has consistently closed stage two complaints in less than 20 days (on average). • More in-depth analysis shows no significant difference in the average number of days taken to respond to complaints closed at stage two for those complaints that were an appeal compared to those that were not an appeal. Timeliness • The LAMCHP allows for an extension to be applied to the time allowed to respond to stage two complaints, similar to the process allowed for stage one. • Figure 11 shows the proportion of complaints closed within the service level agreement irrespective of whether the extension option was applied or not. This shows a relatively positive picture of performance which further supports the council’s compliance in ensuring stage two complaints are closed off within 20 working days. • A similar option is available at stage two as it is at stage one in terms of applying an extension; to date the figures show very little usage of the extension option at stage two. • The low volume of complaints at stage two makes the identification of specific trends and patterns in the data less obvious and it also means that proportions can be distorted when using small numbers. For this reason, the inclusion of graphs at this section will add no value to the reader to aid with interpretation; this is best shown by means of the following summary: - The analysis into the root cause of stage two complaints found little change from stage one and little change over the years as the most prevalent reasons why the public complain remains associated with the quality of service and the service provided. This does not change significantly whether complaints were an appeal or not an appeal. - Service areas experiencing the highest volume of stage two complaints remains the same as stage one - bins and recycling, and education, schools, learning. For all other service areas, the volume of stage two complaints is less than 25 in the year, and in many instances this volume is in single figures. • Very few complaints closed at stage two are not resolved, although there has been an increase in the volume withdrawn and classed as a request for service at stage two since the new system was introduced in 2021/22; this will be reviewed further at the same time as the further analysis for the increase in stage one complaints in this respect. Root cause Page 75 of 288
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North Lanarkshire Council Report Audit & Scrutiny Panel Does this report require to be approved? ☐ Yes ☒ No Ref FS/ASP/ALNov25 Date 13/11/25 Audit and risk related items: Action log From Francis Scott, Chief Officer (Audit and Risk) E-mail scottfr@northlan.gov.uk Telephone 07887 914207 Francis Scott Chief Officer (Audit and Risk) Executive Summary The purpose of this report is to allow elected members to track implementation of outstanding requests and recommendations made by the Panel in respect of audit and risk- related items. The attached log (at Appendix 1) records those audit and risk-related requests and recommendations made by the Panel and when these were addressed and/or are expected to be addressed. Any actions that have previously been reported as complete and noted by the Panel have been removed from the log. Recommendations The Panel is invited to note the report. The Plan for North Lanarkshire Priority All priorities Ambition statement All ambition statements Programme of Work Statutory / corporate / service requirement Item 5 Page 77 of 288
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Appendix 1 Audit and Risk related items: Outstanding action log Date Requests or agreed action Status August 2025 1. Can any update, completed action or reason for delay be included within the Management update narrative in “Register of Outstanding Internal Audit Recommendations”? Complete – amendments have been made to the follow-up report to show reasons for delay, and to more clearly show progress or recommendations with multiple actions. 2. Can benchmarking details be provided of NL Risk Management Register against other Local Authorities? In progress – Differences across authorities (for example the tools used and how information is interpreted and applied in the risk management process) create challenges in making comparisons. A form of benchmarking is used annually in the horizon scanning exercise – details included within Appendix 3 of the Risk Management Update. The Scottish Local Authorities Chief Internal Auditors Group (SLACIAG) are currently conducting an exercise to benchmark corporate risks from Scottish local authorities. Once this exercise is complete, we will bring the outputs to a future meeting of the Panel as part of the Risk Management update. 3. Can an amendment to the format of the Corporate Risk Register be considered to include information on the mitigating actions? Complete – detail has been added to Appendix 2 of the Risk Management Update report to provide information on the controls in place for each corporate risk. 4. Can clarification be provided on NL self-evaluation responses in comparison to other Local Authorities? Complete – paper attached at Appendix 1 of this action log. Page 78 of 288
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Appendix 1 – Self-Evaluation of Audit Committees – Comparison with other Councils Audit & Scrutiny Panel – Self-Assessment August 2025 • Copy of report here ASP Self-Assessment Aug 25 • Based on 24 good practice questions • Summary of aggregated responses below Yes Partially No Don’t Know 2025 Survey 77% 12% 5% 7% 2023 Survey 59% 12% 11% 18% Responses from other Councils Twelve other Councils responded to a request for comparative information. Many use a self-assessment template developed by CIPFA, with 40 standard questions each score between 1 and 5 (which gives a maximum score of 200). Details below: Council Score Comments Angus 182 2023/24 score = 183. Reported average scores of 4.1 (out of 5) for knowledge and 4.05 for skills. Dundee n/a Average score 89% (2023/24 77%). No question had average score below 3. Highland n/a No overall score. Noted response rate was low so difficult to draw conclusions. East Ayrshire n/a Committee is currently discharging its functions effectively and comprehensively in accordance with good practice. Noted as “fully complies – no further improvement”. East Renfrewshire 174 Some recommendations and related actions prepared for approval. Moray n/a Based on CIPFA template but scores removed from committee report. Noted significant compliance with good practice principals and a high degree of effectiveness, but areas of improvement were identified. Scottish Borders 199 A high degree of compliance against the good practice principles. South Ayrshire 192 2023/24 score = 159. A small number of improvement actions raised. Other Council responses received. Council Response East Dunbartonshire Fully compliant, except for annual reporting and independent members. North Ayrshire Assessment will be reported to Audit & Scrutiny Committee in November 2025. South Lanarkshire Assessment will be completed and reported to Committee in December 2025. West Lothian Based on 36 questions agreed by Audit Committee. 94% of all responses were “strongly agree” or “agree”. Page 79 of 288
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North Lanarkshire Council Report Audit and Scrutiny Panel Does this report require to be approved? ☐ Yes ☒ No Ref FS/ASP/PRNov25 Date 13/11/25 Internal Audit: Progress Report From Francis Scott, Chief Officer (Audit and Risk) E-mail scottfr@northlan.gov.uk Telephone 07787 914207 Executive Summary The purpose of this report is to provide an overview of Internal Audit activity and audit reports issued since the last update to the Panel in August 2025, namely: • Fleet Management • Attendance Management • Payroll Leavers Process • Information Governance • Community Asset Transfers This report will also provide an update on performance management. Recommendations The Panel is invited to: (a) note the content of the Internal Audit reports together with the associated management responses. (b) consider whether there are any issues raised by Internal Audit which the Panel consider are sufficiently significant to require a further report from management to be submitted to a future meeting of the Panel. (c) request that Internal Audit report to future meetings of the Panel on the progress in implementing agreed management actions categorised as ‘High’ or ‘Medium’ priority, and (d) otherwise note this report. The Plan for North Lanarkshire Priority All priorities Ambition statement All ambition statements Programme of Work Statutory / corporate / service requirement Item 6 Page 81 of 288
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1. Background 1.1 The 2025-26 Internal Audit Plan was approved by the Audit and Scrutiny Panel in May 2025. The Internal Audit Charter requires that Internal Audit Progress Reports are presented to each meeting of the Panel, providing an update on the progress against the Internal Audit Plan and any other Internal Audit activity. This report fulfils that requirement. 2. Report Audit reviews completed in the period 2.1 The audit reports summarised below have been completed since the last meeting of the Panel in August 2025. While the reports noted contain recommendations for improvement, all have been assessed as providing positive levels of assurance. Management have responded positively to these reports and satisfactory responses and commitments to audit recommendations have been received. 2.2 Appendix 1 provides detailed definitions of the priorities assigned to audit recommendations, and the factors considered when determining the level of assurance provided in the audit opinion. Full copies of these audit reports have been included in the meeting paper in line with the approved reporting protocol. Fleet Management Internal Audit Opinion Reasonable assurance Recommendations High 2 Medium 3 Low 0 2.3 This audit was a review of the arrangement for managing the Council’s fleet, including the recording, maintenance and disposal of vehicles. In general, we found that vehicles are effectively tracked, maintained in line with regulatory and legal requirements, and disposed of through competitive processes designed to secure best value for the Council. We also observed that the establishment of a new workshop facility and team of staff and the introduction of updated record-keeping arrangement will further enhance the service and improve oversight. 2.4 We did, however, identify two areas which require urgent management attention. Firstly, there is a need to formalise contract arrangements for the provision of MOTs and specialist repair to ensure compliance with procurement regulations and Council procedures. The second area relates to vehicles acquired outwith the normal fleet arrangements (such as through donations, fundraising etc.) and ensuring these are identified, tested and serviced in line with other fleet vehicles. 2.5 Further medium priority areas for improvement included the retention, accuracy and completeness of documents and vehicle data, and strengthening governance in the development of polices, approval processes, second officer checks and consistent practices. Attendance Management Internal Audit Opinion Reasonable assurance Recommendations High 0 Medium 0 Low 2 Page 82 of 288
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2.6 This audit assessed compliance by Services with the Council’s policy and procedures for supporting and managing attendance. We noted that the policy and procedures were communicated and known to managers and were being applied across all services, with ongoing monitoring and support being provided by a team within People Resources. Management information on absence levels is reported regularly through management teams and to Chief Officers. 2.7 The audit work did identify some minor areas for improvement for services to ensure all absence processes are followed, actions arising from reviews are managed and the eLearning and masterclass training is promoted to staff. Payroll Leavers Process Internal Audit Opinion Reasonable assurance Recommendations High 0 Medium 3 Low 2 2.8 This audit assessed the controls and processes followed corporately when employees leave the Council, and we are generally satisfied that these arrangements are adequate and operating effectively, with leavers being processed consistently, accurately and in line with guidance, and evidence being retained as appropriate. We also noted that leavers documentation submitted by Services was generally processed accurately and timeously by the various teams within the Employee Service Centre and IT. 2.9 We have identified some areas for improvement relating to the timely completion and processing of leavers forms to avoid the employee’s final pay having to be recalled and recalculated, and to controls to ensure action is taken to recover, and restrict access to, Council property and systems when an employee leaves. We also noted a small number of occasions where the relevant Services had not yet recovered overpayments made to employees following recalculation of final salary payment. Information Governance Internal Audit Opinion Reasonable assurance Recommendations High 0 Medium 1 Low 0 2.9 This audit reviewed the arrangements in place for information governance across the Council. Information governance has been assessed on the Council’s Corporate Risk Register (CRR) as being high risk. In general, we were satisfied that the governance structures in place provide effective oversight, challenge and direction and that appropriate consideration had been given to the relevant information governance risks. The council has appropriate policies, procedures and guidance either in place or planned for review, with training provided to staff as appropriate, and adherence with these policies is being monitored and reported. 2.10 We identified a small number of areas for improvement, which include the need for the Data Governance Board, with assistance from the Data Management and Compliance Group, to continue to monitor and strengthen the council’s information governance arrangements and to address the identified gaps in arrangements in accordance with the DGB’s workplan. Community Asset Transfers Internal Audit Opinion Reasonable assurance Recommendations High 0 Medium 3 Low 1 Page 83 of 288
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2.11 This audit sought assurance that Community Asset Transfer (CAT) applications received by the Council were processed, decided, notified and approved, in accordance with the Community Ownership and Management of Council-Owned Assets Policy, and we are generally satisfied that this is the case and that there are appropriate processes in place for assessing and scoring applications and making outcome decisions to ensure consistency. 2.12 We did recommend some areas for improvement in the process, including strengthening the procedures and guidance to reflect current practices, and improving the monitoring log and the arrangements for the scoring panel. Performance Management 2.13 In line with Internal Audit performance management framework, two performance indicators are subject to quarterly reporting to the Panel. 2.14 The first indicator is the implementation of agreed actions arising from Internal Audit reports by the implementation date. In the period to September 2025, 66% of agreed actions have been implemented by the implementation date (the previous update for the period to June 2025 had a 63% completion rate). 2.15 The second performance indicator measures client satisfaction. There are no survey results available for the current period, however the client satisfaction scores from the recent audits will be reported as part of the progress report at the next meeting of the Panel. 3. Measures of success 3.1 Internal Audit reports annually on its performance to the Panel and is also subject to review annually by the Council’s appointed external auditors. 4. Supporting documentation Appendix 1 Audit Grading Definitions Francis Scott Chief Officer (Audit and Risk) Page 84 of 288
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5. Impacts 5.1 Public Sector Equality Duty and Fairer Scotland Duty Does the report contain information that has an impact as a result of the Public Sector Equality Duty and/or Fairer Scotland Duty? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? If Yes, has an assessment been carried out and published on the council’s website? https://www.northlanarkshire.gov.uk/your-community/equalities/equality- and-fairer-scotland-duty-impact-assessments Yes ☐ No ☒ 5.2 Financial impact Does the report contain any financial impacts? Yes ☐ No ☒ If Yes, have all relevant financial impacts been discussed and agreed with Finance? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact? 5.3 HR policy impact Does the report contain any HR policy or procedure impacts? Yes ☐ No ☒ If Yes, have all relevant HR impacts been discussed and agreed with People Resources? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact? 5.4 Legal impact Does the report contain any legal impacts (such as general legal matters, statutory considerations (including employment law considerations), or new legislation)? Yes ☐ No ☒ If Yes, have all relevant legal impacts been discussed and agreed with Legal and Democratic? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact? 5.5 Data protection impact Does the report / project / practice contain or involve the processing of personal data? Yes ☐ No ☒ If Yes, is the processing of this personal data likely to result in a high risk to the data subject? Yes ☐ No ☐ If Yes, has a Data Protection Impact Assessment (DPIA) been carried out and e- mailed to dataprotection@northlan.gov.uk Yes ☐ No ☐ 5.6 Technology / Digital impact Does the report contain information that has an impact on either technology, digital transformation, service redesign / business change processes, data management, or connectivity / broadband / Wi-Fi? Yes ☐ No ☒ Page 85 of 288
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If Yes, please provide a brief summary of the impact? Where the impact identifies a requirement for significant technology change, has an assessment been carried out (or is scheduled to be carried out) by the Enterprise Architecture Governance Group (EAGG)? Yes ☐ No ☐ 5.7 Environmental / Carbon impact Does the report / project / practice contain information that has an impact on any environmental or carbon matters? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? 5.8 Communications impact Does the report contain any information that has an impact on the council’s communications activities? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? 5.9 Risk impact Is there a risk impact? Yes ☒ No ☐ If Yes, please provide a brief summary of the key risks and potential impacts, highlighting where the risk(s) are assessed and recorded (e.g. Corporate or Service or Project Risk Registers), and how they are managed? Effective responses by management to the weaknesses, control issues and/or areas of improvement identified by Internal Audit will increase the likelihood of the Council achieving its ambitions by improving control frameworks and more effectively mitigating potential risks and threats to the achievement of planned outcomes. 5.10 Armed Forces Covenant Duty Does the report require to take due regard of the Armed Forces Covenant Duty (i.e. does it relate to healthcare, housing, or education services for in-Service or ex- Service personnel, or their families, or widow(er)s)? Yes ☐ No ☒ If Yes, please provide a brief summary of the provision which has been made to ensure there has been appropriate consideration of the particular needs of the Armed Forces community to make sure that they do not face disadvantage compared to other citizens in the provision of public services. 5.11 Children’s rights and wellbeing impact Does the report contain any information regarding any council activity, service delivery, policy, or plan that has an impact on children and young people up to the age of 18, or on a specific group of these? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact and the provision that has been made to ensure there has been appropriate consideration of the relevant Articles from the United Nations Convention on the Rights of the Child (UNCRC). If Yes, has a Children’s Rights and Wellbeing Impact Assessment (CRWIA) been carried out? Yes ☐ No ☐ Page 86 of 288
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Appendix 1 Audit Grading Definitions Audit reports are graded with an overall assurance opinion, and any issues and associated recommendations are classified individually to denote their relative importance, in accordance with the definitions in the tables below. Definition of audit assurance and recommendation categories Assurance Confidence based on sufficient evidence that internal controls are in place, operating effectively and objectives are being achieved. Assurance opinion Substantial Assurance There are minimal or minor control weaknesses that present low risk to the control environment. The control environment has substantially operated as intended although some minor errors have been detected. Very few or no improvements are needed. Reasonable Assurance There are some control weaknesses that present a low to medium risk to the control environment. The control environment has mainly operated as intended although errors have been detected. Some improvements should be made. Limited Assurance There are significant control weaknesses that present medium to high risk to the control environment. The control environment has not operated as intended. Significant errors have been detected. Substantial improvements should be made. No Assurance There are fundamental control weaknesses that present an unacceptable level of risk to the control environment. The control environment has fundamentally broken down and is open to significant error or abuse. Immediate and major changes need to be made. Organisational impact Major The weaknesses identified during the review have left the Council open to significant risk. If the risk materialises it would have a major impact upon the organisation. Moderate The weaknesses identified during the review have left the Council open to medium risk. If the risk materialises it would have a moderate impact upon the organisation. Minor The weaknesses identified during the review have left the Council open to low risk. If the risk materialises it would have a minor impact upon the organisation. Recommendation priority High Significant control failure or weakness that, if not addressed, may lead to a major financial, operational or reputational risk to the organisation and/or significantly impact the successful delivery and achievement of the objectives of the area under review. Urgent/Immediate action is required. Medium Control failure or weakness that, if not addressed, may lead to a moderate financial, operational or reputational risk to the organisation. Weakness may be individually significant, but it is unlikely to affect the successful delivery and achievement of the overall objectives of the area under review. The risk of error would, however, be significantly reduced if corrective action were taken. Prompt action is required Low Control failure or weakness that may lead to a minor financial, operational or reputational risk to the organisation. Weakness does not appear to significantly affect the ability to meet objectives. Minor issue raised to improve the efficiency and effectiveness of controls. Page 87 of 288
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1 INTERNAL AUDIT REPORT FLEET MANAGEMENT Headlines Following a request from the Chief Officer (Community Operations) during 2024-25, Internal Audit undertook some advisory work relating to the disposal of scrap materials and vehicles. This work identified potential areas where established Council procedures may not have been fully adhered to, particularly in relation to the disposal of assets and the engagement of external contractors for vehicle maintenance. In light of these findings, it was agreed that a more comprehensive review of the Fleet service was required, and this audit was included as part of the 2025-26 audit plan to address this. Notable progress has been made in enhancing the Council’s vehicle inspection, servicing, and repair capabilities, supported by the establishment of a new workshop facility in Bellshill and the recruitment of a full team of workshop staff. In addition, updated record-keeping arrangements were introduced in October 2024 to strengthen the audit trail and improve oversight. Based on the results of our audit work, we have categorised this audit as offering reasonable assurance. We are satisfied that in general, vehicles are effectively tracked, maintained in line with regulatory and legal requirements, and disposed of through competitive processes designed to secure best value for the Council. Additionally, the records management process implemented by the service is in its infancy and is expected to strengthen and evolve over time, as ongoing use will lead to the accumulation of more comprehensive data and more reliance can be placed on the electronic fleet system. We did, however, identify two areas which require urgent management attention. Firstly, there is a need to formalise contract arrangements for the provision of MOTs and specialist repair to ensure compliance with procurement regulations and Council procedures. The second area relates to vehicles acquired outwith the normal fleet arrangements (such as through donations, fundraising etc.) and ensuring these are identified, tested and serviced in line with other fleet vehicles. We also noted further areas for improvement including the retention, accuracy and completeness of documents and vehicle data, and strengthening governance in the development of polices, approval processes, second officer checks and consistent practices. Internal Audit Opinion Reasonable assurance Priority of Recommendations High Medium Low 2 3 0 Organisational Impact Moderate Report status Final Audit ref 0800/2026/001 Date issued 22/10/25 Audit Team Euan Campbell & Lesley Armstrong Issued To Chief Officer (Community Operations) Copied To Chief Executive and Depute Chief Executive (once finalised) Page 88 of 288
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2 1. Executive Summary Objectives The audit sought to provide independent assurance on the following areas: • Appropriate policies and procedures are in place for recording, maintaining and disposing of vehicles. • Effective controls ensure that full records of all vehicles, including receipt, maintenance and disposal, are properly documented. • Appropriate mechanisms are in place to ensure that vehicle maintenance is undertaken appropriately, timely, and in a cost-effective manner. This engagement has been conducted in accordance with the Global Internal Audit Standards. The Internal Audit section reports formally on conformance with these standards to the Audit and Scrutiny Panel. We would like to thank officers involved in this audit for their cooperation and assistance. 2. Findings and Recommendations Good practice identified We noted the following areas of good practice during the audit: • There is an electronic fleet management system (Freeway) which in general contains a comprehensive list of vehicles and servicing data. • The service recognised weaknesses in existing records management and scheduling processes and have implemented interim arrangements to maintain compliance on an ongoing basis. • Sample testing highlighted that the vast majority of servicing and inspections, tax, LOLER (Lifting Operations and Lifting Equipment Regulations) inspections and tachograph calibrations are completed by their due date. • Sample testing highlighted that all disposals are made via competitive means and should secure best value for the council. Key areas requiring management action (High Priority) The following key areas requiring urgent management action have been identified: • There is a need to formalise contractual arrangements for MOTs and specialist repairs to ensure legal compliance and service continuity. • There is an urgent need to identify and formally register vehicles acquired outside the replacement programme to ensure inspection, certification, and ongoing compliance with maintenance and safety standards. Other areas for improvement (Medium Priority) A number of other areas for improvement were also identified: • There is a need to establish a formal disposal approval process and ensure supporting documentation is retained to evidence decisions made. • There is scope to improve the completeness and accuracy of vehicle-related data and documentation within Freeway. • There is a need to strengthen governance arrangements through the development of formal policies, approval processes, second officer checks and consistent audit practices across all fleet services. Page 89 of 288
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3 3. Action Plan Fleet Management 0800/2026/001 Ref Finding 1 There is a need to formalise contractual arrangements for MOTs and specialist repairs to ensure legal compliance and service continuity. The service has made notable progress in expanding its inspection, servicing, and repair capacity through the development of a new workshop in Bellshill and the recruitment of a full complement of workshop staff. However, testing identified that MOTs and repair services carried out by external contractors are routinely procured without formal contractual arrangements in place. While this issue had been noted in previous audit work, current testing confirmed that the use of external providers without contracts is the default operational approach, rather than by exception, and the expenditure with each provider is in excess of the regulated procurement threshold of £50,000. The absence of formal agreements limits the Council’s ability to enforce service standards, monitor performance, and ensure value for money. It also exposes the service to potential risks around accountability, quality assurance and compliance with procurement regulations. Implication Recommendation Priority Management response Implementation Date The absence of formal contractual arrangements for MOT testing and specialist repairs increases the risk of procurement non-compliance, reduced service assurance and potential exposure to financial and reputational harm. The Chief Officer (Community Operations) should: (1) Undertake a review of current procurement practices for MOT testing and specialist vehicle repairs to identify instances of recurring non- contract spend and assess the operational reliance on external providers. (2) In collaboration with the Procurement team, implement formal contractual arrangements with frequently used external suppliers to ensure compliance with procurement regulations, improve service assurance and mitigate associated risks. High Agree John McElhinney, Fleet Business Manager (1) We have reviewed the current process for conducting MOTs. Subject to confirmation from the Driving and Vehicle Standards Agency, the Fleet Workshop will soon have the capacity to carry out MOTs in-house, eliminating the need for external providers. (2) The Fleet Team is working closely with the Procurement Department to develop a robust call-off framework for engaging fleet supplier contractors. While the framework has not yet gone out to market, progress is anticipated in 2026. December 2025 September 2026 Page 90 of 288
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4 3. Action Plan Fleet Management 0800/2026/001 Ref Finding 2 There is an urgent need to identify and formally register vehicles acquired outside the replacement programme to ensure inspection, certification, and ongoing compliance with maintenance and safety standards. Through the course of our testing, it was identified that there are a number of vehicles currently in the possession of school establishments which were not acquired through the Council’s formal vehicle replacement programme. These vehicles have been acquired through informal means such as donations from parent councils, churches, or fundraising efforts. Fleet Management stated that these vehicles were not known to them and as a result could not provide assurance that the required checks and maintenance had been performed. To assess the extent of the issue, further testing was conducted on the 13 vehicles identified to determine the level of information recorded in Freeway and the adequacy of scheduled maintenance. The following issues were identified: • Contrary to Fleet’s assertion, all 13 vehicles were recorded in Freeway, with 8 of them having been present in the system since its initial population. • LOLER inspections were either missing or incomplete for 5 vehicles. • LOLER scheduling was not fully in place for 3 vehicles. • Servicing schedules were incomplete or missing for 2 vehicles. • Servicing records were either absent or incomplete for 7 vehicles. These findings highlight a lack of oversight and control in the management of vehicles acquired outside the formal replacement programme. The absence of consistent scheduling and documentation for statutory inspections and servicing poses a risk to regulatory compliance, vehicle safety and operational accountability. Implication Recommendation Priority Management response Implementation Date The lack of formal oversight and registration of vehicles acquired outside the Council’s replacement programme increases the risk of non- compliance with statutory inspection and maintenance requirements, potentially compromising vehicle safety, legal accountability and the Council’s duty of care. The Chief Officer (Community Operations) should: (1) As a matter of urgency, ensure that all vehicles currently known to the service but acquired outside the formal replacement programme are subject to immediate inspection and certification, including confirmation of statutory requirements and servicing schedules prior to any further use. (2) Undertake a reconciliation or fact-finding exercise across all Council Services, to identify any additional vehicles acquired through informal means that may not yet be known to Fleet Management. The outcome of this exercise should be used to update Freeway records and ensure that all vehicles are brought under appropriate inspection, certification and maintenance regimes. (3) Introduce an exception reporting process within Freeway to identify vehicles that deviate from expected standards — such as missing servicing schedules, incomplete inspection records, or overdue statutory checks. This process should be used to support ongoing compliance monitoring and prompt corrective action where required. High Agree John McElhinney, Fleet Business Manager (1) We acknowledge the need for structured support in the procurement and maintenance of non- VRP vehicles used by Education Schools. In response, we will work collaboratively with Education to ensure that all vehicle purchases are aligned with operational requirements and procurement guidelines. (2) A review of all light fleet vehicles is currently underway. This includes evaluating service patterns, identifying responsible officers for each vehicle, and confirming the assigned drivers within each department. (3) Exception reporting will be incorporated into the existing weekly checks. The Performance and Compliance team, in collaboration with the workshop, will identify any assets that do not have any required maintenance or certification schedules set up in freeway or manual spreadsheets. April 2026 March 2026 October 2025 Page 91 of 288
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5 3. Action Plan Fleet Management 0800/2026/001 Ref Finding 3 There is a need to establish a formal disposal approval process and ensure supporting documentation is retained to evidence decisions made. In accordance with section 17.3 of the Council’s Financial Regulations, assets that are obsolete or beyond economic repair should be disposed of through either a sealed offer or public auction. We were pleased to note that, in general, the service is compliant with this requirement. Currently, approval for asset disposals is provided by the Fleet Business Manager, but this is facilitated through informal means such as email or verbal communication, rather than a documented procedure. As a result, there is limited evidence of disposal decisions being formally approved. In addition to the absence of formal approval, we noted further concerns regarding transparency in the asset disposal process. Sample testing revealed a lack of recorded evidence within Freeway to confirm that disposals had taken place. The absence of a clear audit trail initially prevented us from determining how and why assets were disposed of, and whether the appropriate checks and procedures had been carried out prior to disposal. While some supporting information was subsequently provided by the service, this was done retrospectively and was not readily available within Freeway at the time of testing. Implication Recommendation Priority Management response Implementation Date In the absence of a documented and consistently applied disposal approval process, there is an increased risk of unauthorised or inappropriate asset disposals and may result in non- compliance with Financial Regulations. The Chief Officer (Community Operations) should: (1) Implement a formal asset disposal approval process that clearly outlines roles, responsibilities, and required documentation in line with Financial Regulations. This process should ensure that all disposals are subject to documented approval prior to execution. (2) Consider enhancing the use of Freeway to record disposal decisions and supporting evidence in a consistent and accessible manner. This should include details of the disposal method, rationale, and confirmation of compliance with relevant procedures to ensure a clear audit trail is maintained. Medium Agree John McElhinney, Fleet Business Manager (1) A formal approval process will be implemented, requiring documented sign-off from the Fleet Business Manager. (2) The sales report will be retained on Freeway going forward, providing documented details of each asset sale. October 2025 January 2026 Page 92 of 288
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6 3. Action Plan Fleet Management 0800/2026/001 Ref Finding 4 There is scope to improve the completeness and accuracy of vehicle-related data and documentation within the Freeway fleet management system. The fleet service utilise both Freeway and paper manual records to facilitate asset tracking and maintenance scheduling. The use of manual records mainly relates to the management of HGV and PSV vehicles which are subject to increased scrutiny to comply with operator license requirements while cars and vans are managed through Freeway. This hybrid approach is relatively recent having been introduced in Oct 2024 however testing identified widespread deficiencies in the scheduling, execution, and documentation of fleet-related activities within the Freeway system. Key issues included: • Incomplete or irregular scheduling for servicing, inspections, MOTs, LOLER, tachograph calibrations, and tax renewals, with several vehicles lacking schedules entirely or not adhering to expected frequencies. • Inconsistent recording of ‘due dates’ where users do not always use the official due date on documentation and will intentionally enter an earlier date which provides some room for error. • Inconsistent documentation, where job cards, certificates, and inspection reports were frequently missing, incorrectly linked, or contained discrepancies in dates across all activity types. • Poor asset disposal records, with limited supporting documentation and incorrect vehicle status updates in Freeway. • Vehicle profile inaccuracies, including missing base locations, contact details, V5 documents, and pre-delivery inspections • Reactive repairs lacking evidence such as defect sheets missing for a number of sampled repairs. These issues reflect a lack of robust controls and oversight in fleet management processes, undermining data integrity, regulatory compliance, and operational accountability. Implication Recommendation Priority Management response Implementation Date The lack of complete and accurate vehicle-related data and documentation within Freeway may result in missed or delayed maintenance activities, potentially compromising vehicle safety, service continuity and lead to breaches in legal and regulatory requirements. The Chief Officer (Community Operations) should: (1) Undertake a review of current data management practices within Freeway to identify gaps in vehicle- related documentation and ensure that all relevant maintenance, inspection, and compliance records are complete and up to date. (2) Consider implementing a formal process to routinely validate the accuracy and completeness of vehicle data within Freeway, supported by periodic audits and staff training. This will help ensure that maintenance schedules are adhered to, legal and regulatory requirements are met, and risks to vehicle safety and service continuity are effectively mitigated. Medium Agree John McElinney, Fleet Business Manager (1) comprehensive review of vehicle asset data management practices on Freeway is currently underway. (2) The Business Support Team will carry out second officer checks to validate all new vehicle data entered into the Freeway system. April 2026 October 2025 Page 93 of 288
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7 3. Action Plan Fleet Management 0800/2026/001 Ref Finding 5 There is a need to strengthen governance arrangements through the development of formal policies, approval processes, second officer checks, and consistent audit practices across all fleet services. The fleet service currently lacks formal governance arrangements to support key operational areas. There are no documented policies or procedures in place for the use of the Freeway system, records management, maintenance and repairs, asset disposals, or compliance checks. This absence of structured guidance contributes to inconsistent practices and limits accountability. In addition, there are no second-officer checks undertaken on data entered into Freeway during vehicle profile setup for cars and vans, including servicing schedules and technical information. This absence of verification increases the risk of errors and undermines data reliability. While compliance audit processes – designed to identify defects missed by daily driver inspections and escalate issues for continuous improvement – are in place for waste management, they have not yet been extended to the wider fleet. This limits the effectiveness of oversight and reduces opportunities for service-wide learning and improvement. Collectively, these issues highlight significant gaps in governance, control and assurance across fleet operations. Implication Recommendation Priority Management response Implementation Date The absence of formal governance arrangements across fleet services increases the risk of operational inconsistencies, data inaccuracies, and non- compliance with regulatory and internal requirements. This reduces assurance over fleet activities and limits opportunities for continuous improvement. The Chief Officer (Community Operations) should: (1) Implement formal governance arrangements across fleet services, including documented policies and procedures for key operational areas such as Freeway system usage, records management, maintenance and repairs, asset disposals, and compliance checks. (2) Consider introducing second-officer verification for critical data inputs into Freeway – particularly during vehicle profile setup – to improve data accuracy and reliability. (3) Consider expanding the existing compliance audit process currently used in waste management to cover the wider fleet, ensuring consistent oversight and promoting continuous improvement across all service areas. Medium Agree John McElinney, Fleet Business Manager (1) The Performance and Compliance Team will support the Fleet Team in conducting spot checks of vehicle data within Freeway. While this will not involve a formal policy change, it will introduce a second officer check as a consistent and documented practice. (2) The Business Support Team will perform second officer checks to validate all new vehicle data entered into the Freeway system, ensuring accuracy and consistency. (3) Compliance audits have been expanded to cover the entire fleet. April 2026 October 2025 October 2025 Page 94 of 288
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INTERNAL AUDIT REPORT ATTENDANCE MANAGEMENT Headlines This audit assessed compliance by Services with the Council’s Supporting Attendance Policy (SAP), Procedure and Toolkit, to ensure that absences are being managed effectively and consistently and have been processed and recorded in line with the guidance. Based on the results of our work, we consider that the Council’s absence management arrangements are generally adequate and are being applied across all services with the support of the Employment and Policy Team (EPT). The SAP, procedure and toolkit are widely known to service managers as the guidance by which all absence is to be controlled. The EPT provides a consistent and ongoing monitoring and support function to service managers on a case- by-case basis to ensure absent employees are treated fairly and in accordance with the SAP. The EPT also provides a more intensive support role to service areas with absence concerns including targeted absence reviews on request. Quarterly absence information reflecting current service absence levels and comparison with targets, prior years and LGBF performance measures is presented to Chief Officers and discussed at BMT meetings, which includes general commentary on the uptake of activity designed to positively influence absence levels across services such as Health and wellbeing support, training opportunities for managers. An absence dashboard on iTrent is also available to all Chief Officers and Senior Managers within services. The audit work did identify some minor areas for improvement for services to ensure all absence processes are followed, actions arising from reviews are managed and the eLearning and masterclass training is promoted to staff. We have therefore assessed this audit as providing reasonable assurance. Internal Audit Opinion Reasonable assurance Priority of Recommendations High Medium Low 0 0 2 Organisational Impact Minor Report status FINAL Audit ref 0350/2026/001 Date issued 29/10/25 Audit Team Elaine MacDonald and Lesley Armstrong Issued To Chief Officer (People Resources) and Employment and Policy Manager Copied To Chief Executive and Depute Chief Executive (once finalised) Page 95 of 288
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1. Executive Summary Objectives The audit sought to consider the following issues: • That the Supporting Attendance Policy (SAP), Procedure and Toolkit has been clearly communicated to employees and managers. • That there are appropriate management arrangements in place to ensure compliance with the SAP, Procedure and Toolkit and that these arrangements are operating effectively. • That performance data relating to sickness absence is regularly reported to senior management and appropriate management action is taken where performance is below target and/or scope for improvement has been identified. This engagement has been conducted in accordance with the Global Internal Audit Standards. The Internal Audit section reports formally on conformance with these standards to the Audit and Scrutiny Panel. We would like to thank officers involved in this audit for their cooperation and assistance. 2. Findings and Recommendations Good practice identified We noted the following areas of good practice during the audit: • The SAP and procedure aim to support employees in improving their health & wellbeing and maximise their attendance at work. The SAP & procedure also provide fair and consistent standards and procedures for the management of sickness absence and ill health. The SAP is aligned to other corporate policies and frameworks including Smarter Working, Special Leave, Workforce Change and Mental Health and Wellbeing strategy. • A series of toolkits has been developed to accompany the SAP and to provide additional support and guidance to managers on supporting attendance. These cover a range of topics including early support procedures, guidance on the new short and long-term sickness absence stages, conducting return to work discussions and absence support meetings and on using the occupational health service referral process. • There are also various supports and resources available on MyNL, LearnNL and Workwell relating to absence topics, and all managers have access to the support and advice of the Employment and Policy Team (EPT). • Absence is a standing agenda item at Service Management Meetings and individual service leadership team meetings. • Dedicated Employment and Policy Advisors (EPAs) have been assigned to each service to ensure that absence levels are being appropriately monitored monthly; to identify and discuss any underlying issues with service managers; attend monthly attendance meetings with service managers; and to provide ongoing support and/or guidance to service managers as required. • Performance data for sickness absence in respect of Teaching and Single Status staff is submitted to the Improvement Service (IS) as part of the Local Government Benchmarking Framework (LGBF). Key areas requiring management action (High Priority) No areas requiring urgent management action have been identified. Other areas for improvement (Medium Priority) No other areas for improvement were identified. Page 96 of 288
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4. Action Plan Attendance Management 0350/2026/001 Ref Finding 1 There is scope for service managers to ensure all absence management processes are followed and increase the uptake of the eLearning and masterclass training. Managing staff absence is the responsibility of the service managers. The SAP and accompanying procedure and toolkits detail the requirements of managers and provide support and guidance on managing absence. The documents have been promoted across all services and are accessible to all managers on myNL and myTeam. Service managers confirmed during audit testing that they were fully aware of these documents and the content of them. The EPT supports service managers across the Council with their absence management responsibilities. This consists of attending their monthly absence meetings, correspondence and ad hoc engagement with service managers to discuss actions and ensure compliance with the SAP. However, the effectiveness of the process varies across services depending on the level of engagement from service managers. Audit testing highlighted occasions where service managers had not engaged with the monthly absence meeting processes or had not completed iTrent absence updates in a timely manner. An eLearning module and masterclass sessions have been made available to supplement the SAP and toolkit, to provide additional guidance if required by service managers. Audit fieldwork undertaken with a sample of 22 managers with responsibility for managing attendance found that 6 had not completed the eLearning module and 15 had not attended a masterclass session. The masterclass training is delivered in-house by the EPT and the Talent and Organisational Development team. Due to the interactive nature of the training, if offers a better learning experience for candidates when well attended (approx. 12 candidates). The course runs several times a year with dates set in advance, although the course scheduled at the end of August 2025 had to be cancelled due to a lack of candidates signed up to attend, with alternative dates offered. While there is no requirement to undertake this training or attend a masterclass, several of the managers advised they were unaware that these training options were available and expressed an interest in engaging with the training going forward. Implication Recommendation Priority Management response Implementation Date Non-compliance with the SAP and lack of engagement with process may adversely impact attendance levels. Service managers may feel better supported if they accessed the training options which supplement the SAP, procedure and toolkit. The Chief Officer (People Resources) should request that all Chief Officers: (1) Remind their service managers with absence responsibilities to ensure all absence management processes, including iTrent updates, are addressed in a timely manner and in accordance with SAP. (2) Promote the eLearning module and masterclass sessions, encouraging service managers to sign up where required. Low Agree The Chief Officer (People Resources) will issue a communication to all Chief Officers, reinforcing their responsibilities in managing absence and ensuring adherence to the relevant policy and timescales. This communication will also promote the eLearning module and masterclass as key resources to support managers in the application of the policy and accompanying toolkits. Responsible Officer: Linda Cullen Designation: Employment & Policy Manager November 2025 Page 97 of 288
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3. Action Plan Attendance Management 0350/2026/001 Ref Finding 2 There is scope to ensure action plans from targeted absence management compliance reviews are fully completed. At the request of senior management, the EPT have carried out reviews of Homecare and Education absence, and a further, more extensive review of Education staff is currently being concluded and expected to be reported shortly. The purpose of these reviews is to consider whether managers are complying with the SAP and procedures, and that they are taking the appropriate action at each stage of an employee’s sickness absence. Areas of non-compliance identified from these reviews were included in an action plan with a RAG status to demonstrate priority of each action. From our review of the process, reports and action plans, we noted that the action plans could be better completed to ensure all areas for improvement, the responsible officer, timeframe for completion and overdue/outstanding actions are clearly documented, and that deviations from the initial timeframe commitments are explained and reset. Implication Recommendation Priority Management response Implementation Date If action plans are not fully completed, the actions arising may not be implemented as intended, resulting in the risks identified (particularly those with a Red or Amber status) not being closed. The Chief Officer (People Resources) should remind relevant staff to ensure action plans arising from targeted absence management compliance reviews are fully completed, and that progress against actions and deviations from original commitments from the action plan are adequately documented and managed. Low Agree The Chief Officer (People Resources) will issue an email to all Chief Officers, emphasising the importance of ensuring that managers complete action plans and that these are consistently maintained, updated, and implemented as necessary. Responsible Officer: Linda Cullen Designation: Employment & Policy Officer November 2025 Page 98 of 288
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https://nlcgov.sharepoint.com/sites/AUR-INTERNALAUDITMANAGEMENT/Shared Documents/AUDIT AND SCRUTINY PANEL/2025/6. November/C1 - Pack of Audit Reports.docx 12 INTERNAL AUDIT REPORT PAYROLL – LEAVERS’ PROCESS Headlines The purpose of this audit was to assess the adequacy and effectiveness of the guidance and processes followed corporately when employees leave the Council. Based on the results of our work, we have categorised this audit as offering reasonable assurance. We are generally satisfied that the control framework and management arrangements associated with employees leaving the Council are adequate and operating effectively, with leavers being processed consistently, accurately and in line with guidance, and evidence being retained as appropriate. In addition, we noted that the documentation submitted by Services in relation to employees leaving was generally processed accurately and timeously by the various teams within the Employee Service Centre and IT. We did, however, note occurrences where the employee and their Reporting Manager did not give sufficient notice or complete the necessary documentation to enable the leaver’s employment to be ended promptly, resulting in the employee’s final pay often having to be recalled and recalculated. We also noted a small number of occasions where the relevant Service(s) have not yet taken appropriate action to recover overpayments made to employees following recalculation of final salary payment. We have identified some areas for improvement which management should consider. These are detailed in the action plan at section 3 of this report and include: • Improvements are needed to ensure all aspects of the leavers’ process are adhered to and carried out timeously. • There is scope to improve reporting to Chief Officers on payroll overpayments to ensure that monies are promptly recovered. • There is scope to improve the controls for ensuring that appropriate action is taken in relation to recovery of, and restricting access to, Council property and systems when an employee leaves. Internal Audit Opinion Reasonable Assurance Priority of Recommendations High Medium Low 0 3 2 Organisational Impact Moderate Report status DRAFT Audit ref 0350/2026/002 Date Issued 31/10/25 Audit Team Lynn McCrum and Lesley Armstrong Issued To Chief Officer (People Resources) and Employee Service Centre Manager Chief Officers (Education) and Chief Officer (Enterprise and Communities) (Point 2 only) Copied To Chief Executive and Deputy Chief Executive Page 99 of 288
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https://nlcgov.sharepoint.com/sites/AUR-INTERNALAUDITMANAGEMENT/Shared Documents/AUDIT AND SCRUTINY PANEL/2025/6. November/C1 - Pack of Audit Reports.docx 13 1. Executive Summary Objectives The audit sought to provide independent assurance on the following areas: • A clear, robust leavers’ process, covering the three aspects (payroll, IT and physical security), is in place and has been clearly communicated to all relevant officers. • Services are adhering to all key parts of the leavers’ process, including any timely reporting, completion of required documentation and retention of appropriate evidence. • Leavers’ forms submitted by Services are accurately processed and promptly actioned by the appropriate teams. Testing of the relevant aspects of the control framework was undertaken on a sample of 20 leavers, across the different service areas of the Council, in the period December 2024 to June 2025. This engagement has been conducted in accordance with the Global Internal Audit Standards. The Internal Audit section reports formally on conformance with these standards to the Audit and Scrutiny Panel. We would like to thank officers involved in this audit for their cooperation and assistance. 2. Findings and Recommendations Good practice identified We noted the following areas of good practice during the audit: • There are written procedures and guidance available to employees and managers, which document the processes which are expected to be followed when an employee leaves the Council. • The leaver’s Reporting Manager undertakes the necessary steps to ensure removal of access to the Council network, e-mail system and IT systems and return of Council owned equipment, such as the employee’s security fob, ID badge, uniforms, mobile phones, laptops and other devices. • An employee’s final salary payment will be calculated based on their resignation date and any annual leave owed to them. • Checks are undertaken by the Employee Service Centre to determine if the employee owes any monies to the Council (e.g. in respect of bought leave, training bonds, overpayments etc.) and subsequently deduct these from the final salary payment. Where the full amount cannot be recovered from the final pay, a letter and invoice will be sent to the employee to recoup any monies outstanding. • Where late notification of a leaver occurs and the employee is paid beyond their resignation date, the final salary payment is recalculated and adjusted accordingly, with any resultant overpayment recorded and the Reporting Manager notified of the need to take appropriate action to seek recovery of this overpayment. • An ‘Unactioned Leavers’ report is run before every pay cycle to identify any employees who have submitted their resignation, but this has not yet been actioned by the Reporting Manager. Future payments to these employees are suspended, thus preventing overpayments being made to the employee, and the Reporting Manager notified of the need to take appropriate action to rectify the situation. Key areas requiring management action (High Priority) No areas requiring urgent management action have been identified. Other areas for improvement (Medium Priority) The following other areas for improvement were identified: • Improvements are needed to ensure all aspects of the leavers’ process are adhered to and carried out timeously. • There is scope to improve reporting to Chief Officers on payroll overpayments to ensure that monies are promptly recovered. • There is scope to improve the controls for ensuring that appropriate action is taken to recover, and restrict access to, Council property and systems when an employee leaves. Page 100 of 288
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14 5. Action Plan Payroll – Leavers’ Process 0350/2026/002 Ref Finding 1 Improvements are needed to ensure all aspects of the leavers’ process are adhered to and carried out timeously. Our review of a sample of 20 leavers highlighted that, despite mySelf being the preferred method for self-resignation and authorisation by the Reporting Manager, only six were actioned by these means, with the remainder being processed via an Employee Change Form or similar. We understand that sometimes this can arise due to the payrun being closed at the time the employee submitted their resignation, and the Reporting Manager being unable to authorise it. We also noted the following instances where the employee and/or their Reporting Manager did not fully comply with all aspects of the leavers’ process: • One case where there was no Employee Change Form or record on the Daily Leavers’ Report to evidence that the Reporting Manager had authorised the employee’s resignation. This was identified by the Payroll and Pensions Team upon reviewing the Unactioned Leavers’ Report, which is run before every pay cycle for every payrun. Payments to the employee were supressed and the Reporting Manager advised of the need to take appropriate action in relation to the employee’s resignation. • Four cases where the resignation was not tendered by the employee and/or actioned by the Reporting Manager promptly prior to their leaving date. • For four of the five cases referenced in the points above, late notification by the employee or Service affected the final pay, meaning that the salary payment had to be recalled and/or recalculated, with an adjustment made in the next pay cycle. It should be noted that none of these payments resulted in an invoice needing to be raised as any ‘overpayments’ were offset against monies paid in the next pay cycle (e.g. Pay in Lieu of Holiday Pay etc.). Implication Recommendation Priority Management response Implementation Date If the correct processes are not followed, employees may not be removed from the payroll system in a timely manner, resulting in potential overpayment and monetary loss to the Council where there is difficulty in recovering such overpayments. The Chief Officer (People Resources) should remind all staff of the importance of ensuring that all aspects of the leavers’ process are adhered to and actioned timeously. This should include, but not be limited to, ensuring that employees, and their Reporting Manager, are fully aware that when resigning, this should be initiated by the employee via mySelf and authorised by the Reporting Manager via myTeam. Medium Agree Further communications will be developed and offered around the Leavers process. The business process flow, along with supporting documentation of FAQs, ICT leavers checklists, targeted comms to managers from both ESC Engagement and Corp Comms will be utilised. All training material will be updated, the HR Update will go out with an article informing managers of changes and signposting them to appropriate supporting documentation. The Managers Toolkit training for leavers will be updated and promoted again and will detail the move to the updated leavers process and outline what managers need to do. The ESC will continue to request that the managers toolkit training is made mandatory and will ensure that new managers are going through the managers toolkit as part of their induction and not only the Authorised Signatory part of the toolkit which is the only mandatory part of this training. Responsible Officer: Gillian Quinn Designation: ESC Manager March 2026 Page 101 of 288
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15 3. Action Plan Payroll – Leavers’ Process 0350/2026/002 Ref Finding 2 There is scope to improve reporting to Chief Officers on payroll overpayments to ensure that monies are promptly recovered. There have been recent changes to the way in which payroll overpayments are dealt with. Previously, the Payroll and Pensions Team were responsible for identifying/calculating overpayments, e-mailing employees to advise them of their overpayment and the methods of repayment, and raising debtors’ accounts on the ASH debtors’ system. However, responsibility for the recovery of overpayments, including raising of debtors’ accounts and monitoring payment, has now transferred to the Service. The Payroll and Pensions Team regularly monitor overpayments and prepare a quarterly report, which provides a general overview of overpayments recorded across the Council with individual tabs detailing overpayments by Service, for issue by the Chief Officer (People Resources) to all other Chief Officers. A separate e-mail is issued to each Service with the details of the specific overpayments pertaining to them, including the number and value of overpayments for each recovery method (i.e. Account, Bank Transfer, Cancelled/Waived, Payroll Recovery and Pending). The report only includes details of overpayments which fall within the period being reviewed and therefore does not include those from previous quarters which have not been actioned. Our review highlighted two overpayments, identified by Payroll and Pensions staff, where no action had yet been taken by the Service to recover monies overpaid. These overpayments were valued at £153.57 and £842.60. Implication Recommendation Priority Management response Implementation Date Prompt action to recover overpayments may not be taken which could result in reputational damage and financial losses being incurred. (1) The Chief Officer (People Resources) should strengthen the e-mails issued to Chief Officers to ensure that they are made fully aware of the need to undertake robust checks to ensure that prompt action is taken to recover all overpayments identified. (2) With regards to the two unactioned overpayments identified during our review, the (a) Chief Officers (Education) and (b) Chief Officer (Enterprise and Communities) should ensure that prompt action is taken to recover these overpayments. Medium Agree (1) Email to be issued from Fiona Whittaker and Greg Telfer to all HOS to ensure Quarterly reports are checked and Services are processing debtors accounts received from Payroll & Pension team. Responsible Officer: Fiona Whittaker Designation: Chief Officer (People Resources) (2)(a) The raising of accounts to recover salary overpayments involving school-based employees is being actioned by nominated HQ officers. In this specific case an invoice for £842.60 was issued to the respective ex-employee on 8 September 2025. Responsible Officer: Thomas O’Hagan Designation: Senior Education & Families Manager (2)(b) Unactioned overpayments are being actively addressed. Additional measures have been implemented to ensure Employee Change Forms are used for terminations when a resignation is submitted via MySelf but the payrun has already closed, in order to prevent overpayments. Responsible Officer: Lyall Rennie Designation: Chief Officer (Community Operations) January 2026 September 2025 November 2025 Page 102 of 288
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16 3. Action Plan Payroll – Leavers’ Process 0350/2026/002 Ref Finding 3 There is scope to improve the controls for ensuring that appropriate action is taken to recover, and restrict access to, Council property and systems when an employee leaves. As part of the leavers’ process, the Reporting Manager is required to complete an ICT Leavers’ Checklist to confirm that they have taken the necessary action to ensure removal of access to the Council network and e-mail system (via the IT Service Portal) and relevant IT systems (by contacting system administrator(s)), and return of Council owned equipment (such as security fob, ID badges, uniforms, mobile phones and other devices). This document acts as an aide memoir and there are no instructions with regards to completion of the checklist, including the action required once the Council owned equipment and ID badge have been returned, and where, and for how long, the checklist should be retained. We also consider it to be unclear from the checklist whether the Reporting Manager is responsible for arranging the removal of access to IT systems and, if so, there is no information on who should be contacted (e.g. Service Administrators), or how, for each of the listed systems to notify them that an employee is leaving. From our review of the checklist, we noted that the first section does not allow for data/text to be entered electronically and that some of the references are out of date and refer to processes and documentation which is no longer in use (i.e. Etarmis, Notification of Change Form and Resignation Letter). Our review of the sample of 20 leavers identified the following issues regarding completion of the checklist and/or action taken to recover/restrict access to Council property and systems: • Four cases where no checklist was completed and a further two cases where the checklist had been completed, but only as a result of our testing. • One case where, shortly after leaving, the employee was re-employed by the Council on a sessional contract and retained their ID badge and key fob. • Three cases where the employee still appears on e-mail and/or MS Teams. The IT Service Desk confirmed that they had not received a leaver’s request for these employees and their people record in ServiceNow was not made inactive via the nightly sync with iTrent. • One case where the employee’s system access (HSMS) had not been deactivated at the time of our testing, however action has now been taken to rectify this. • One case where the system admin had not been made aware of the employee leaving (Civica) but access was removed as part of the periodic access review when employee did not submit a return. Implication Recommendation Priority Management response Implementation Date Access to Council buildings and IT systems may not be removed promptly, resulting in an increased risk of unauthorised access and cyber security threats. Council assets, equipment and technology may not be recovered which may result in additional costs being incurred by the Council, cyber security threats and reputational damage. The Chief Officer (Finance and Technology) should ensure that: (1) The ICT Leavers’ checklist is reviewed and updated to reflect and reference current practices. Consideration should be given to developing and issuing guidance/instructions on the completion, submission and retention of this document. (2) All Managers are reminded of the need to ensure that all relevant sections on the ICT Leavers’ Checklist are fully completed and actioned, including requesting via the IT Service Portal that the employee’s network and e-mail accounts are disabled; requesting that systems’ admin remove access to relevant IT systems; and ensuring the return of ID badges and Council-owned equipment. Medium Agreed (1) The ICT Leavers checklist will be reviewed along with associated guidance. Responsible Officer: Grant Reid Designation: Technology Strategy Manager (2) A reminder to ensure all sections of the ICT Leavers’ Checklist are completed will be included in the communications issued as part of the action at recommendation 1. Responsible Officer: Gillian Quinn Designation ESC Manager November 2025 March 2026 Page 103 of 288
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17 3. Action Plan Payroll – Leavers’ Process 0350/2026/002 Ref Finding 4 There were a small number of errors identified with regards to the calculation of payments made to employees. From our review of a sample of 20 leavers, we are generally satisfied that payments are correctly calculated, in accordance with contractual entitlement and termination date. We did, however, identify the following issues: • One case where Pay in Lieu of Holiday Pay has been incorrectly calculated, and the employee has been underpaid (value of £54.79). • One case where the employee should have, but did not, receive payment for holiday pay adjustment for overtime worked and has been underpaid (value of £102.66). Details of the employees affected will be provided to People Resources under separate cover. Implication Recommendation Priority Management response Implementation Date If payments are incorrectly calculated, this may result in employees being under or overpaid and may lead to the Council experiencing financial loss and/or reputational damage. The Chief Officer (People Resources) should: (1) Remind staff that appropriate checks should be undertaken to verify the accuracy of payments being made to employees when they leave the Council. (2) Review the two cases referenced above and consider the best course of action to be taken. Low Agree Action on this has now been completed. Pay in lieu of holiday pay hours paid Week 32 (11th Nov 2025). Holiday pay paid Week 32 (11th Nov 2025) Email sent to audit to confirm payments made by ESC 27th Oct 2025. Responsible Officer: Lorraine Buttery Designation: Payroll & Pension Manager November 2025 Page 104 of 288
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18 3. Action Plan Payroll – Leavers’ Process 0350/2026/002 Ref Finding 5 A small number of other minor areas were identified with regards to the processes in place and/or compliance with these. During the review, we identified a small number of other areas with regards to the processes in place and/or compliance with these, including: • The Manager User Guide for processing leavers on myTeam states that the manager must ensure that checks are taken to ascertain any remaining annual leave and complete the fields on the Occupancy Details screen on mySelf to confirm that any remaining annual leave has been discussed with the employee to determine whether they will use this before leaving or if authorisation is given for this to be paid to the employee. We noted, however, that completion of these fields is not mandatory and are therefore not always completed, resulting in the People Operations Team needing to contact the Reporting Manager to determine whether the remaining annual leave balance should be paid or will be used prior to leaving. • The Manager User Guide for processing leavers on myTeam requires the Reporting Manager to tick the box on the Occupancy Details screen on mySelf to confirm that they have completed/sent the ICT Leavers’ Checklist. We noted that completion of this field is not mandatory and is therefore not always completed. No independent checks are undertaken to ensure that the Reporting Manager has completed this field and/or the ICT Leavers’ Checklist. Implication Recommendation Priority Management response Implementation Date Failure to complete the necessary fields on the system may result in a delay in appropriate action being taken and could lead to inaccuracies in payments made to the leaver. The Chief Officer (People Resources) should consider whether system updates could be made to iTrent to ensure that the fields in respect of annual leave and completion of the ICT Leavers’ Checklist are mandatory. In the interim, a reminder should be issued to all managers to remind them of the need to ensure that all fields on mySelf are fully and accurately completed. Low Agree A review will take place of both the occupancy details screen as well as the leaver information screen on MyTeam to remove any unnecessary fields and change non mandatory fields to mandatory where appropriate. The guidance will also be reviewed and updated in line with these changes. All of this will be communicated with the wider workforce. Further improvements will be implemented as part of the changes to help streamline the leaver process. Such as workflows to relevant departments who may need to take action as a result of an employee leaving. E.g. IT could be notified and the signpost to their checklist could be included in that notification. Further to this, an escalation step will be added to the resignation approval step where a chaser email will be sent 10 days after the original resignation request was submitted in the event of no action being taken by the manager within this time. This escalation notification will go to the employee, manager and manager’s manager in the first instance. Other departments can also be notified if deemed appropriate. Responsible Officer: Paul Scoular Designation: Systems and Analytics Manager March 2026 Page 105 of 288
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19 INTERNAL AUDIT REPORT INFORMATION GOVERNANCE Headlines The purpose of this audit was to assess the adequacy and effectiveness of the arrangements in place for information governance across the Council. Information governance has been assessed on the Council’s Corporate Risk Register (CRR) as being high risk. The Council has well-established information governance arrangements in place which have recently been subject to significant changes and improvements. The Data Governance Board (DGB) continues to be responsible for the strategic oversight of the Council’s information governance arrangements, with a new Data Management and Compliance Group (DMCG) responsible for assisting the DGB in providing relevant assurance that effective arrangements are in place for the safe and secure collection, storage, use and sharing of data. Terms of reference for both these forums have recently been reviewed and agreed by the DGB and the DMCG met for the first time in August 2025. Internal Audit recognises the changes which have already taken place and the plans in place to address further improvements already identified via the DGB and the Corporate Management Team. Based on the results of our work, we have categorised this audit as offering reasonable assurance. In general, we were satisfied that the governance structures in place provide effective oversight, challenge and direction and that appropriate consideration had been given to the relevant information governance risks. The council has appropriate policies, procedures and guidance either in place or planned for review, with training provided to staff as appropriate, and adherence with these policies is being monitored and reported. We have identified a small number of areas for improvement, which include the need for the DGB, with assistance from the DMCG, to continue to monitor and strengthen the council’s information governance arrangements and to address the identified gaps in arrangements in accordance with the DGB’s workplan. Internal Audit Opinion Reasonable assurance Priority of Recommendations High Medium Low 0 1 0 Organisational Impact Moderate Report status FINAL Audit ref 0900/2026/005 Date issued 31/10/2025 Audit Team Jacquie Howden and Lesley Armstrong Issued To Chief Officer (Legal and Democratic), Principal Solicitor (Information Governance) and Legal Manager (Enterprise) Copied To Chief Executive and Depute Chief Executive Page 106 of 288
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20 1. Executive Summary Objectives The audit sought to provide independent assurance on the following: • There are effective governance structures that provide effective oversight, challenge and direction. This includes appropriate consideration of relevant risks and how key risks are being managed. • There are appropriate policies, procedures and guidance in place to ensure Council staff are aware of the requirements and the importance of strong information governance. • Progress and adherence to these policies is monitored and reported. This engagement has been conducted in accordance with the Global Internal Audit Standards. The Internal Audit section reports formally on conformance with these standards to the Audit and Scrutiny Panel. We would like to thank officers involved in this audit for their cooperation and assistance. 2. Findings and Recommendations Good practice identified We noted the following areas of good practice during the audit: • Information Governance has been identified as a key corporate risk and is included in the Council’s CRR. • The Council’s Senior Information Risk Owner (SIRO) is responsible for information risk and security and for managing the Council’s information governance arrangements. • In accordance with the Data Protection legislation, the Council also has a designated Data Protection Officer (DPO) who is responsible for providing operational oversight of information governance, data protection compliance and Freedom of Information arrangements to ensure that the Council’s approach reflects legal requirements, best practice and evolving regulatory standards, • There is a well-established governance structure in place for information governance. This includes the DGB, which is responsible for the strategic oversight of the Council’s information governance arrangements, and the DMCG, which is responsible for assisting the DGB in providing relevant assurances that effective arrangements are in place for the safe and secure collection, storage, use and sharing of data. • The DGB has a formal workplan which sets out the planned actions and agenda items which ensures it fulfils its terms of reference. The actions are grouped depending on the type of assurance (i.e. approach, deployment, assessment and review) and includes the name of the officer responsible for reporting to the DGB and the corresponding reporting date. • The council has a range of information governance policies and guidance notes which are now being monitored as sub-policies of the Council’s Digital and IT strategy 2024-2027 and contribute to the development and delivery of the Council’s digital vision. • An annual SIRO report, which is presented to the Finance & Resources Committee, summarises the DGB’s oversight of information governance arrangements for the year and provides the SIRO’s assessment of the Council’s existing information governance and data accuracy arrangements. The report outlines what is going well, highlights key matters of concern and details the improvement action which require to be processed (via the DMCG) during the following year to strengthen the arrangements. • In addition, an annual Data Protection report is presented to the Finance & Resources Committee highlighting the key activity, trends and areas for improvement in relation to personal data breaches, complaints to the Information Commissioner’s Officer (ICO), mandatory and service specific training and Subject Access Request (SAR) compliance. Key areas requiring management action (High Priority) No key areas requiring urgent management action have been identified. Other areas for improvement (Medium Priority) A small number of other areas for improvement were identified as follows: • There is scope to further strengthen the Council’s information governance arrangements and address the identified gaps in accordance with the Data Governance Board’s workplan. Page 107 of 288
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6. Action Plan Information Governance 0900/2026/005 Ref Finding 1 There is scope to further strengthen the Council’s information Governance arrangements and to address the identified gaps in accordance with the Data Governance Board’s workplan Following a restructure of the Chief Executive’s Service, the Information Security and Risk function transferred from Business and Digital to Legal and Democratic Services in April 2025, creating a central point for information governance to ensure compliance across all related functions. The Council already had a well-established information governance structure in place, which included a Data Governance Board (DGB) responsible for the strategic oversight of the information governance arrangements. The restructure and subsequent transfer of responsibility for information governance, however, has provided an opportunity for the Council to review and enhance its arrangements to ensure continued compliance with all information governance legislative and regulatory requirements. As a result, several changes have recently been made including the creation of a new Data Management and Compliance Group (DMCG), which replaced the Data Management Team, and which is responsible for assisting the DGB in providing relevant assurances that effective arrangements are in place for the safe and secure collection, storage, use and sharing of data. Revised terms of reference for both the DGB and the DMCG have recently been approved, which reflect the increased need for clear compliance and assurance roles. Membership of the DMCG has recently been agreed and will be regularly reviewed by the DGB to ensure that officers with the right skill sets and knowledge are in place. The initial meeting of the DMCG was held in August 2025. In addition, the Council’s Senior Information Risk Owner (SIRO) and Data Protection Officer (DPO) roles have been re-defined to ensure that there is appropriate segregation of operational and oversight responsibilities. The Council’s existing information governance policies and guidance have also now been re-defined as sub-policies of the Council’s Data and IT strategy which help deliver the council’s digital vision. The policies are all still subject to the biennial review approved under the previous Information Governance Framework. The DGB has a formal workplan which details the actions required to address most of the gaps in the current arrangements and that actions have been assigned to designated responsible officers with expected timescales for completion. Internal Audit recognises the improvements which have already been made through the DGB and those which are currently planned for completion. We have, however, identified a small number of areas which we consider should be incorporated into the arrangements as follows: • Job descriptions for the SIRO and DPO roles have been updated to reflect the re-allocation of data protection responsibilities. We noted, however, that the SIRO document still referred to the Chief Officer (Legal & Democratic) being responsible for the DPO role. In addition, at the time of the audit fieldwork the DPO job description had only been issued in draft. Both documents therefore require to be fully updated to reflect the roles and responsibilities and issued to the relevant officers as soon as possible. • At the time of the audit fieldwork, most of the Information Governance policies and guidance had not been reviewed and updated in accordance with the two-year timeframes. We were pleased to note, however, that all the reviews were underway and that all policies are due to be presented to Committee for approval by March 2026. The DGB should ensure that all revised policies are published on SharePoint and notified to all relevant officers on a timely basis thereafter. • The Council has three mandatory eLearning modules in relation to Information Governance which require to be completed by all staff. The modules contain links to the key documents, but at present these are for the old policies. The training materials therefore require to be reviewed/updated to reflect the new/revised policies as they as approved to ensure that they remain up to date. We understand that this is being progressed via the DGB, with the Talent and Leadership team due to make all necessary changes following committee approval of the policies. • Reviews are currently underway of the Council’s Data Sharing agreements, third party processing agreements, retention plans and retentions schedules. Whilst updates are reported to the DGB, we understand that the completion date for the reviews has recently been extended from November 2025 to January 2026. In addition, work is currently underway to develop and update the information on the Council’s Information Asset Register. We understand that this process is in its early stages and progress will be reported to the DGB via the DMCG. We consider that the DGB and DMCG should ensure that these reviews are completed within a reasonable timescale. • Guidance on the Council’s Subject Access Request (SAR) process and revised proforma templates were approved by the DGB and DMCG in August 2025. We understand, however, that the final version of the revised guidance has not yet been issued. We consider that this guidance should be issued to all relevant staff as soon as possible. Page 108 of 288
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3. Action Plan Information Governance 0900/2026/005 Implication Recommendation Priority Management response Implementation Date Without clearly defined roles, staff may not be fully aware of their responsibilities. Policies would not be reviewed in accordance with the expected timescales and may not be appropriate and/or reflect the current legislation and requirements. Training materials may not be current and reflect the latest legislation requirements and/or good practice. Without clear protocols for data sharing, third party processing and retention of documents, the Council arrangements may be in breach of GDPR legislative requirements. Without an up-to- date Information Asset Register, management may not be aware of all its IT assets which may result in misuse of these assets. The Chief Officer (Legal and Democratic Services), in conjunction with the DGB, should continue to review/enhance the information governance arrangements. This should include, but not be limited to, consideration of the specific issues referenced in the finding. Medium Agree Responsible Officer: Rachel Blair Designation: Chief Officer (Legal and Democratic) Management acknowledges the findings of the audit and agrees with the recommendation. The Council is committed to maintaining robust and compliant information governance arrangements that align with legislative and regulatory requirements and support the Council’s digital vision. Action has already been taken to strengthen governance structures following the transfer of the Information Security and Risk function to Legal and Democratic Services in April 2025. The DGB and DMCG continue to play key roles in providing oversight and assurance of the Council’s information governance framework. In response to the specific areas identified within the audit: 1. SIRO and DPO Job Descriptions: The description for the DPO has now been finalised and issued to the postholder. The HR Business Partner Manager has been made aware of the requirement to update the SIRO job description to fully reflect the revised allocation of data protection responsibilities and ensure a clear separation of oversight and operational roles. 2. Policy and Guidance Reviews: All Information Governance policies and guidance are currently undergoing review in accordance with the Council’s biennial review cycle. Revised policies will be presented to Committee for approval by Cycle 2 and once approved, will be published on SharePoint and communicated to all relevant staff to ensure awareness and compliance. 3. Training Materials: The mandatory eLearning modules on Information Governance are being updated in parallel with the policy reviews to ensure alignment with revised content and current legislative requirements. Updates will be implemented following Committee approval of the new policies, with refreshed modules expected to be launched in collaboration with the Talent and Leadership Team. 4. Data Sharing, Third Party Processing and Retention Reviews: The ongoing reviews of Data Sharing Agreements, Third Party Processing Agreements, Retention Plans and Retention Schedules are being progressed through the DGB and DMCG. Revised completion timescales have been agreed, with all reviews to be finalised by January 2026. Updates to the Council’s Information Asset Register are also underway, with progress monitored via the DMCG to ensure completion within the same timeframe. 5. Subject Access Request (SAR) Guidance: The revised SAR guidance and proforma templates approved by the DGB and DMCG in August 2025 will be finalised and issued to all relevant staff to ensure consistency and compliance across services. The DGB and DMCG will continue to monitor progress against these actions through regular reporting and oversight, ensuring that improvements are embedded, and that the Council continues to demonstrate compliance with the relevant data protection and information governance standards. December 2025 April 2026 June 2026 January 2026 November 2025 Page 109 of 288
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INTERNAL AUDIT REPORT COMMUNITY ASSET TRANSFERS Headlines The Community Empowerment (Scotland) Act 2015 provides the legal framework for Community Asset Transfers (CATs), leases and other rights, such as management or use of a property. The primary purpose of a CAT is to allow local communities to apply for control over assets owned or leased by public bodies, to address local need, promote community development and enhance wellbeing. The purpose of this audit was to provide assurance that CAT applications received by the Council have been processed, and decisions have been made, in accordance with the Community Ownership and Management of Council-Owned Assets policy (the Policy), which was approved by the Policy and Strategy Committee in June 2024. The audit considered the full process from initial enquiry, application, final decision, approval by the Communities Committee, notification of outcome and independent review process. Based on the results of our work, we have categorised this audit as providing reasonable assurance. We are generally satisfied that CAT applications are being processed in line with the Policy and that there are appropriate processes in place for assessing and scoring applications and making outcome decisions to ensure consistency. We have, however, identified some areas for improvement which management should consider. These are detailed in the action plan at section 3 of this report and include: • There is a need to strengthen the current Policy and associated procedures and guidance to fully reflect current practice. • There is scope to improve the log for monitoring progress of CAT applications. • There is a need to review and improve the arrangements for the Scoring Panel process. Internal Audit Opinion Reasonable assurance Priority of Recommendations High Medium Low 0 3 1 Organisational Impact Minor Report status Final Audit ref 0300/2026/001 Date Issued 29/10/25 Audit Team Kimberley Hall and Lesley Armstrong Issued To Acting Chief Officer (Strategic Communications and Engagement) and Community Partnership Manager Copied To Chief Executive and Depute Chief Executive Page 110 of 288
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1. Executive Summary Objectives The audit sought to provide assurance on whether applications received for CATs have been processed in accordance with the Policy and that all decisions made are justified, consistent and fair. The audit did not include a detailed review of the content of the Policy. A sample of six completed CAT applications, consisting of a mix of approved and rejected outcomes, were selected for testing, which included a review of the application and supporting documentation, the assessment and decision-making process, notification of the outcome to applicants and, where appropriate, the appeals process. This engagement has been conducted in accordance with the Global Internal Audit Standards. The Internal Audit section reports formally on conformance with these standards to the Audit and Scrutiny Panel. We would like to thank officers involved in this audit for their cooperation and assistance. 2. Findings and Recommendations Good practice identified We noted the following areas of good practice during the audit: • The Council has a Community Ownership and Management of Council Owned Asset Policy, which is applicable to all Council services and officers receiving requests or expressions of interest from communities related to community ownership or management of council owned assets. • There is an assessment process, with a scoring framework aligned with the Best Value principles and assessment themes from the Scottish Government Guidance, which is used by officers to score and assess CAT applications. • The Corporate Community Assets Working Group oversees the development and implementation of processes relating to community ownership and management of assets, setting priorities, providing strategic guidance and ensuring consistency of practice across Council services. • The Community Asset Leadership Group (the Leadership Group), which comprises of various Chief Officers and meets on a quarterly basis, is responsible for independently assessing the decision of the scoring panel and finalising decision to be presented to Committee. • A report was submitted to the Communities Committee in August 2025 providing the annual progress update on Community Asset Transfer and Participation Requests in North Lanarkshire. This report is used to populate the annual return required to Scottish Government relating to Community Asset Transfer Requests and Participation Requests under the legislation. Key areas requiring management action (High Priority) No key areas requiring urgent management action have been identified. Other areas for improvement (Medium Priority) A number of other areas for improvement were also identified: • There is a need to strengthen the current Policy and associated procedures and guidance to fully reflect current practice. • There is scope to improve the log for monitoring progress of Community Asset Transfer (CAT) applications. • There is a need to review and improve the arrangements for the Scoring Panel process. Page 111 of 288
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3. Action Plan Community Asset Transfers 0300/2026/001 Ref Finding 1 There is a need to strengthen the current Policy and associated procedures and guidance to fully reflect current practice. Whilst we did not undertake a detailed review of the Policy, from the work undertaken during this audit, we identified a number of areas in relation to the Policy and associated procedures and processes which we consider could be improved: • Appendix 2 of the Policy contains a flowchart which provides a high-level overview of the process for receiving and assessing CAT enquiries and applications. The flowchart states that the Leadership Group will be notified of all CAT enquiries, however, we noted that the Policy does not state this, and we were advised that this does not happen in practice. • The Policy does not provide clear guidance on the eligibility criteria for organisations to submit a CAT and does not state the documentation required to support an application or the essential criteria that require to be met for an application to be accepted. From our review of a sample of CATs, it was often difficult to determine whether all the essential criteria had been sufficiently met. • There is currently no written procedures or guidance outlining the process for reviewing and assessing applications received. We understand that the Corporate Community Assets Working Group (CCAWG) is responsible for developing and improving processes and that the Community Partnership team is currently developing guidance notes for organisations (i.e. Welcome Pack and FAQs), which are still in draft form. However, this guidance does not extend to officers involved in the CAT process. • There is a lack of evidence of the initial assessment of CAT applications undertaken by the Community Partnership team. We consider that there should be a formal checklist completed for each application to confirm that the required documentation has been received, the organisation meets the eligibility criteria, the documentation submitted meets each of the essential criteria and to support the outcome of initial assessment. • The requirement for organisations to submit a risk assessment or risk management plan as part of their CAT application is not part of the essential criteria despite the risk impact being one of the eight scoring categories in the assessment process • The Policy does not require officers involved in the CAT application and assessment process to declare any conflict of interest with a specific organisation. Implication Recommendation Priority Management response Implementation Date If policies and procedures do not fully detail expected practice, the Council may fail to comply with legal and statutory requirements and there may be inconsistencies in the way in which officers carry out the required tasks. To take cognisance of the areas for improvement highlighted in the finding, the Chief Officer (Strategic Communication and Engagement) should: (1) Update the Policy to clearly state whether and how the Leadership Group should be notified of CAT enquiries and that submission of a risk assessment or risk management plan is a mandatory requirement for all applications. The policy should also be updated to include clear eligibility requirements and the required essential criteria to support consistent CAT applications. (2) Ensure the guidance notes are finalised and issued and formal written policies are developed and implemented to guide officers in reviewing and assessing CAT applications. (3) A conflict-of-interest declaration process should be implemented for all officers involved in assessing and making decisions on CAT applications. Medium Agree Responsible Officer: Leanne Pollock Designation: Community Partnership Manager (1) Leadership is currently notified of new applications received via an email to Chief Officer (Strategy and Engagement) and all COs represented on the Leadership Group have access to the MS Teams files. It is accepted that this should be formalised with a notification going to all relevant COs on receipt of an application. To date this has been considered an operational detail, but the policy will now be updated to reflect arrangements. LOOP system is being developed for logging, reminders and allocation and progressing of actions. This should assist with tightening operational procedures. (2) Work is underway to review and develop more streamlined documentation, logging and guidance paperwork for key stages such as application, assessment and decision making. This includes guidance for staff and community organisations, elected members and consistent guidance and checklist for submission and storage of information. (3) Conflict of interest form currently in draft form as part of the wider review of paperwork and procedures. March 2026 December 2025 December 2025 Page 112 of 288
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3. Action Plan Community Asset Transfers 0300/2026/001 Ref Finding 2 There is scope to improve the log for monitoring progress of CAT applications. The Community Partnership team have created a log of enquiries and applications for CATs, which is accessible by all officers involved in the process, to enable submission and progress of CAT applications to be monitored. The log provides details of the organisation making the request, the asset, type of enquiry, when, how and by whom the enquiry was received, details of the progress of the application, the outcome decision and any additional notes. From our review of the log, we noted that it is not updated on a consistent basis for each application, with some cells blank or containing vague information and we consider that it could be expanded to provide more consistent key information and dates in relation to the progress of each application, including: • Key dates for all supporting information being received, scoring panel meeting, Leadership Group meeting, Committee report and decision notice issued. • Details of the current status, with allocation of stages (e.g. review of application, assessment, scoring panel, Leadership Group, Committee). • Information, status and key dates of the review process for rejected applications. Additionally, we consider that the log should be monitored on a regular basis to ensure that it is fully and promptly updated, with any outstanding information being chased up. Implication Recommendation Priority Management response Implementation Date If the CAT log does not contain appropriate information and is not updated promptly and consistently for all application, it may be difficult for users of the log to determine the progress of each application, any issues arising and whether each has been processed on a consistent basis. The Chief Officer (Strategic Communications and Engagement) should: (1) Update the log of enquiries and applications for CATs to provide more detailed information on the progress of each CAT application, including, but not limited to, the areas highlighted in the finding above. (2) Consider introducing a process for monitoring the log on a regular basis to ensure that it is fully and promptly updated for all applications and chasing up any outstanding information. Medium Agree Responsible Officer: Leanne Pollock Designation: Community Partnership Manager (1) As above log will be updated and is being reviewed by officers as part of wider review. (2) While the CPT has oversight for the process, populating the log is not the responsibility of one service but of individual officers involved at various stages of the process. This will be reiterated to ensure that all services are using log and updating regularly. In the short-term CPT officers will identify the best approach to sending alerts and prompts to officers to update the log. A LOOP log is being developed which will assist with prompting, alerting, assigning actions and ensuring updates are provided and logged centrally. March 2026 Page 113 of 288
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3. Action Plan Community Asset Transfers 0300/2026/001 Ref Finding 3 There is a need to review and improve the arrangements for the Scoring Panel process. All CAT applications are initially assessed by staff within the Community Partnership team and subsequently reviewed by a Scoring Panel, consisting of officers from relevant Services. We noted that the Policy does not clearly state the responsibilities or expectations of the Scoring Panel. We were advised that the Community Partnership team takes notes of the Panel meeting, and these are translated into the final assessment report, however, no formal minutes outlining the discussions held and decisions made are taken. The final assessment report is circulated to all members of the Scoring Panel for comment and agreement prior to submission to the Leadership Group meeting, however, a response is not always provided by each member of the Panel. We consider that the email which accompanies the final assessment report does not clearly state the expectations for Panel members to review the report and confirm their agreement with the report or provide comments. Implication Recommendation Priority Management response Implementation Date If the responsibilities of the Scoring Panel are not recorded, Panel members may not fully understand the expectations of the role and may not provide sufficient challenge to the initial assessment and outcome decision of CAT applications. If decisions in relation to CAT applications are not properly recorded and agreed by all Scoring Panel members, there is scope for unauthorised amendments to be made without the Panel’s knowledge and applications to be treated inconsistently or with bias. The Chief Officer (Strategic Communications & Engagement) should: (1) Ensure that formal minutes of Scoring Panel meetings, providing details of discussions held and decisions made, are taken. (2) Update the email circulated to all members of the Scoring Panel to clearly set out the expectations for Panel members to confirm their agreement with the final assessment report or provide comments. Medium Agree Responsible Officer: Leanne Pollock Designation: Community Partnership Manager (1) More formal minute taking arrangements will be put in place to supplement the assessment notes and report. (2) Assessment and scoring process currently being developed as part of the review of procedures and paperwork will result in each service completing scoring from their service in advance of scoring meetings. Email to scoring panel in advance scoring meetings will include standard text outlining expectations and timescales. Flowchart for scoring panel members to be developed. November 2025 December 2025 Page 114 of 288
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3. Action Plan Community Asset Transfers 0300/2026/001 Ref Finding 4 A small number of issues and areas for improvement in respect of CATs were identified. Our testing of a sample of six CAT applications identified a small number of areas for improvement, as follows: • Application forms were not always appropriately signed on behalf of the organisation submitting the CAT. Of the six applications reviewed, three forms were not signed and two of these contained no details of office bearers for the organisation. • Where CAT applications are rejected, there is a requirement within the Policy that the organisation cannot submit a further CAT application for 12 months, however, the decision notice does not include reference to this. Additionally, there is no monitoring or checking in place to ensure that organisations submitting CAT applications have not had a rejected application within the previous 12 months. • Where an organisation appeals the CAT decision, a Review Panel consisting of elected members is formed. From our testing of two reviews, we noted that the documentation provided to members was a duplication of the papers submitted to the Communities Committee where the original decision was made, however for one of the reviews, a separate review report providing a summary of the application, assessment process, rationale for decision, review process and review considerations was also provided. We were advised that it was previously agreed that there was no requirement to submit a separate report for the review panel, however, we consider that, whilst the review report provides a summary of the information to the original committee report, it also provides additional information on the review process and specific considerations on the reasons for the application being rejected, and therefore would be beneficial for members of the Panel when assessing the documentation and making the review decision. Implication Recommendation Priority Management response Implementation Date If CAT application forms are not signed on behalf of the organisation, there may be a lack of ownership and commitment. If organisations of rejected applications are not informed that they are not permitted to submit further applications for 12 months or checks are not undertaken on previous applications prior to commencing the assessment process, organisations may submit multiple applications which are likely to be refused, and this could lead to inefficient use of time and strained relationships with community organisations. The original committee report may have insufficient detail on the original decision and may lack critical context in relation to the review. The Chief Officer (Strategic Communications & Engagement) should: (1) Ensure that all CAT application forms are appropriately signed on behalf of the organisation. (2) Update the decision notice for rejected applications to include reference to the organisation being excluded from submitting a further application for 12 months. (3) Introduce a check for new CAT applications, to ensure that the organisation has not had a rejected application within the last 12 months and is currently not excluded from submitting further applications. (4) Consider including additional information into the report to the Review Panel to provide an overview of the application being reviewed, the assessment process, original decision and review considerations. Low Agree Responsible Officer: Leanne Pollock Designation: Community Partnership Manager (1) This should be happening before applications accepted/scored however check will identify why this hasn’t been the case in some instances and the checking process will be tightened. (2) To date Scottish Government template letters have been used. Based on this recommendation the decision notice letter will be updated with additional text. (3) This information is currently documented and can be checked through committee reports, annual report, shared log and through information published on the council’s website. However, the process can be formalised by including a clear check question in the checklist for officers and organisations as part of the wider review of paperwork. (4) Some of the observations around the internal review process are reflective of the small number of internal reviews that have taken place (4 since the introduction of the CE Legislation) and the changes in council policy, process and personnel in the time between reviews resulting potentially resulting in inconsistency of approach (albeit still aligned to and reflective of the policy and procedures at a given time). Engagement will be scheduled with Legal and Democratic Services to consider the approach and ensure consistency of application as well as clear guidance. November 2025 December 2025 December 2025 March 2026 Page 115 of 288
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North Lanarkshire Council Report Audit and Scrutiny Panel Does this report require to be approved? ☐ Yes ☒ No Ref FS/ACComm Date 13/11/25 Accounts Commission – Council Exit Packages From Chief Officer (Audit and Risk) E-mail scottfr@northlan.gov.uk Telephone 07887 914207 Executive Summary Following publication of a report into the circumstances of the exit packages at Glasgow City Council, the Accounts Commission requested that the report and accompanying letter be shared with all Council Leaders and Chief Executives and the matter discussed at the appropriate audit committee. The letter and report from the Accounts Commission are appended to this report. This report provides contextual background to the issues identified at Glasgow City Council and outlines work undertaken by Audit Scotland in reviewing recent exit packages for two Chief Officers at North Lanarkshire Council. The findings highlight the importance of transparency, governance, and appropriate oversight in the approval and documentation of senior officer severance arrangements. The report also provides an opportunity for North Lanarkshire Council to reflect on existing governance frameworks, ensuring they remain robust, compliant, and capable of withstanding scrutiny. Recommendation It is recommended that the Panel acknowledge: 1. The contents of this report and the attached communication and report from the Accounts Commission; and 2. That the review of the Council’s democratic, committee and decision-making governance processes, approved by the Policy and Strategy Committee on 25 September 2025, will include an update of the Schemes of Administration and Delegation to take account of the observations made by Audit Scotland in relation to the governance and scrutiny of senior officer exit arrangements. The Plan for North Lanarkshire Priority All priorities Ambition statement All ambition statements Programme of Work Statutory / corporate / service requirement Item 7 Page 117 of 288
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1. Background 1.1 Following the retiral of a number of senior officers at Glasgow City Council, issues have been raised around the governance and approval of exit packages. The issues at Glasgow have been investigated both internally and externally, with reports being presented and discussed at public Council committees, and this has resulted in the Council being subject to significant adverse coverage across media channels. 1.2 On 8 September 2025, the Deputy Chair of the Accounts Commission wrote to all Council Leaders and Chief Executives requesting that the issues highlighted by the Commission’s report on Glasgow City Council’s exit packages are discussed at their appropriate audit and scrutiny committee. 2. Report Glasgow City Council Exit Packages 2.1 In 2021, a proposal to restructure of the Chief Executive’s department at Glasgow City Council was prepared, setting out the financial arrangements relating to the exit of five senior officers, including the then Chief Executive. The total cost of the exit packages was over £1m, with £770k of this relating to strain on the fund costs payable to Strathclyde Pension Fund. 2.2 Following publication in the remuneration report of the unaudited financial statements in July 2024, the Council Leader and City Treasurer raised concerns over the financial settlements, which led to both an internal review and, following legal advice, an independent external review of the circumstances. The outcomes of these reviews were reported publicly at the Council’s Finance and Audit Scrutiny Committee. 2.3 Under reporting powers available from s102(1) of the Local Government (Scotland) Act 1973, the Controller of Audit brought these matters to the attention of the Accounts Commission. The Controller of Audit’s report highlighted issues and serious concerns with the decisions made in relation to the exit packages, including: • The process for approving the business case for restructuring the senior management of the Chief Executive’s department is not formally documented. • Approval of the exit and the terms for four of the five officers were in line with policy. • Approval of the Chief Executive’s exit did not follow the scheme of delegated functions. • Elected members were not involved in the decision-making or approval processes. • Appropriate scrutiny, transparency and accountability was lacking. 2.4 The Accounts Commission decided to publish these findings and write to Councils to ensure they take action to recognise the important learnings from the Controller’s report. In his letter to all Councils, the Deputy Chair of the Accounts Commission states: “Where decisions around exit packages and restructuring are being taken, councils must ensure there is clear evidence of effective governance, independent scrutiny, and value for money, as well as robust and transparent record keeping.” Page 118 of 288
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Relevance to North Lanarkshire Council 2.5 Audit Scotland presented their annual audit report on the Council to the special Audit and Scrutiny Panel on 24 September 2025. The report confirmed that the retirals of two Chief Officers in April 2025 were processed in accordance with the discretionary provisions of the Local Government Pension Scheme with appropriate authorisation from the Chief Executive. In line with the Council’s Scheme of Delegation, the retiral applications were considered and approved by a sub-group of the Workforce Change Steering Group comprising senior officers who were independent of the applicants. Audit Scotland concluded that the decisions had been taken appropriately, independently and in accordance with established procedures. 2.6 Although these retirals were in line with relevant internal processes and governance requirements, Audit Scotland observed that the decisions did not allow for Committee approval or scrutiny. To strengthen existing arrangements, Audit Scotland recommended that the Council should review its policies and procedures to ensure that exit packages of senior officers are subject to elected member oversight and scrutiny. Audit Scotland also observed that documentation could be further enhanced to more clearly demonstrate that alternative options such as redeployment and training had been considered in each case. 2.7 At Policy and Strategy Committee on 25 September 2025, members approved a comprehensive review of the Council’s democratic, committee and decision-making governance framework. This review will include an update of the Scheme of Administration and Scheme of Delegation, considering the observations made by Audit Scotland in relation to the governance and scrutiny of senior officer exit arrangements. 2.8 Progress on all recommendations made by Audit Scotland will continue to be included in regular updates to the Audit and Scrutiny Panel. 3. Measures of success 3.1 Success will be measured by the Council’s effective review and reinforcement of its governance and oversight frameworks, ensuring that procedures relating to senior officer severance are fully transparent, properly authorised, and capable of withstanding scrutiny. 4. Supporting Documentation Appendix 1 – Accounts Commission Letter to Councils Appendix 2 – Accounts Commission Report - Glasgow City Council Exit Packages (link to external website) Francis Scott Chief Officer (Audit and Risk) Page 119 of 288
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5. Impacts 5.1 Public Sector Equality Duty and Fairer Scotland Duty Does the report contain information that has an impact as a result of the Public Sector Equality Duty and/or Fairer Scotland Duty? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? If Yes, has an assessment been carried out and published on the council’s website? https://www.northlanarkshire.gov.uk/your-community/equalities/equality- and-fairer-scotland-duty-impact-assessments Yes ☐ No ☐ 5.2 Financial impact Does the report contain any financial impacts? Yes ☐ No ☒ If Yes, have all relevant financial impacts been discussed and agreed with Finance? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact? 5.3 HR policy impact Does the report contain any HR policy or procedure impacts? Yes ☒ No ☐ If Yes, have all relevant HR impacts been discussed and agreed with People Resources? Yes ☒ No ☐ If Yes, please provide a brief summary of the impact? The report highlights the need to review and reinforce HR policies and procedures related to senior officer exit packages. It underscores the importance of transparency, proper documentation, and adherence to governance frameworks when approving severance arrangements, ensuring that all processes are compliant, consistent, and defensible under scrutiny. 5.4 Legal impact Does the report contain any legal impacts (such as general legal matters, statutory considerations (including employment law considerations), or new legislation)? Yes ☒ No ☐ If Yes, have all relevant legal impacts been discussed and agreed with Legal and Democratic? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact? The report identifies potential legal implications related to the approval and documentation of senior officer exit packages, including compliance with employment law and statutory requirements. It highlights the need for robust governance and adherence to legal frameworks to ensure that severance arrangements are lawful, properly authorised, and defensible in the event of scrutiny or challenge. 5.5 Data protection impact Does the report / project / practice contain or involve the processing of personal data? Yes ☐ No ☒ If Yes, is the processing of this personal data likely to result in a high risk to the data subject? Yes ☐ No ☐ Page 120 of 288
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If Yes, has a Data Protection Impact Assessment (DPIA) been carried out and e- mailed to dataprotection@northlan.gov.uk Yes ☐ No ☐ 5.6 Technology / Digital impact Does the report contain information that has an impact on either technology, digital transformation, service redesign / business change processes, data management, or connectivity / broadband / Wi-Fi? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? Where the impact identifies a requirement for significant technology change, has an assessment been carried out (or is scheduled to be carried out) by the Enterprise Architecture Governance Group (EAGG)? Yes ☐ No ☐ 5.7 Environmental / Carbon impact Does the report / project / practice contain information that has an impact on any environmental or carbon matters? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? 5.8 Communications impact Does the report contain any information that has an impact on the council’s communications activities? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? 5.9 Risk impact Is there a risk impact? Yes ☐ No ☒ If Yes, please provide a brief summary of the key risks and potential impacts, highlighting where the risk(s) are assessed and recorded (e.g. Corporate or Service or Project Risk Registers), and how they are managed? 5.10 Armed Forces Covenant Duty Does the report require to take due regard of the Armed Forces Covenant Duty (i.e. does it relate to healthcare, housing, or education services for in-Service or ex- Service personnel, or their families, or widow(er)s)? Yes ☐ No ☒ If Yes, please provide a brief summary of the provision which has been made to ensure there has been appropriate consideration of the particular needs of the Armed Forces community to make sure that they do not face disadvantage compared to other citizens in the provision of public services. 5.11 Children’s rights and wellbeing impact Does the report contain any information regarding any council activity, service delivery, policy, or plan that has an impact on children and young people up to the age of 18, or on a specific group of these? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact and the provision that has been made to ensure there has been appropriate consideration of the relevant Articles from the United Nations Convention on the Rights of the Child (UNCRC). If Yes, has a Children’s Rights and Wellbeing Impact Assessment (CRWIA) been carried out? Yes ☐ No ☐ Page 121 of 288
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4th Floor 102 West Port Edinburgh EH3 9DN T: 0131 625 1500 E: info@audit-scotland.gov.uk www.audit-scotland.gov.uk To All Leaders and Chief Executives 08 September 2025 Copied to: Directors of Finance; External auditors Dear Leader and Chief Executive, On 14 August, the Accounts Commission considered a report from the Controller of Audit (under powers in s102 (1) of the Local Government (Scotland) Act 1973) in relation to the scrutiny, governance and transparency of decision making of exit packages of senior officers in Glasgow City Council. The Controller highlighted issues and serious concerns on how decisions were made around these exit packages and set out the council’s response. The Commission welcomed the actions of the new chief executive in commissioning an internal review, an independent investigation of these issues and reporting the outcome publicly. I look forward to discussing this matter further with the Glasgow City Council when we meet in the coming weeks. In response to the Controller’s report, the Commission considered carefully the most appropriate way to use the powers available to it, including holding a hearing, making recommendations to Scottish Ministers or censuring in light of the concerning issues presented in the report. On this occasion, alongside publishing findings, it is vital that all councils take action to recognise the important learnings from this report. The Commission expects that this letter - also copied to Directors of Finance and external auditors - and the issues the report highlights, will be discussed by your audit and scrutiny committee. We expect that steps will be taken to review your Scheme of Delegation and decision-making processes. The Commission recognises that as councils continue to face financial challenges, service redesign and restructuring are key tools available to councils to respond to these challenges. However, transparency and good governance around decision-making is essential. The decisions of elected members and officers should uphold the nine Key Principles of Public Life in Scotland – selflessness, integrity, objectivity, accountability, openness, honesty, leadership, public services, respect. Sadly, the Commission believes that the way in which the restructuring packages were dealt with in this case did not. Where decisions around restructuring and exit packages are being taken, councils must ensure there is clear evidence of effective governance, independent scrutiny, and value for money, as well as robust and transparent record keeping. Lessons learnt are set out clearly in our report at paragraphs 46 - 48. Concerningly, this recent report is not the first time that this issue has been considered by the Accounts Commission. In 1997 and 2003, reports were published on managing early retirement and their key messages are as relevant today as they were then, not only for decisions relating to early retirement packages but also to any senior officer exit packages. Below are five key recommendations from the 2003 report, adapted for today’s context: Page 122 of 288
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1. Frameworks for decision-making: policies in relation to the exit packages of senior officers should be approved by councillors and reviewed regularly. 2. Informing councillors: councillors should receive a report at least annually that details the number of early retirals, and redundancy decisions made in the year, along with the associated costs and savings attached to these decisions. 3. Decision-making: councils should rigorously appraise individual business cases to ensure the expected savings associated with a retiral or redundancy outweigh the costs, ensuring value for money. 4. To improve accountability and assist in monitoring, the costs of early retirement should be charged to the appropriate service budget. 5. Elected members should be involved in approving early retirement and redundancy decisions for senior staff, providing the independent scrutiny that is essential to issues and decisions where there are potential conflicts of interest. I would urge all councils to take action now to ensure that all officers and members are familiar with the Key Principles of Public Life, and that you can evidence that your organisational culture respects and supports them fully. If you have any questions or queries in relation to the report on Glasgow City Council or on any other aspect of the Commission’s work, please do not hesitate to get in touch: acsupport@audit-scotland.gov.uk I look forward to engaging with you in the future. Yours sincerely, Andrew Burns Deputy Chair, Accounts Commission Page 123 of 288
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North Lanarkshire Council Report Audit and Scrutiny Panel Does this report require to be approved? ☐ Yes ☒ No Ref FS/ASP/HCreferral Date 13/11/25 Referral from Housing Committee From Francis Scott, Chief Officer (Audit and Risk) E-mail scottfr@northlan.gov.uk Telephone 07787 914207 1. Background 1.1 A report was presented to the Housing Committee on 7th May 2025 providing an update on procurement activity in relation to the new build housing programme and seeking approval for the award of three works contracts. 1.2 One of these contracts related to the delivery of 7 modular homes at a site on Main Street, Glenboig. Officers advised that Committee had previously approved this work, but the contractor had entered administration prior to commencing on site and could no longer progress the development. To ensure the project continued as planned, officers engaged with a national procurement framework (Scotland Excel) to identify a suitable contractor, with the value of the proposed contract being £1.95m. From this framework, Executive Summary Following a meeting of the Housing Committee on 7 May 2025, members requested that Internal Audit review the circumstances of a direct contract award through an external procurement framework as part of the Council’s new build housing programme. The original report the Housing Committee is included at Appendix 1 for information. The contract award complied with the Council’s General Contract Standing Orders and was in accordance with public sector procurement regulations, and benchmarking of the supplier’s costs confirmed that the contract provided value for money. More generally, the use of public sector procurement frameworks continues to the preferred method of procurement, providing cost and time savings, compliance with procurement regulations and reduction of risk to the Council. Recommendations The Panel is invited to: (1) note the contents of the report, and (2) remit report to the Housing Committee for consideration at a future meeting. The Plan for North Lanarkshire Priority All priorities Ambition statement All ambition statements Programme of Work Statutory / corporate / service requirement Item 8 Page 125 of 288
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this contract was awarded directly to the contractor (CCG Construction Limited), without going through a procurement exercise or a mini competition. 1.3 During the Committee meeting, members raised questions around the demonstration of best value by making a direct award to this contractor, when testing the market may have identified other contractors who could provide a lower tender price. Members also had a more general discussion around the ongoing use of procurement frameworks, and whether they still provided value or were working against the Council. 1.4 Committee agreed to refer the matter to Internal Audit, in order to provide an overview of the circumstances which had been discussed. 2. Report Direct Award to CCG Construction Limited 2.1 The Council’s General Contract Standing Orders (GCSOs) apply to all council contracts, and GCSO 13.4 refers to calling off a contract from an external framework (including by direct award) and that the procedures specified in the framework agreement showed be followed. The award of the contract was made through a Scotland Excel framework for new-build residential construction, and the contract lot was specifically related to the design and build of between 1-16 units. The direct award to suppliers on this lot is permitted under the terms of the framework. 2.2 The value of the contract award was £1.95m, which is below the thresholds within the scope of Scottish public procurement regulations for works contracts (the threshold under the Procurement Reform (Scotland) Act 2014 is £2m excluding VAT, and under the Public Contracts (Scotland) Regulations 2015 the threshold is currently £4.48m excluding VAT). 2.3 CCG was selected as the supplier for the direct award. CCG was the highest ranked supplier on the framework lot in terms of commercial score (cost) and the joint third ranked supplier for technical score (quality). CCG had recently delivered multiple, competitively tendered housing developments for the Council, and officers were satisfied that a high standard of product and level of service would be provided at a competitive cost. Due to the administration of the previous contractor there were significant delays to the delivery timescales, and officers were satisfied that CCG could deliver the project at pace. It was also considered that due to the relatively small size of the contract (7 units) it would be unattractive to medium or larger contractors if tendered competitively, so a direct award was the preferred option. 2.4 GCSO 2.6 states that all contracts must secure best value. To ensure the award of the contract to represented value, the costs provided by CCG were split between developmental and construction costs and benchmarked: • Developmental costs – these costs were compared on a line-by-line basis to two projects of a similar scale and demonstrated that the costs submitted by CCG provided value. • Construction costs – these were benchmarked against the costs provided by the original contractor for the project and showed a favourable variance in the construction cost per unit and confirmed the costs were within the original budget for the project approved by Committee. 2.5 More generally, the Council can demonstrate that its new build housing programme secures value for money and fully meets the requirements of the Scottish Government’s Continuous Improvement Programme. A Development Value for Money report issued by the Scottish Housing Network in May 2025 benchmarked a number of housing projects by local authorities, registered social landlords and other social housing providers within an urban setting and demonstrated that the cost of development via the Council’s housing programme is comparable. Page 126 of 288
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2.6 Based on a review of the documentation provided and explanations provided by officers, I am satisfied that the contract award to CCG was undertaken in accordance with procurement regulations, the Council’s GCSOs and the conditions of the external procurement framework. Additionally, officers provided reasonable justification for the direct award and demonstrated that the costs submitted by the contractor were benchmarked to ensure value. The Use of Procurement Frameworks 2.7 For the purposes of securing contractors to provide new-build housing, the Council utilises three frameworks, which have been approved by Committee are compliant with the GCSOs: • Scotland Excel. • Scottish Procurement Alliance. • Hub Southwest. 2.8 In general terms, the use of public sector procurement frameworks is seen as being greatly beneficial to local authorities and provide a number of key advantages. • Efficient and time savings – suppliers on frameworks have already passed quality, financial and compliance checks, and allows for faster procurement reducing the need for lengthy tender processes. • Compliance and risk reduction – frameworks used by the Council are compliant with public procurement regulations and provide a clear audit trail of documentation and process. Additionally, use of a compliant framework helps avoid legal challenges or disputes over procurement processes. • Cost savings – frameworks can negotiate better prices through collective purchasing and save on internal resources and costs associated with running a full tender exercise (for example, staff costs are likely to be substantial for an open tender that can take between 6-9 months). • Flexibility – allows for direct award or mini-competitions depending on the needs of the organisation and can be suitable for small- and large-scale procurements. 2.9 There can be associated costs with the use of frameworks. Scotland Excel is the centre of procurement excellence for local government and serves all 32 councils who pay an annual fee to access the frameworks. Other frameworks charge a fee or levy paid on a project-by-project basis. 2.10 It is recognised that some local suppliers or small and medium-sized enterprises (SMEs) may feel disadvantaged by the Council using framework agreements. Supplier engagement is a key part of the procurement landscape and local suppliers and SMEs should be encouraged to join frameworks where possible. This would allow the suppliers to demonstrate their cost and quality and confirm their financial viability and compliance with legal and regulatory requirements. It could also increase contract opportunities for the supplier with other organisations included in the framework. 2.11 As an alternative to traditional framework agreements, a Dynamic Purchasing System (DPS) is a flexible approach to procurement. Unlike frameworks, a DPS allows suppliers to join at anytime during the life of the agreement which can increase competition and encourage innovation and responsiveness to changing needs. 2.12 The current advice from the Corporate Procurement Team is that the use of frameworks should be the default for goods and services contracts as they demonstrate best value, are less resource intensive, faster in terms of delivery timescales and ensure a quality product. Open and restricted tender procedures are known to take several months longer to conclude procurement activity and market feedback is that these routes are unattractive to bidding contractors due to the resource involved in tendering with unknown probability of success. There is also a risk that abnormally low bids are received through these routes resulting in poor quality product and the risk of substantial contract challenges and claims. Page 127 of 288
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3. Measures of success 3.1 The Council follows procurement processes which are compliant with regulations and internal processes and achieve value for money. 4. Supporting documentation 4.1 Appendix 1 – Report to Housing Committee 7 May 2025 Francis Scott Chief Officer (Audit and Risk) Page 128 of 288
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5. Impacts 5.1 Public Sector Equality Duty and Fairer Scotland Duty Does the report contain information that has an impact because of the Public Sector Equality Duty and/or Fairer Scotland Duty? Yes ☐ No ☒ 5.2 Financial impact Does the report contain any financial impacts? Yes ☐ No ☒ 5.3 HR policy impact Does the report contain any HR policy or procedure impacts? Yes ☐ No ☒ 5.4 Legal impact Does the report contain any legal impacts (such as general legal matters, statutory considerations (including employment law considerations), or new legislation)? Yes ☐ No ☒ 5.5 Data protection impact Does the report / project / practice contain or involve the processing of personal data? Yes ☐ No ☒ 5.6 Technology / Digital impact Does the report contain information that has an impact on either technology, digital transformation, service redesign / business change processes, data management, or connectivity / broadband / Wi-Fi? Yes ☐ No ☒ 5.7 Environmental / Carbon impact Does the report / project / practice contain information that has an impact on any environmental or carbon matters? Yes ☐ No ☒ 5.8 Communications impact Does the report contain any information that has an impact on the council’s communications activities? Yes ☐ No ☒ 5.9 Risk impact Is there a risk impact? Yes ☐ No ☒ If yes, please provide a summary of the key risks and potential impacts, highlighting where the risk(s) are assessed and recorded (e.g. Corporate or Service or Project Risk Registers), and how they are managed? . 5.10 Armed Forces Covenant Duty Does the report require to take due regard of the Armed Forces Covenant Duty (i.e. does it relate to healthcare, housing, or education services for in-Service or ex-Service personnel, or their families, or widow(er)s)? Yes ☐ No ☒ 5.11 Children’s rights and wellbeing impact Does the report contain any information regarding any council activity, service delivery, policy, or plan that has an impact on children and young people up to the age of 18, or on a specific group of these? Yes ☐ No ☒ Page 129 of 288
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North Lanarkshire Council Report Housing Committee Does this report require to be approved? ☒ Yes ☐ No Ref PH/JS/KS Date 07/05/25 New Housing Supply Programme – Procurement Update From Pamela Humphries, Chief Officer (Place) E-mail stevensonjam@northlan.gov.uk Telephone James Stevenson, Housing Development Manager, 07583098631 Executive Summary The purpose of this report is to update Committee on current procurement activity relating to the new build housing programme and seek approval to progress procurement arrangements as outlined in the report. Recommendations It is recommended that the Housing Committee: (1) Approves the award of a contractsprocured via a “Direct Award” procedure via the Scotland Excel New Build Residential Construction framework agreement (the “Framework”) for the following site: • Main Street, Glenboig to CCG Construction Limited up to the value of £1.95M, including contingency allowance (2) Approves the award of contracts to be procured via a “Mini Competition” procedure via the Scottish Procurement Alliance H2 New Build Housing framework agreement for the following sites • Site of Coursington, Allan and Draffen Towers, Motherwell up to the value of £16.00M, including contingency allowance. • Coats Street, Coatbridge (Site of the former Jackson Tower) up to the value of £14.25M, including contingency allowance. (3) Acknowledges the award of contracts for the following sites previously approved at Housing Committee: • Conversion of Old Town Hall, Motherwell to social housing awarded to Clark Contracts on 31 January 2025 at a value of £5,856,022.99. • New Build Social Housing at Dunottar Avenue, Shawhead, Coatbridge awarded to CCG (Scotland) Ltd at a value of £23,716,921.47. • New Build Social Housing at Coshneuk Road, Millerston awarded to JR Construction (Scotland) Limited at a value of £4,291,648.92 Page 130 of 288
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1. Background 1.1 The council has an approved programme to deliver 6,000 new homes by 2035. The delivery of such a large-scale programme presents several challenges, which include procurement of competent contractors with a track record of delivering new build homes to the Councils standard, within the timescale required and at a competitive cost. To increase the pace of delivery, secure best value and minimise risk to the Council, a range of procurement options have been utilised. 1.2 For each project a bespoke Contract Strategy is undertaken to assess the most appropriate procurement route. These include but are not limited to the use of SPA and Scotland Excel frameworks utilising the direct award and mini comp procedures, and in some cases the use of Hub Southwest or a traditional “Restricted” style tendering procedure within the open market. 1.3 Within this report, one project has been identified to be procured via the direct award procedure. For this project, the direct award procedure has been identified as the optimum route to market, as it allows early engagement with contractors leading to economies and efficiencies being achieved in design, risk, early engagement for utilities and programme benefits to be achieved. 2. Report 2.1 Committee previously approved the delivery of 7 modular homes at the Main Street site in Glenboig (former police station). Unfortunately, the contractor tasked with delivering the modular homes recently entered administration and was unable to progress with the development. In order to progress the project and mitigate further delay, officers engaged with the Scotland Excel New Build Residential Framework and CCG Construction Limited to ascertain feasibility costs and contractor availability. Feasibility costs have been returned at the value of £1.95M, including contingency allowance. The feasibility costs obtained are considered to represent best value and, subject to benchmarking against the appropriate framework rates, it is proposed that a final tender price be agreed to allow the contract award. 2.2 It is proposed to tender via a mini competition call off procedure from the Scottish Procurement Alliance H2 New Build Housing Framework to procure contracts for the following sites: • Site of Coursington, Allan and Draffen towers, Motherwell (64 units) up to the value of £16.00M, including contingency allowance. • Coats Street, Coatbridge (Site of Jackson tower) (57 units) up to the value of £14.25M, including contingency allowance. The Plan for North Lanarkshire Priority Improve economic opportunities and outcomes Ambition statement (1) Ensure a housing mix that supports social inclusion and economic growth Programme of Work Transforming Places Page 131 of 288
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The mini competition call-off procedure will be progressed and, subject to tender checking, the most economically advantageous tender will be checked and recommended to allow the contract award. 2.3 The projects listed above in sections 2.1 – 2.2 are still in live procurement procedures. Accordingly, the recommendations listed on page one of this report are for the approval for the award of each contract (in accordance with the council’s General Contract Standing Orders) up to the values stated as and when they are finalised outwith the council’s committee cycle. Adopting this approach shall expedite the programme and allow appointed contractors to progress works in a more efficient and effective manner. Additionally, this approach shall also prove beneficial where any pre-construction / enabling works are required whilst also allowing appointed contractors to engage third party companies i.e. utility companies to undertake works required to enable housing construction methods to commence. Should the recommendations within this report be approved, more detailed information on any contract awarded for each site shall reported to the next available Housing Committee following award. Should contracts to be awarded exceed the values stated in the recommendations, further details and approvals shall be sought from a future Housing Committee. 2.4 The pricing mechanism is a Priced Contract with Activity Schedule offering a good level of cost certainty. However, there are currently no cashable savings attributed to the contract outlined within above within sections 2.1 - 2.2 at this time. 2.5 The council is committed to maximising the delivery of community benefits. The procurement includes a community benefit requirement, this approach is designed to deliver local community benefits where possible. Given the current stage of the procurement processes for each of the sites listed within this report, there are currently no Community Benefits identified. However, once contracts have been formally awarded, an overview of community benefits committed to by contractors will be reported to Committee. 2.6 All contractors appointed to the Framework have evidenced fair working practices within their organisations as part of the procurement procedures to be appointed to the respective arrangements 2.7 In addition to the sites listed above in section 2.1 – 2.2, work has progressed to award contracts following approval at the Housing Committee on 06 November 2024. • Conversion of Old Town Hall, Motherwell to social housing (20 units) awarded to Clark Contracts on 31 January 2025 at a value of £5,856,022.99. • New build social housing at Dunottar Avenue, Shawhead, Coatbridge (100 units) awarded to CCG (Scotland) Limited at a value of £23,716,921.47. • New build social housing at Coshneuk Road, Millerston (17 units) awarded to JR Construction (Scotland) Limited at a value of £4,291,648.92. Further information on the contract awarded above can be found within Appendix 1 of this report. Page 132 of 288
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2.8 Officers from New Supply will be responsible for managing all contracts once awarded which will be undertaken in accordance with the council’s agreed approach to contract and supplier management. 2.9 In addition to the sites detailed above, the next batch of sites will be identified and assessed, and a suitable procurement route will be identified to progress these projects to deliver new build housing to align with the Plan for North Lanarkshire. 3. Measures of success 3.1 The proposed contract awards detailed within this report will deliver the following outcomes: a) The appointment of contractors who have the experience and capability to deliver new build social housing. b) The procurement procedures applied are compliant with the procurement legislation, overarching framework agreements and internal procedures. c) That best value is both demonstrable and achieved. d) That contracts awarded secure a range of community benefits. e) Those contracts awarded support payment of the real Living Wage to staff employed in the delivery of the requirements; and f) That the performance of contracts awarded are proactively managed against several Key Performance Indicators. 4. Supporting Documents Appendix 1 Summary of Contracts Awarded Pamela Humphries Chief Officer (Place) Page 133 of 288
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5. Impacts ( http://connect/report-template-guidance ) 5.1 Public Sector Equality Duty and Fairer Scotland Duty Does the report contain information that has an impact as a result of the Public Sector Equality Duty and/or Fairer Scotland Duty? Yes ☒ No ☐ If Yes, please provide a brief summary of the impact? The new build programme includes measures that will help reduce inequalities of outcome through certain design features including: • Housing for Varying Needs to make homes as accessible as possible. • Secure by Design to make homes and the surrounding environment as safe and secure as possible. • Achieving the Scottish Government requirements for Greener Homes to • reduce the incidence of fuel Poverty. • Facilitating improved access to high-speed internet capabilities including installation of ‘fibre to the property’. If Yes, has an assessment been carried out and published on the council’s website? https://www.northlanarkshire.gov.uk/your-community/equalities/equality-and-fairer- scotland-duty-impact-assessments Yes ☒ No ☐ 5.2 Financial impact Does the report contain any financial impacts? Yes ☒ No ☐ If Yes, have all relevant financial impacts have been discussed and agreed with Finance? Yes ☒ No ☐ If Yes, please provide a brief summary of the impact? The funding for projects referred to in this report can be met from the Council’s Housing Revenue Account budget for the New Supply Programme. Grant support is also provided by the Scottish Government. The costs associated with contract delivery will be contained within the HRA New Supply capital programme. Grant funding for new build is £104,353 per unit, based on a 3-person equivalent as well as additional grant funding for increased quality measures and renewables. 5.3 HR policy impact Does the report contain any HR policy or procedure impacts? Yes ☐ No ☒ If Yes, have all relevant HR impacts have been discussed and agreed with People Resources? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact? 5.4 Legal impact Does the report contain any legal impacts (such as general legal matters, statutory considerations (including employment law considerations), or new legislation)? Yes ☐ No ☒ If Yes, have all relevant legal impacts have been discussed and agreed with Legal and Democratic? Yes ☐ No ☐ Page 134 of 288
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If Yes, please provide a brief summary of the impact? 5.5 Data protection impact Does the report / project / practice contain or involve the processing of personal data? Yes ☐ No ☒ If Yes, is the processing of this personal data likely to result in a high risk to the data subject? Yes ☐ No ☐ If Yes, has a Data Protection Impact Assessment (DPIA) been carried out and e- mailed to dataprotection@northlan.gov.uk Yes ☐ No ☐ 5.6 Technology / Digital impact Does the report contain information that has an impact on either technology, digital transformation, service redesign / business change processes, data management, or connectivity / broadband / Wi-Fi? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact? Where the impact identifies a requirement for significant technology change, has an assessment been carried out (or is scheduled to be carried out) by the Enterprise Architecture Governance Group (EAGG)? Yes ☐ No ☐ 5.7 Environmental / Carbon impact Does the report / project / practice contain information that has an impact on any environmental or carbon matters? Yes ☒ No ☐ If Yes, please provide a brief summary of the impact? The new homes are built to higher energy efficiency and sustainability standards, which helps to reduce future carbon emissions from the properties. This is done via a fabric first approach, while incorporating renewable technologies where appropriate, e.g. providing minimum of EPC B certification, Silver Standards 1 and 2, non-gas heating systems and EV charging. The Council’s New Supply Programme will ensure that the impact on the Council’s carbon footprint is mitigated. The specifications incorporated within the contract documentation will: deliver reduced energy need; encourage sustainable construction; promote health and wellbeing; reduce waste and resources through effective storage, collection and composting of waste and recyclable materials and include measures which will reduce CO2 emissions. 5.8 Communications impact Does the report contain any information that has an impact on the council’s communications activities? Yes ☒ No ☐ If Yes, please provide a brief summary of the impact? The implementation and delivery of the New Supply programme will be promoted through the New Supply PR plan and via communications with elected members and local stakeholders Page 135 of 288
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5.9 Risk impact Is there a risk impact? Yes ☒ No ☐ If Yes, please provide a brief summary of the key risks and potential impacts, highlighting where the risk(s) are assessed and recorded (e.g. Corporate or Service or Project Risk Registers), and how they are managed? Risk associated with the New Supply Programme is managed within the council’s project management and risk register process. By undertaking detailed Ground Investigation and other relevant site assessments, prior to proceeding with the development of any site, the council is mitigating the risk of unforeseen costs relating to ground conditions, although this risk cannot be eliminated entirely. 5.10 Armed Forces Covenant Duty Does the report require to take due regard of the Armed Forces Covenant Duty (i.e. does it relate to healthcare, housing, or education services for in-Service or ex- Service personnel, or their families, or widow(er)s)? Yes ☒ No ☐ If Yes, please provide a brief summary of the provision which has been made to ensure there has been appropriate consideration of the particular needs of the Armed Forces community to make sure that they do not face disadvantage compared to other citizens in the provision of public services. The Council’s New Supply housing programme previously partnered with Veterans Housing Scotland to deliver housing for Armed Forces Veterans and the current SHIP supports new affordable housing project for Scottish Veterans' Garden City Association. 5.11 Children’s rights and wellbeing impact Does the report contain any information regarding any council activity, service delivery, policy, or plan that has an impact on children and young people up to the age of 18, or on a specific group of these? Yes ☐ No ☒ If Yes, please provide a brief summary of the impact and the provision that has been made to ensure there has been appropriate consideration of the relevant Articles from the United Nations Convention on the Rights of the Child (UNCRC). If Yes, has a Children’s Rights and Wellbeing Impact Assessment (CRWIA) been carried out? Yes ☐ No ☐ Page 136 of 288
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Appendix 1 – Summary of Contracts Awarded Contract Ref NLC-SLP-23--035 Title Conversion of Old Town Hall, Motherwell to Social Housing Classification Works Competition Governance by Value The Framework terms & conditions, with adherence to the council’s GCSO 13 on 3rd party frameworks Procurement Route Mini Competition No. of Framework Contractors Five Comments This contract was procured considering the relevant information technical and commercial proposals from the Scottish Procurement Alliance H2 New Build Housing framework agreement, Lot 12 Workstream 4 (Refurbishment, Conversions, Extensions and Adaptations) Over £2m. Award Details Contract Award Date 31 January 2025 Awarded Value £5,856,022.99 Contract Duration 30 Months Contractor Name Clark Contracts Contractor Size SME Contractor Location Inverclyde Payment of Living Wage? Yes Living Wage Accredited? No Community Benefits Committed 1 x New Employee Full Time Job (from Priority Group) 1 x New Employee Part Time Job (from Priority Group) 1 x Apprentice New Start - Full Time (from Priority Group) 1 x New Entrant Graduate - Part Time (from Priority Group) 1 x MCR Pathways 1-2-1 Mentoring Programme (or equivalent Programme) 1 x Work Experience Placement – School Trades e.g. bricklaying etc (to be discussed and agreed upon award 1 x Build Your Future – Practical Activity 1 x Careers Events (Face to Face) 2 x Workplace Visit 1 x Primary School Engagement (mini careers event for P6/P7) 1 x Careers Event Page 137 of 288
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1 x Supply Chain Briefings 1 x Business Mentoring 1 x Financial Support (minimum £1500) 1 x non-financial support for a community project (Minimum 7 hours). Contract Ref NLC-SLP-23-123 Title New Build Social Housing at Dunottar Avenue, Shawhead, Coatbridge Classification Works Competition Governance by Value The Framework terms & conditions, with adherence to the council’s GCSO 13 on 3rd party frameworks Procurement Route Direct Award No. of Framework Contractors One Comments This contract was procured considering the relevant information technical and commercial proposals from the Scottish Procurement Alliance H2 New Build Housing framework agreement, Lot 12 Workstream 4 (Refurbishment, Conversions, Extensions and Adaptations) Over £2m. Award Details Contract Award Date 7 April 2025 Awarded Value £23,716,921.47 Contract Duration 27 Months Contractor Name CCG Contractor Size SME Contractor Location South Lanarkshire Payment of Living Wage? Yes Living Wage Accredited? No Community Benefits Committed 4 x New Employee Full Time Job (from Priority Group) 1 x New Employee Part Time Job (from Priority Group) 2 x Apprentice New Start - Full Time (from Priority Group) 4 x Work Experience Placement – Foundation Apprenticeship 4 x Work Experience Placement – School Trades e.g. bricklaying etc (to be discussed and agreed upon award 4 x Work Experience Placement – Non School 2 x Careers Events (Face to Face) - (March or October) Page 138 of 288
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4 x Workplace Visit 2 x Work Experience Summer Placement (PAID) 2 x Primary School Engagement (mini careers event for P6 / P7) 2 x Careers Event (Virtual Teams Session 2 x Supply Chain Briefings 6 x Financial Support (minimum £1500) 3 x Non-financial support for a community project (Minimum 7 hours). Contract Ref NLC-SLP-23-048 Title New Build Social Housing at Coshneuk Road, Millerston Classification Works Competition Governance by Value The Framework terms & conditions, with adherence to the council’s GCSO 13 on 3rd party frameworks Procurement Route Direct Award No. of Framework Contractors One Comments This contract was procured considering the relevant information technical and commercial proposals from the Scottish Procurement Alliance H2 New Build Housing framework agreement, Lot 12 Workstream 4 (Refurbishment, Conversions, Extensions and Adaptations) Over £2m. Award Details Contract Award Date 31 March 2025 Awarded Value £4,291,648.92 Contract Duration 14 Months Contractor Name JR Construction Contractor Size SME Contractor Location Renfrewshire Payment of Living Wage? Yes Living Wage Accredited? No Community Benefits Committed 1 x New Employee Full Time Job (from Priority Group) 1 x Apprentice New Start - Full Time (from Priority Group) 2 x School Mentoring or Enterprise Programme Page 139 of 288
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1 x Work Experience Placement – School Trades e.g. bricklaying etc (to be discussed and agreed upon award 1 x Work Experience Placement - Non School – 2 per annum 1 x Careers Events (Face to Face) – 1 per annum 1 x Supply Chain Briefings – 2 in 1st year 1 x Financial Support (minimum £1500) – 3 per annum Page 140 of 288
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North Lanarkshire Council Report Audit and Scrutiny Panel Does this report require to be approved? ☐ Yes ☒ No Ref FS/LM/ASP/Nov 2025 Date 13/11/25 Internal Audit: Follow-up of implementation of audit recommendations From Francis Scott, Chief Officer (Audit and Risk) E-mail ScottFr@northlan.gov.uk Telephone 07887 914207 Executive Summary The purpose of this report is to update the Panel on the progress made by management in the implementation of Internal and External Audit recommendations. In the period to 30 September 2025, of the 20 High and Medium priority recommendations that were due, 12 have been fully implemented and eight remain outstanding. Of the eight recommendations that remain outstanding, two have an implementation date which is more than 12 months overdue. Since April 2021, 97% of all relevant audit recommendations have been satisfactorily implemented by Services, meaning that only 3% of these audit recommendations remain outstanding. In respect of recommendations from External Audit reports, six of the 20 agreed actions have been completed, two are partially implemented, one is no longer relevant and 11 are not yet due. Recommendations The Panel is invited to: (a) Note the contents of this report. (b) Consider whether there are any issues arising from this report on which they wish to receive further information from relevant management. The Plan for North Lanarkshire Priority All priorities Ambition statement All ambition statements Programme of Work All Programmes of Work Item 9 Page 141 of 288
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1. Background 1.1 This report presents an overview of the progress of all High and Medium priority Internal Audit recommendations in the period to 30 September 2025. 1.2 This report also provides an update on progress made in addressing recommendations arising from External Audit reports issued as part of the 2022-23, 2023-24 and 2024- 25 audits. 1.3 The updates from management on progress to date have been verified on a sample basis by Internal Audit as part of the preparation of this report. However, it should be noted that this review has focused on whether planned actions have been completed and has not included detailed substantive testing of whether the implemented actions have been effective in addressing previously identified weaknesses. 2. Report Internal Audit recommendations 2.1 Table 1 below summarises the progress of all High and Medium priority recommendations which were due to be completed in the period to 30 September 2025. Overall, 12 of the agreed actions have been completed and eight remain outstanding. Table 1 Completed No Longer Relevant Outstanding Total Chief Officer Area Community Operations 3 0 1 4 Education 2 0 5 7 Finance and Technology 1 0 1 2 Housing 1 0 0 1 People Resources 4 0 1 5 Planning, Performance and Quality Assurance 1 0 0 1 TOTAL 12 0 8 20 2.2 For the eight outstanding recommendations, revised implementation dates have been agreed. Appendix 1 provides detail of these recommendations with an update on progress provided by service management. Appendix 1 also references instances where the original implementation date of a recommendation was more than 12 months overdue. In this period there are two such actions, referenced 1.1–1.2 in the appendix. The relevant Chief Officer has been invited to attend the Panel meeting to provide explanations. 2.3 As at 30 September 2025, 97% of all relevant audit recommendations, where the original agreed implementation date was either due or had passed, have been fully implemented by Services, meaning that the percentage overall of all audit recommendations made since April 2021, which remain outstanding, is 3%. This highlights an improvement since the last period when 94% were complete and 6% were outstanding. External Audit recommendations 2.7 Table 2 shows the status of actions agreed by management in response to External Audit reports issued as part of the 2022-23, 2023-24 and 2024-25 audits. As at 30 September 2025, six of these recommendations are complete, two are partially implemented, 11 are not yet due and one is no longer relevant. Page 142 of 288
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Table 2 Completed Partially implemented Not yet due No longer relevant Total Report Title 2022-23 Annual Report 2021/22 1 1 0 1 3 Best Value Thematic Report 3 0 0 0 3 2023-24 Annual Report 2 1 2 0 5 Best Value Thematic Report 0 0 3 0 3 2024-25 Annual Report 0 0 4 0 4 Best Value Thematic Report 0 0 2 0 2 TOTAL 6 2 11 1 20 2.8 The action reported as no longer relevant refers to issues relating to capital processes. Two of the three points made within this action have been implemented and the third has been superseded by an action raised in the 2024-25 External Audit Annual Report. 2.9 A six-monthly tracking report of progress in implementing these recommendations is included at Appendix 2. 3. Measures of success 3.1 Internal Audit reports each cycle to the Audit and Scrutiny Panel on the progress made by management in implementing actions in response to Internal and External Audit reports. 4. Supporting documentation Appendix 1 Register of Outstanding Internal Audit Recommendations Appendix 2 External Audit Recommendations Francis Scott Chief Officer (Audit and Risk) Page 143 of 288
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5. Impacts 5.1 Public Sector Equality Duty and Fairer Scotland Duty Does the report contain information that has an impact because of the Public Sector Equality Duty and/or Fairer Scotland Duty? Yes ☐ No ☒ 5.2 Financial impact Does the report contain any financial impacts? Yes ☐ No ☒ 5.3 HR policy impact Does the report contain any HR policy or procedure impacts? Yes ☐ No ☒ 5.4 Legal impact Does the report contain any legal impacts (such as general legal matters, statutory considerations (including employment law considerations), or new legislation)? Yes ☐ No ☒ 5.5 Data protection impact Does the report / project / practice contain or involve the processing of personal data? Yes ☐ No ☒ 5.6 Technology / Digital impact Does the report contain information that has an impact on either technology, digital transformation, service redesign / business change processes, data management, or connectivity / broadband / Wi-Fi? Yes ☐ No ☒ 5.7 Environmental / Carbon impact Does the report / project / practice contain information that has an impact on any environmental or carbon matters? Yes ☐ No ☒ 5.8 Communications impact Does the report contain any information that has an impact on the council’s communications activities? Yes ☐ No ☒ 5.9 Risk impact Is there a risk impact? Yes ☒ No ☐ If Yes, please provide a summary of the key risks and potential impacts, highlighting where the risk(s) are assessed and recorded (e.g. Corporate or Service or Project Risk Registers), and how they are managed? Failure by Services to address previously identified issues and/or weaknesses will impact on the effectiveness of the relevant control framework. This, depending on the nature of the issue, will be captured and should be reflected in the relevant service risk register or the corporate risk register (as appropriate). 5.10 Armed Forces Covenant Duty Does the report require to take due regard of the Armed Forces Covenant Duty (i.e. does it relate to healthcare, housing, or education services for in-Service or ex- Service personnel, or their families, or widow(er)s)? Yes ☐ No ☒ 5.11 Children’s rights and wellbeing impact Does the report contain any information regarding any council activity, service delivery, policy, or plan that has an impact on children and young people up to the age of 18, or on a specific group of these? Yes ☐ No ☒ Page 144 of 288
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APPENDIX 1 – Register of Outstanding Internal Audit Recommendations Ref. Report Details Recommendation Original & revised timescales Management update 1.1 Chief Officer (Education) School Excursions (October 2023) The Chief Officers of Education (North and South) should ensure that: (1) A comprehensive formal review of both the Council’s Educational Excursions and Outdoor Activities Policy and the Risk Assessment Guidance on Educational Excursions and Outdoor Activities is undertaken to revisit and refresh all aspects of these documents with a view to improving the robustness of the Council’s arrangements associated with school trips and excursions. This should take account of, but not limited to, the information contained in Appendix 2 and the need for roles and responsibilities of all relevant parties, including those within other Council services to be clearly documented in the revised guidance. (2) Any revised arrangements are fully communicated to all Council Services with a role in the process. (3) They explore how best to gather/record details of all school trips and excursions and thereafter monitor compliance with the Council’s expected arrangements associated with such trips and excursions. Category: High April 2024 March 2025 September 2025 June 2026 (>12 months overdue) A review has been undertaken by HQ officers to re-assess the scope and delivery time of the project. This review identified a number of technical tasks which require to be undertaken, including systems reviews and alignment with other Service and Council policies. The Head Teachers have been briefed on the requirement to undertake a review of the policy, and a short life working group has been created. Due to the nature of the task, and to comply with all of the Internal Audit recommendations, this work will now be undertaken in line with the Council’s project management arrangements/guidelines. In the interim, best practice advice has, and will, continue to be given to schools based on the existing policy. The delay in implementation is largely due to staff resources being allocated to responding to school transport issues and enquiries. Going forward, there will be greater clarity regarding the post(s) within the Resources Team which will have HQ governance responsibility for overseeing school trip/excursion policy and activity. Page 145 of 288
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Ref. Report Details Recommendation Original & revised timescales Management update 1.2 Chief Officer (Education) School Excursions (October 2023) The Chief Officers of Education (North and South) should as part of the formal review referenced at Action Plan point 1 (ref 1.1 above), ensure that this includes the creation of a dedicated section within the policy and/or associated procedures which outlines clear expectations around the financial aspects associated with the organisation and execution of trips. This should include, but not be limited to: (a) A clear and detailed protocol for booking trips where a travel company/tour operator is not going to be used ensuring arrangements minimise the risks associated with such payments and ensure that the use of personal credit cards to book trips is prohibited. (b) Consideration to promoting iPay Impact as the primary means for collecting monies in schools thus reducing cash payments and the subsequent flow of physical cash in the school. (c) Determining the additional checks/monitoring that need to be carried out at establishment level to ensure all monies due are received and duly banked in line with Council policy. (d) clear guidance on the levels of physical cash that can/should be taken on a trip/excursion, the required records to be completed and documentary evidence required/expected to support any such spend. Category: High April 2024 March 2025 September 2025 June 2026 (>12 months overdue) A review has been undertaken by HQ officers to re-assess the scope and delivery time of the project. This review identified a number of technical tasks which require to be undertaken, including systems reviews and alignment with other Service and Council policies. The Head Teachers have been briefed on the requirement to undertake a review of the policy, and a short life working group has been created. Due to the nature of the task, and to comply with all of the Internal Audit recommendations, this work will now be undertaken in line with the Council’s project management arrangements/guidelines. In the interim, best practice advice has, and will, continue to be given to schools based on the existing policy. The delay in implementation is largely due to staff resources being allocated to responding to school transport issues and enquiries. Going forward, there will be greater clarity regarding the post(s) within the Resources Team which will have HQ governance responsibility for overseeing school trip/excursion policy and activity. 1.3 Chief Officer (Education) School H – School Funds (December 2024) Education should ensure that, as a matter of urgency, liaise with the Bank of Scotland to establish the current balance and a list of any transactions from February 2020 to date for both the Primary School and Nursery accounts. Once established, arrangements should be made for any balance remaining to be transferred to the current bank account for the school and nursery and these ‘old’ accounts closed. Priority: High December 2024 May 2025 September 2025 November 2025 While the Bank of Scotland have now closed the bank account for the Primary School and transferred the monies to their current bank account, this process has still to be completed for the Nursery Class bank account. The school are liaising with the bank and previous signatories to the account to ensure that the Nursery Class bank account is closed and the monies transferred to their current bank account. The delay in implementation is due to the Head Teacher being unaware that the Nursery Class held such an account. Page 146 of 288
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Ref. Report Details Recommendation Original & revised timescales Management update 1.4 Chief Officer (People Resources) Payroll: Follow-up of Overtime Duplicate Payments (August 2024) The Chief Officer (People Resources) should ensure that a review is undertaken, after a sufficient period to allow arrangements to become embedded, to determine the adequacy and effectiveness of the processes in place to monitor and address those cases where employees repeatedly submit duplicate claims, with amendments made as necessary. Priority: High March 2025 December 2025 There is now a Duplicate Claims Protocol in place which clearly outlines the process that will be followed for both employees who submit duplicate claims and managers who authorise them. Once this protocol has had time to embed, it will be reviewed and assessed to determine the adequacy and effectiveness of the processes put in place. Implementation was delayed to allow for trade union consultation and formal approval as well as ensuring managers and employees were informed of the protocol and understood the consequences of submitting or authorising duplicate claims. 1.5 Chief Officer (Education) Devolved School Management (May 2025) The Chief Officer (Education - South) should: (1) ensure that all relevant officers within Education and Families and/or key stakeholders who utilise or influence the DSM scheme are identified and that appropriate training on all relevant aspects of the DSM scheme, tailored to their respective roles, is developed and subsequently rolled out. Refresher training should be delivered on a periodic basis to ensure stakeholders remain appropriately informed; and (2) consider whether attendance at DSM training should be mandatory for all new and existing Heads of Establishment. If considered mandatory, arrangements for monitoring attendance and taking appropriate remedial action should be established. Priority: Medium May 2025 October 2025 (1) Partially implemented - Staffing groups who utilise or influence the DSM scheme have been identified and the arrangements for training have been outlined as part of the overall DSM training programme which is documented in the revised DSM Scheme. The DSM training will include many of the existing modules, manuals and guidance documents. Any gaps in training materials will be identified and further options developed. Thereafter, the full list of DSM materials will be incorporated into a DSM training directory and the programme forwarded to all relevant staff thus enabling training to be rolled out. Staff continue to receive updates and guidance on procurement/purchasing with an update provided at the Headteachers’ Briefing Session in October 2025. (2) Fully implemented - Consideration was given as to whether attendance at DSM training should be mandatory for all new and existing Heads of Establishment and the decision made to only make it mandatory for new Heads of Establishment. This is reflected in the revised DSM Scheme approved at the Education, Children and Families Committee in May 2025 and training will be rolled out to the new cohort of Heads of Establishment as part of the scheduled induction training at the start of each academic year. A register will be taken to monitor attendance at such training, and remedial action will be taken as necessary. Delay in implementation is due to the timing of the training to be delivered. Page 147 of 288
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Ref. Report Details Recommendation Original & revised timescales Management update 1.6 Chief Officer (Education) Devolved School Management (May 2025) The Chief Officer (Education - South) should identify all staff within the Service who are involved in making procurement decisions and ensure that these staff are provided with appropriate procurement training relevant to their respective roles. Priority: High June 2025 December 2025 Core individuals who are involved in procurement activity/decisions have been identified and the arrangements for procurement training have been outlined as part of the overall DSM training programme which is documented in the revised DSM Scheme. The DSM training will include many of the existing modules, manuals and guidance documents and there has been a review of existing training materials across a number of functions which contribute to the DSM. The first training session for new Head Teachers will take place in October 2025. The Service will review the feedback from this initial meeting and review training materials to identify any gaps and develop further options. Thereafter, the full list of DSM materials will be incorporated into a DSM training directory and the programme forwarded to all relevant staff, thus enabling training to be rolled out. For session 2025/26, priority will be given to new Head Teachers, Depute Head Teachers, AFAs, Education and Families Managers and aspiring Head Teachers before thereafter being delivered to other cohorts of staff who have purchasing/procurement responsibilities. Delay in implementation is due to the timing of the training to be delivered. 1.7 Chief Officer (Finance and Technology) Use of Purchase Cards (January 2025) The Chief Officer (Finance) should ensure that the Policy expectation for Treasury to undertake the system administrator role is implemented with all key responsibilities of that role being fully undertaken, including an annual review of all active cards. Priority: Medium June 2025 October 2025 Work has been undertaken with the Royal Bank of Scotland (card provider) to update the online card management process and enable credit and purchase cards to be managed within the same portal, with training being provided by the Royal Bank of Scotland. The portal works well with an appropriate level of reporting for service(s) and reconciliation/ledgering of expenditure. An initial draft review of the Policy review has been undertaken, pending changes to be incorporated as a result of review findings and a roll out of the Purchase to Pay (P2P) model. The proposed extension to the implementation date, will enable the P2P model to be fully embedded and for full consideration to thereafter be given to requirements, including administrator responsibilities prior to establishing and/or making changes to the Policy on use of purchase cards moving forward. Implementation of this recommendation has been delayed as the work required has taken longer than initially anticipated. Page 148 of 288
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Ref. Report Details Recommendation Original & revised timescales Management update 1.8 Chief Officer (Community Operations) Business Continuity Planning (April 2025) The Depute Chief Executive should ensure that, as intended: (1) Appropriate review and consideration are given to both the responses received from Chief Officers in respect of business continuity and the information provided directly by Services in relation to the testing of their business continuity arrangements. (2) A report is thereafter prepared and submitted to the Environment and Climate Committee providing assurance on the extent to which expected practices are being applied appropriately and consistently across all areas of the Council and that the Council is complying with its statutory obligations. Priority: Medium September 2025 December 2025 (1) Fully implemented – Chief Officers’ Annual Assurance Returns have been received by the Strategy and Performance Team and shared with the Resilience Planning Unit. (2) Partially implemented – An annual report, as per the recommendation, will be provided to the Environment and Climate Change Committee at the next meeting in October 2025. The delay in implementation is due to the timing of the Environment and Climate Change Committee meeting. Page 149 of 288
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APPENDIX 2 – External Audit recommendations Ref Recommendation Agreed Management Action Responsible Officer Due Date Update 2022/23 – Annual Report 2.1 Land and Buildings Valuations The Council should continue to consider its approach to the valuation of land and buildings going forward and continue to ensure this is appropriate to assess whether asset values have moved materially in year and as at 31 March. The Council should work with its valuers to ensure valuations are in accordance with accounting code requirements. Appropriate scrutiny of the valuation work completed should be undertaken to ensure these are consistent with the Council’s records. The Council will continue to review its revaluation policy in line with code requirements and in conjunction with the professional valuers. This will take cognisance of the recommended actions from the Audit Scotland round table discussion including that ‘where the valuation exercise is carried out in- year but earlier than 31 March for reasons of expediency, any material changes in value in the interim should be adjusted for’. The Council will give full consideration to the practicalities of undertaking valuations at 31 March to ensure this will not impact the annual statutory requirement to submit the unaudited accounts by 30 June. The Council will also continue to assess whether there is a material difference between the carrying value in the fixed asset register and current value, and ensure the accounts are code compliant. Chief Officer (Finance) Chief Officer (Asset and Procurement) June 2024 June 2025 Ongoing Ongoing The Finance Team has arrangements in collaboration with the external valuers to make an assessment of any material change in value between 1 February and 31 March to ensure that the carrying value of land and buildings is accurate and is not materially mis-stated. Recent history has shown there has not been any material movement to the carrying value. This will also be considered in light of potential future changes to accounting requirements around valuations of non-current assets. Page 150 of 288
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Ref Recommendation Agreed Management Action Responsible Officer Due Date Update 2.2 Capital Processes The Council should review a number of its capital processes to ensure the value of assets is correctly held in the accounts, including: • The Council should review the revaluations provided by its valuers to ensure all assets have been included. • The Council should review its capital impairment process to ensure it is robust enough to identify potential indicators of impairment across all assets. • The Council should also consider how assets are held on its fixed asset register to ensure compliance with the componentisation requirements of the Code. The Council will: • review the revaluation practices to ensure all relevant assets are incorporated • review the process of identifying impairments to ensure all assets are considered • review and consider how assets are held on its fixed asset register to ensure full compliance with the componentisation aspects of the code Chief Officer (Finance) Chief Officer (Asset and Procurement) June 2024 June 2025 No longer relevant While the first two points have been fully implemented (see narrative below), the third has been superseded by the Replacement of Assets recommendation made in the 2024/25 External Audit Annual Report. • Complete - reviews are undertaken of Fixed Asset Register (FAR) when selecting the representative sample of 20% across all asset categories to ensure that all assets that required to be incorporated (e.g. last valuation was 5 years ago etc) are included in the valuation programme. • Complete - a revised process has been established. A list of all assets within the FAR is provided to Chief Officers as part of the year-end exercise to ensure full consideration of assets within service. Any impairments are considered as part of the valuations process. 2.3 Significant Trading Operation The Council should review the trading operation to examine the cost effectiveness of the service provided to ensure that it continues to represent best value for the Council. As currently presented the Trading Account shows a rolling three-year deficit. However, this performance incorporates non-cash adjustments for Employee Benefits. Following the same accounting treatment as Council, these costs would be reversed back out resulting in a cumulative three-year surplus being reported, demonstrating continued value for money in the operation of the Council's Trading Account. The Council will seek to amend the presentation of the Trading Account note for the 2023/24 annual accounts to reflect the cash and non-cash elements of Trading Account operations. Chief Officer (Finance) June 2024 Complete. Reported to Panel in August 2024. Page 151 of 288
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Ref Recommendation Agreed Management Action Responsible Officer Due Date Update 2022/23 – Best Value Thematic Report 2.4 Involvement of Members in Strategic Planning The Council should look to improve its existing processes for engaging elected members on the overall strategic planning process. As part of its scheduled annual review, we will refresh the narrative presently contained within the Strategic Policy Framework in respect of elected members’ strategic planning role and will thereafter emphasise through the CMT and Community Co-ordinator role the importance of engaging elected members on the strategic elements of the integrated Programme of Work Delivery Plan. Elected member role in strategic planning to also be clearly documented in the developing Programme of Work Governance Framework. Chief Officer (Business and Digital) September 2024 Complete. Reported to Panel in November 2024. 2.5 Engagement with Communities The Council should consider how it measures the level of engagement with communities and equalities groups. This will be aligned with actions arising from new communication strategy to be considered by council in March 2024. The strategy will also define what is meant by seldom-heard communities and groups. Chief Officer (Strategic Communication and Engagement) March 2024 Complete. Reported to Panel in August 2024. Page 152 of 288
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Ref Recommendation Agreed Management Action Responsible Officer Due Date Update 2.6 Elected Members Training and Development Programme The Council should work with members to understand the reasons for the poor attendance to ensure its training and development programme is fit for purpose. The number of attendees at development sessions has been low, however there has been a slight increase in numbers attending recent events. The Talent and Organisational Development Team will continue to communicate regularly with Political Group Business Managers to encourage discussions around training, low attendance and engagement to be included on business meeting agendas. A survey will be sent to all Elected Members to help identify any restrictions and reason for low attendance. Development of the Elected Members area on LearnNL will continue, with all development session recordings and presentation slides being uploaded for members to access at any time. A monthly communication is sent to all Elected Members with direct links to new recorded sessions. Chief Officer (People Resources) November 2023 Complete. Reported to Panel in February 2024. 2023/24 – Annual Report 2.7 Replacement of Assets Management should establish a process to ensure assets replaced are appropriately removed from the asset register and accounted for as a disposal appropriately. In the absence of componentisation, it is unclear as to how we can put in place a process to remove the value of elements of assets which have been replaced. However, we will commit to a review of expectations around componentisation with a view to future discussions with External Audit. Chief Officer (Finance) June 2025 Complete Services are now requested to identify and report any works that are/could be replacement of major components during the capitalisation process. Management ensured that assets with significant subsequent spend are included as part of the revaluation exercise. 2.8 Statutory Override The Council should proactively work with CIPFA and the wider local government sector to arrive at appropriate solution for the implementation of accounting for infrastructure assets. The Council will work with CIPFA and the wider Local Government sector as appropriate to inform a decision on the accounting treatment for infrastructure assets. Chief Officer (Finance) Ongoing Not yet due. Position as at October 2025. CIPFA/LASAAC issued a consultation for the 2025/26 accounting code which includes the proposal to extending the statutory override within the UK. The statutory override has been extended until 2026/27. Page 153 of 288
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Ref Recommendation Agreed Management Action Responsible Officer Due Date Update 2.9 Reinforced Autoclave Aerated Concrete (RAAC) For those properties where RAAC was confirmed, the Council should determine a more accurate measure of the level, of impairment in line with the requirement of accounting standards. Further engagement with the Council’s valuers is required to determine an appropriate methodology, subject to full investigation being carried out to determine the extent of costs/remedial works required. Chief Officer (Finance) Chief Officer (Asset and Procurement) June 2025 Complete Audit work confirmed that the Valuers considered the remediation costs of RAAC as part of their valuation. 2.10 Continuity and Security of IT Operations The Council should ensure that there is appropriate oversight of its continuity and security of IT operations and ensure the necessary assurances are obtained for externally hosted systems. Services will continue to own and manage their Business Continuity arrangements – with support and guidance from the Resilience Planning Team. Business Continuity testing framework has been implemented. It is recommended that Services test their plans annually and a corporate test will be arranged every 3 years. Oversight of IT security and IT Disaster Recovery will continue to be managed through established corporate working groups and Service Management Teams. Development of assurances on externally hosted systems will be monitored through the established arrangements of the Digital North Lanarkshire Programme of Work. Depute Chief Executive Chief Officer (Business & Digital) November 2026 April 2025 Ongoing Ongoing Depute Chief Executive – Complete - reported to Panel May 2025 Business and Digital Oversight of IT disaster recovery arrangements are managed through working groups and service management teams. The BCP and DR Champions Group, together with Data Management and Compliance Group, act as the forums through which DR planning arrangements are agreed and reported. Service Management Teams are provided updates on the DR planning arrangements for the systems that they own. This last set of updates was provided in Feb/March 2025. Externally hosted systems are evaluated and assured using standardised assessment criteria. These criteria are defined through adoption of the Scottish Government’s Cyber Security Procurement Support Tool. Continual improvement of process is undertaken. Improvements to the current process are being steered through the Council’s Programme of Work ambitions, specifically the DigitalNL/Performance Optimisation theme. Further improvements include the potential adoption of a new Scottish Government-sponsored supplier assurance tool for which is currently under development and expected to be released imminently. Page 154 of 288
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Ref Recommendation Agreed Management Action Responsible Officer Due Date Update 2.11 Public Performance Reporting The Council should improve its public performance reporting to provide its citizens and communities with a clear summary of performance. Following various programme of work reports to each committee cycle throughout the year, regular news articles and updates on delivery and performance are reported through the council’s website. With the Programme of Work to 2028 and its associated governance arrangements well established, work will be undertaken during 2025/26 to formally review and redevelop public performance reporting arrangements. Chief Officer (Strategic Communication and Engagement) March 2026 Not yet due. Position as at October 2025. Work continues towards updated and redeveloped public performance reporting arrangements ahead of the agreed implementation date. 2023/24 – Best Value Thematic Report 2.12 Acting on Staff Engagement Feedback As the council develops its staff engagement approach, it should ensure that as well as providing information to staff on council decisions, it also incorporates the views of staff and trade unions to support transparent decision making, and evidence how it is acting on findings from the Summer 2024 Roadshow sessions. There are several strands of work underway which will allow the council to progress this recommendation, including a refreshed staff survey and a review of trade union consultation arrangements. These will be taken forward along with the feedback from our 2024 Roadshow sessions to deliver an improved engagement approach. Chief Officer (People Resources) December 2025 Not yet due 2.13 Hybrid Working Policy The council should continue to monitor the impact of its hybrid working approach. It should continually assess the impact of increasing the number of office days, in terms of performance, staff wellbeing, and recruitment and retention. The council will continue to monitor the impact of its permanent Hybrid Working Scheme, through both manager and staff surveys, and in terms of performance, recruitment and retention in hybrid roles. Chief Officer (People Resources) January 2026 Not yet due 2.14 Temporary Workforce The council should include data reporting on its temporary workforce as part of published workforce data, and once available it should include data on agency workers. Work is underway to implement a more centralised approach to reporting on and managing temporary workforce resources, including agency workers. This work will be fully progressed to improve future reporting. Chief Officer (People Resources) December 2025 Not yet due Page 155 of 288
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Ref Recommendation Agreed Management Action Responsible Officer Due Date Update 2024/25 – Annual Report 2.15 Fixed Asset Register The Council should undertake a review of the fixed asset register to assess its capability to support accurate reporting. The Council fully reviews and reconciles all fixed asset transactions within the overall Fixed Asset Register to the financial ledger and financial statements to ensure accurate reporting. However, the Council will review the specific summary FAR extract report and reporting tool mechanics relating to depreciation charged to enhance reconciliations processes. Chief Officer (Finance and Technology) June 2026 Not yet due 2.16 Common Good Assets The Council should continue to review requirements to disclose Common Good assets separately from council assets. The Council agrees to continue to review the disclosure requirements in respect of Common Good assets. Chief Officer (Finance and Technology) June 2026 Not yet due 2.17 Strategic Use of Reserves The Council should undertake a review of its reserves to determine what the planned or targeted level of reserves is appropriate. It should also look to define when certain earmarked reserves such as those earmarked for future budget pressures would be utilised as it is unclear whether these would be used to address short term pressures or to support investment to support long-term sustainability and improved outcomes. The Council will undertake a review of its reserves to determine a planned/target level appropriate and timing of use. Chief Officer (Finance and Technology) June 2026 Not yet due Page 156 of 288
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Ref Recommendation Agreed Management Action Responsible Officer Due Date Update 2.18 Exit Packages There are opportunities for the council to enhance the standard of documentation of early retirement decisions. The council should also review its policies and procedures to ensure that exit packages of senior officers are subject to additional scrutiny. The Council intends to undertake a wider review of its democratic, committee and decision-making governance procedures with a report due to be presented to Policy and Strategy Committee on 25 September 2025. Phase 4 of this review includes a review and update of the Scheme of Administration and Delegation, which will now incorporate consideration of the governance around early release of senior staff. Chief Officer (Legal and Democratic) December 2026 Not yet due 2024/25 – Best Value Thematic Report 2.19 Benefits Realisation The Council should prioritise completion of its benefits realisation framework and incorporate reporting on both financial and non-financial benefits into regular monitoring reports. Given the financial challenges the council is facing there is a need to increasingly monitor and track cost and benefits of transformation projects. This will help inform officers and members of the extent to which transformation projects are delivering their intended benefits. Following the Framework to the One Service Board in March 2025, arrangements are being made to roll this out to all of the other Programme of Work Boards. Chief Officer (Strategy and Engagement) June 2026 Not yet due 2.20 Improving Public Reporting of Progress Against the 28 Health Check Indicators The council should ensure that the reporting of progress against its 28 Health Check Indicators is more accessible to the public. There is a dedicated section within the Programme of Work pages on the website for “Performance”, however this is under re development to ensure it captures, and provides access to, all relevant and already existing Council and Programme of Work performance in one place. This will include regular updates on the 28 health check indicators in a way that is meaningful to the reader. Chief Officer (Strategy and Engagement) June 2026 Not yet due Page 157 of 288
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North Lanarkshire Council Report Audit and Scrutiny Panel Does this report require to be approved? ☐ Yes ☒ No Ref FS/ASP/RMNov25 Date 13/11/25 Risk Management Update From Francis Scott, Chief Officer (Audit and Risk) E-mail ScottFr@northlan.gov.uk Telephone 07887 914207 Executive Summary This report seeks to support the Audit and Scrutiny Panel in the discharge of the aspect of its remit of monitoring the effective development and operation of risk management in the Council. The report provides an overview the Corporate Risk Register (CRR) and developments on Corporate Risks since the August update. The report concludes with a summary of the key considerations of the Risk Management Corporate Working Group (RMCWG) within the reporting period. Recommendations The Panel is asked to consider the contents of the report and note: (1) the CRR for 2025-26 as detailed in Appendix 1. (2) the changes to corporate risk assessments in section 2.2. (3) the Corporate Risk Register Controls report detailed in Appendix 2 and described at section 2.4. (4) Corporate Risk Benchmarking detailed in Appendix 3 and described at section 2.5. (5) the summary of other risk management developments as noted at section 2.7. The Plan for North Lanarkshire Priority All priorities Ambition statement All ambition statements Programme of Work Statutory / corporate / service requirement Item 10 Page 159 of 288
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1. Background 1.1 The Audit and Scrutiny Panel terms of reference include the remit to monitor the effective development and operation of risk management in the Council. This report supports the Panel in discharging that aspect of its remit by providing an overview of how certain requirements of the Risk Management Strategy have been delivered during the reporting period. 2. Report Corporate Risk Register 2025-26 2.1 The CRR for 2025-26 is included at Appendix 1. This version includes any changes captured since the update to Panel in August. Risks on the CRR are subject to ongoing monitoring and review, with higher scoring risks being subject to more frequent review. Management considers factors such as changes in the operating environment, the effectiveness of existing controls, the development of additional controls and progress of agreed actions to determine whether it would be appropriate to adjust the risk assessment in line with the Risk Management Strategy. Changes to Corporate Risk Assessments 2.2 There was one risk with a change in assessment during the reporting period. This risk reflects the uncertainty around the effectiveness of the Council’s arrangements for Governance, Leadership and Decision Making and the potential for ineffective arrangements to limit the ability to deliver our objectives. At the latest review management considered that the implementation of additional controls supplemented the already well established and effective arrangements already in place. Management was also mindful of the assurance on the control environment that is provided from the self-assessment undertaken in developing the Annual Governance Statement. Additionally, two Internal Audit reports reported to the Panel in August (on Corporate Governance and Strategic Governance Arrangements) provided substantial assurance opinions, and the External Audit Annual Report commented that the Council had effective governance arrangements in place to oversee its transformation work. 2.3 Based on the positive progress made on the risk control environment and the outcomes of recent assessments of those arrangements, the likelihood score was reduced from 4 (Probable) to 3 (Possible). Management intends to revisit the assessment at the next scheduled review and will also consider any other relevant reports, such as the Best Value Review or the review of the Programme of Work. Corporate Risk Register Controls 2.4 Following a request from Panel members at the meeting in August, we have included a report at Appendix 2 to provide Members with a summary of the controls that are captured for each entry on the CRR. These controls are used to mitigate the inherent assessment of each risk and calculate the residual risk score which is reported in the CRR update to Panel. Further information such as risk context, risk assessment rationale and relevant actions aligned to controls are captured during the risk review process and recorded in our risk management system. Corporate Risk Benchmarking 2.5 At the previous Panel meeting in August, members also requested information on benchmarking of corporate risks with other local authorities. Detailed comparison and Page 160 of 288
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benchmarking can be challenging due to differences across authorities (for example the tools used and how information is interpreted and applied in the risk management process). A form of benchmarking is used annually in the horizon scanning exercise, and details of this for the most recent exercise are included in Appendix 3. 2.6 The Scottish Local Authorities Chief Internal Auditors’ Group (SLACIAG) is currently conducting an exercise to benchmark corporate risks from Scottish local authorities. Once this exercise is complete, we will bring the outputs to a future meeting of the Panel as part of the Risk Management update. Other Risk Management Developments 2.7 The RMCWG co-ordinates activities and resources in order to implement the Risk Management Strategy and promote good risk management practice throughout the Council. There were two sessions of the RMCWG since the last report to Panel, with the notable discussion points noted below: • Risk Management Information System – proposed refinements to capture additional information • Training – mandatory internal training completion rates continue to show positive progress 2.8 We were delighted to welcome our new Corporate Risk Officer, Amy Costello Marshall, to the team at the beginning of October. Amy’s appointment brings the team up to a full complement of staff. 3. Measures of success 3.1 The Corporate Risk Team will continue to report quarterly to CMT and the Audit and Scrutiny Panel, providing an overview of key developments in risk management and updating on progress in respect of planned improvements to the Council’s risk management arrangements. 3.2 The adequacy and effectiveness of the Council’s risk management arrangements will be subject to independent review by Internal Audit, who will report directly on the results of that work to the Audit and Scrutiny Panel. 3.3 Effective risk management arrangements assist the Council in achieving planned outcomes and/or help the Council mitigate the impacts of adverse events. 4. Supporting documentation Appendix 1: Corporate Risk Register 2025 - 2026 Appendix 2: Corporate Risk Register Controls Appendix 3: Corporate Risk Benchmarking Francis Scott Chief Officer (Audit and Risk) Page 161 of 288
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5. Impacts 5.1 Public Sector Equality Duty and Fairer Scotland Duty Does the report contain information that has an impact because of the Public Sector Equality Duty and/or Fairer Scotland Duty? Yes ☐ No ☒ 5.2 Financial impact Does the report contain any financial impacts? Yes ☐ No ☒ 5.3 HR policy impact Does the report contain any HR policy or procedure impacts? Yes ☐ No ☒ 5.4 Legal impact Does the report contain any legal impacts (such as general legal matters, statutory considerations (including employment law considerations), or new legislation)? Yes ☐ No ☒ 5.5 Data protection impact Does the report / project / practice contain or involve the processing of personal data? Yes ☐ No ☒ 5.6 Technology / Digital impact Does the report contain information that has an impact on either technology, digital transformation, service redesign / business change processes, data management, or connectivity / broadband / Wi-Fi? Yes ☐ No ☒ 5.7 Environmental / Carbon impact Does the report / project / practice contain information that has an impact on any environmental or carbon matters? Yes ☐ No ☒ 5.8 Communications impact Does the report contain any information that has an impact on the council’s communications activities? Yes ☐ No ☒ 5.9 Risk impact Is there a risk impact? Yes ☒ No ☐ If yes, please provide a summary of the key risks and potential impacts, highlighting where the risk(s) are assessed and recorded (e.g. Corporate or Service or Project Risk Registers), and how they are managed? Effective risk management arrangements will enable the Council to manage its risks more effectively, increasing the likelihood of the Council achieving its plans and ambitions by minimising or mitigating potential threats to planned outcomes. A robust risk management strategy lays out the framework and underpins all risk management activity across the organisation. 5.10 Armed Forces Covenant Duty Does the report require to take due regard of the Armed Forces Covenant Duty (i.e. does it relate to healthcare, housing, or education services for in-Service or ex-Service personnel, or their families, or widow(er)s)? Yes ☐ No ☒ 5.11 Children’s rights and wellbeing impact Does the report contain any information regarding any council activity, service delivery, policy, or plan that has an impact on children and young people up to the age of 18, or on a specific group of these? Yes ☐ No ☒ Page 162 of 288
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Appendix 1 – Corporate Risk Register 2025-26 CORPORATE RISKS (Operational) Likelihood Impact Rating Evaluation Change 1. Home support service delivery/ sustainability 4 5 20 High No 2. Information security and governance 5 4 20 High No 3. ICT operational capability 5 4 20 High No 4. Human resources (workforce planning) 4 4 16 High No 5. Public protection 4 4 16 High No 6. Health and Safety 5 3 15 Medium No 7. Business continuity planning 5 3 15 Medium No 8. Terrorism 3 5 15 Medium No 9. Governance, leadership and decision- making 3 4 12 Medium Was 16 10. Procurement risk 3 4 12 Medium No 11. RAAC 3 4 12 Medium No 12. Failure of Council’s Resilience Planning Arrangements 2 5 10 Medium No 13. Enterprise Contract Management 2 5 10 Medium No 14. Serious organised crime, fraud and corruption 3 3 9 Medium No CORPORATE RISKS (Strategic) Likelihood Impact Rating Evaluation Change 15. Tackling poverty 5 4 20 High No 16. Power resilience (Black Start) 4 5 20 High No 17. Climate change 5 4 20 High No 18. Digital adoption 4 4 16 High No 19. Improving educational outcomes 4 4 16 High No 20. Financial sustainability 3 5 15 Medium No 21. Digital and IT strategy 4 3 12 Medium No 22. Engagement and consultation 3 3 9 Medium No 23. Delivery of approved programme of work 2 4 8 Low No Page 163 of 288
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Appendix 2 – Corporate Risk Register Mitigating Controls FINANCIAL SUSTAINABILITY Inherent Likelihood Inherent Impact Inherent score There is a risk that the Council's financial strategy does not adequately ensure the Council is able to respond to changing internal and external circumstances, and/ or is unable to maintain its existing controls and arrangements to ensure that the approved Budget Strategy provides adequate resources (revenue, capital or reserves) to deliver Council priorities and any additional services, particularly in response to an emergency situation, thus putting the financial sustainability of the Council at risk. 5 5 25 Residual Likelihood Residual Impact Residual Score 3 5 15 CON0000019 Reinforcement of Balanced Budget statutory requirements on elected members and senior officers. Continual review of financial forecasts to respond to and manage emerging issues that may impact the Council's overall financial position. CON0000021 The Chief Officer Finance is a member of the Corporate Management Team whilst Business Finance Managers are part of Service Management Teams and other corporate working groups, which ensure robust governance and decision-making arrangements and helps ensure financial implications are robust, affordable and sustainable. This is a continuous process. CON0000024 Working towards a rolling 3-year budget and continue to ensure appropriate level and use of reserves in accordance with policy. This is a continuous process. CON0000025 Ongoing continuous engagement and regular research of external influences and participation in a number of key financial and funding groups including; Directors of Finance, COSLA, SOLACE etc. ensures awareness of current issues impacting NLC and enables robust briefings and advice to CMT and Elected Members. CON0000703 Overarching Financial Strategy and the implementation of the key principles of the Revenue Resources Budget Strategy strengthens the Council's ability to respond to changing circumstances including managing emergency situations. Reviews of all capital and revenue financial plans are embedded in our existing financial governance arrangements. Integration of all capital and revenue financial plans, and TM Strategy, are embedded in our existing financial governance arrangements. This is a continuous process. CON0000704 Medium Term Financial Plan (MTFP) which incorporates a range of planning scenarios, reported to Committee. Incorporates internal and external factors affecting the Council's financial position. Interim Financial outlook updates prior to budget setting. Undertaken annually. CON0000705 Review of Financial Governance arrangements including Financial Regulations and robust Financial Management & Reporting arrangements. CON0001878 In the event of a financial emergency situation similar to the COVID-19 pandemic, all associated costs and available funding options to be given full consideration and where necessary be subject to a separate budgeting exercise. Page 164 of 288
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HUMAN RESOURCES (WORKFORCE PLANNING) Inherent Likelihood Inherent Impact Inherent score We do not ensure that Council has sufficient number of capable and motivated staff to provide the full range of services required at present and in the future. That the Council does not comply with the large range of legislation and regulation relating to employment. That we fail to ensure, so far as is reasonably practicable, the health, safety and welfare at work of the Council's employees and others engaged to undertake activities on behalf of the Council. This incorporates both physical and mental welfare. 5 5 25 Residual Likelihood Residual Impact Residual Score 4 4 16 CON0000026 People Resources owns and cascades all HR polices, has subject matter expertise and is the point for all specialised HR advice, supported by external expert advice where required. There is continued review and communication of the suite of policies and processes, and regular publication of HR related content via MYNL. CON0000027 A comprehensive range of HR polices encompassing work life balance; employee conduct and performance, health, safety & wellbeing and hybrid working scheme are in place, embedded and practices are adhered to by all Services. Where new policies are developed training is undertaken. CON0000028 The Council is bound by and adheres to employment and pay and grading frameworks governed by COSLA and regularly attends COSLA sessions for Heads of Human Resources to ensure that it is up to date with development across all 32 Councils and with the Scottish Government in the realms of HR and Employment Legislation. Specialist support to maintain the credibility of the Councils pay and grading model and job evaluation scheme. Includes ongoing harmonization of CLNL staff. CON0000029 Monitoring and overview of HR activities across the Council is undertaken by the Senior Management Team, CMT and Finance & Resources Committee. CON0000030 Team consists of highly competent and knowledgeable PR staff/HR Business Partners are embedded within the services/Employment Relations advisors working closely with services alongside managers to anticipate and deal with issues, and these are supported by specialist corporate teams with sound knowledge and experience of all matters relating to employment legislation e.g. Employment lawyers and Corporate Legal Function. CPD is in place. CON0000031 Highly specialist team of Employment Relations advisors work closely with the services to deal with matters which arise, and the team are fully up to date with current employment legislation; the team also works closely with the Councils Employment Lawyers and Corporate Legal Function. CON0000033 Joint consultative and negotiating structures are in place and working effectively at both corporate level formally through the JCC and the JNCT and at local level within the Services. These meet on a regular basis throughout the year to raise and discuss HR issues. Updated framework for Trade Union Consultation approved at Committee. CON0000034 Training and development is available for managers & employees. eLearning system part of training and development and also used where there is a regulatory requirement for specific training and awareness. Includes leader and manager development to improve skills in people management and dealing with difficult issues. Redesigning the learning curriculum leveraging digital technologies to ensure a quality provision to maintain a suitably trained workforce. CON0000035 The Employee Service Centre maintains and controls access to all HR data stored within existing systems across the Council. This includes the storage of employee files CON0000036 Use of I-Trent for Payroll across NLC and certain ALEOS. Provides assurance that staff are paid correctly on time and in adherence with legal requirements including HMRC requirements. Ongoing enhancements to the Itrent system that will continue to drive efficiencies and provide enhanced workforce information to aid decision making e.g. absence management, workforce profiling, time and attendance. CON0000037 Supporting attendance policies are applied and absence levels are regularly reported on, with analysis and consideration at management level of key plans and targets for reducing the instance of absence across the Council. CON0000038 Comprehensive Occupational Health referral service, including physiotherapy, as well as access to appropriate wellbeing activities, employee counselling. CON0000039 People Resources works jointly with the Employee Service Centre to manage and control the end-to-end recruitment process across the council. This ensures an adequate process is in place for screening staff for relevant roles e.g. those involved with children and vulnerable adults. Page 165 of 288
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CON0000040 Oversight and control of the Council's staffing establishment through the Workforce Change Steering Group. CON0001637 Corporate and Service Business Continuity Plans in place and stress tested to inform priorities and decision making and control is at Chief Officer level. CON0001638 Ongoing attendance at Local Authority forums, SPDS portfolio group, national/regional groups to share practice, resources, expertise to support our plans CON0001639 Digital transformation e.g. MS365 migration CON0001640 Continued focus on employee Mental Health and Well-being through WorkwellNL, signposting supports through employee communication channels. Council service based mental health groups in place with a Council group having oversight. CON0002997 Preparation and agreement of the Corporate Workplace plan and roll out of responsibilities. Progressing, monitoring and reporting of actions and changes across NLC. Reporting to Policy & Strategy CON0002998 Standard Service Level Workforce Plans which align with the Corporate Workforce Plan. Agreement on each services ownership responsibilities and development of their plan; including implementation of controls actions aligned with corporate objectives. Reporting of overall position and status of Service Workforce Plan to Policy and Strategy Committee CON0002999 Workforce Plan for Social Care and reporting to Committee and HR CON0003000 Plan for Education & Families and reporting to Committee and HR CON0003001 Workforce Plan for Chief Executives and reporting to Committee and HR. CON0003002 Workforce Plan for Enterprise and Communities and reporting to Committee and HR CON0003003 Restructured full-scale pay model (or alternative compensating control(s) CON0003004 Cross skilled/up skilled staff within services to improve skills and efficiency, create better flexibility and resilience and to deal with peaks and troughs in work demand. Each service to ensure an adequate level of cross skills. CON0003005 Refined and materially changed service structures and operating models optimising service operations and skills within staffing groups CON0003006 Demand Planning Process which includes replacement for staff leaving (principally through retirement but also for other reasons). CON0003007 Streamlined recruitment process that is fit for purpose CON0003008 Enhanced training which aids staff development and retention CON0003009 Optimising staff ability and use of digital enhancements (Corporate Risk Digital Adoption RIS 0000702) CON0003010 Strategy and practices for recruiting and retaining specialist roles CON0003011 Equality Strategy and Diversified Workforce CON0003012 Liaison with Glasgow City Region (GCR) and pathway for recruitment initially trainee planners but to later include other roles which experience recruitment shortages CON0003013 Graduate apprenticeship scheme for Social Work. CON0003014 Liaison with Routes to Work to optimise employment opportunities this is part of our BAU activities. WF Resourcing Manager engages with Routes to Work on a regular basis to see how best we can support individuals using this route with employment opportunities, and in turn, tap into this route as a bonified labour market route to bring new starters into NLC. Page 166 of 288
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HEALTH AND SAFETY Inherent Likelihood Inherent Impact Inherent score The Council fails to comply with the Health & Safety at Work etc. Act 1974, and associated legislation protecting the health, safety & welfare (including mental health) of its employees and anyone else who can be affected by its activities. 5 5 25 Residual Likelihood Residual Impact Residual Score 5 3 15 CON0000041 Professional Centralised Occupational Safety & Wellbeing team provide advice and support across the Council, and are fully mobile, able to work remotely and adapt and flex to changing circumstances. CON0000042 Health & Safety training carried out across the Council to ensure that all employees are competent to undertake their role; all employees made aware of Health & Safety requirements and supervisors/managers are trained to an appropriate level. Safety training is adapted to includes use of digital platforms to ensure appropriate reach as the workforce continues to change shape. CON0000043 Auditing and monitoring programme providing information on whether the Council is legally compliant including control of contractors. CON0000044 Competent risk assessors across the Council and health & safety professionals for specific assessments e.g. Noise, fire etc. Risk Assessment registers detailing risk assessments undertaken as well as generic. Risk assessment approach also includes self-assessment approaches for individuals home working, including DSE/workstation/homeworker assessments. CON0000045 Incident monitoring and investigation. Investigations into liability claims help to identify areas for improvement. CON0000046 Work equipment purchased in line with Council policy, employees trained in its use and appropriate maintenance regime implemented. CON0000048 Health surveillance and occupational health contract monitoring employee health or addressing issues as they arise. CON0000049 Health and safety committees including Service/Section based and Health, Safety & Welfare Forum (Joint Consultative Committees). Regular and ongoing union consultation with GMB, Unison and Unite, EIS, NASUWT and SSTA. CON0000050 PAS 79 Fire Risk Assessment Format adopted within Council. CON0000734 Communications: Work Well NL - effective and relevant programme of wellbeing support for employees, linking with absence, targeted interventions in response to absence stats. Inside NL and work well pages used to convey information and campaigns. People Resources manager bulletin also used to inform and communicate with managers for them to cascade to employees as appropriate. CON0002851 Ongoing promotion and availability of safety e-learning modules and online teams training Page 167 of 288
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PUBLIC PROTECTION RISK Inherent Likelihood Inherent Impact Inherent score NLC fails to comply with its legal obligations with respect to public protection or fails to adequately support, resource or scrutinise performance of its public protection functions in particular in relation to the specific arrangements around child protection, adult support and protection, high risk offenders, domestic abuse, sexual exploitation or human trafficking. There is a risk also that irrespective of quality systems, decision-making by individual(s) may contribute to adverse impacts. 5 5 25 Residual Likelihood Residual Impact Residual Score 4 4 16 CON0000051 North Lanarkshire Chief Officers Public Protection Group (NLCOPPG) is responsible for ensuring that all agencies work effectively both individually and collectively to protect the communities of North Lanarkshire. Group (chaired by CEO NLC) comprises NLC, Police Scotland, North Lanarkshire Health & Social Care and North Lanarkshire Health Board. SCRA. Self-Evaluation & Development Sessions have generated improvements: A further Self Evaluation Exercise was completed 2021/22. In addition, an internal audit on the effectiveness of governance arrangements for public protection was concluded in November 2021 concluding that there was reasonable assurance. As a result of both exercise a small number of improvement actions have been progressed by the supporting Lead Officers Group. Current engagement with the Care Inspectorate alongside ongoing review will inform any further amendments required to strengthen local COG arrangements. CON0000052 North Lanarkshire Public Protection Lead Officers Group (NLPPLOG) supports co-ordination and delivery of public protection responsibilities on behalf of NLCOPPG. The group were tasked 2019 with reviewing the resourcing of multi-agency public protection functions and full reviews of the pan-Lanarkshire MAPPA unit and the VAWG were also undertaken with recommended changes agreed by the COG in February 2020 including introducing a strengthened two- tiered structure: VAW Strategic and Operational Groups and enhanced administrative support. Implementation of two tier VAW structure paused during the pandemic but has now been implemented. A further annual review of resourcing in 2022 led to NLPPCOG agreeing temporary enhancement of multi-agency resourcing to support enhancement of MARAC arrangement and additional support to the CPC and APC to support the implementation of new guidance. Additional resource for MARAC and for Senior Officer Training and Development posts for the APC and CPC have since been consolidated. CON0000053 National Guidance and legislation is used as basis for local procedures and guidance which are implemented across key services. Including with respect to new risks e.g. new local multi-agency guidance on FGM, forced marriage and Honour Based Violence published in early 2018 and updated procedures on child trafficking in 2019. ASP procedures have also recently been reviewed with briefing session for staff to enhance understanding of roles and legal duties. Updated procedures take cognisance of new and emerging risks for adults. New National Child Protection Guidance was published in September 2021 supported by a national implementation group. NLCPC has an associated work plan progressed over 2022/23 in line with national expectation with regular updates to the COG through quarterly reporting arrangements. CON0000054 Multi Agency Co-ordinators for Child Protection, Adult Protection, Domestic Abuse and MAPPA are employed with responsibilities for multi-agency collaboration and work closely together enhancing the ability to address cross cutting issues. An annual review of PP Multi Agency Resource is undertaken. CON0000055 Multi and Single Agency training programme and awareness raising in place to support key public protection activity. CON0000056 A range of audit activity takes place on a multi-agency and service basis, including an annual themed CPC & APC file audit and activity to support identified improvement areas e.g. of IRDs. Process is in place for notification and review of critical incidents. Initial and Significant Case Reviews are reported through regular activity reports to the COG, with COG involvement in key decisions on SCRs and any associated improvement actions monitored by the relevant committee/oversight group. In 2020 a new tracker was introduced to support COG oversight. CON0000057 Reporting on activity and performance to relevant committees, including via the sharing of the annual report and business plans of the Adult and Child Protection Committees, Lanarkshire MAPPA and CSWO report, in 2018/19 further to consideration of risk at Audit and Scrutiny Panel, a further report was also provided on learning from case reviews. Page 168 of 288
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CON0000059 Supervision and consultation is in place for staff in relation to public protection work and arrangements are in place to ensure only suitably qualified/trained staff undertake lead roles. CON0000060 CSE Oversight Group established 2018 in response to identification of need to strengthen multi-agency information sharing and co-ordination in this area. CON0000061 A range of activity is undertaken to raise public awareness of public protection issues including via targeted campaigns. New public protection web pages were launched in May 2025 to enhance accessibility of key information to public and practitioners. Controls enforced through CPC, APC, MAPPA, SOG, and VAWG. CON0001481 Regular liaison with key commissioned providers to discuss capacity, prioritisation of work and redirection of resource where required. Control Owners, Head of Performance and Planning, Manager QA & Commissioning CON0002962 External Scrutiny of Adult Protection via joint inspection led by the Care Inspectorate was completed in November 2022 and of Services for Children and Young People at Risk of Harm in October 2023. Key processes and leadership with respect to adult inspection were evaluated as effective with some areas for improvement largely consistent with the partnerships self-evaluation. With respect to Child Protection evaluation of impact on children and young people was very good with key strengths highlighted and no specific recommendations but a small number of improvement areas identified within the report and the service's own self-evaluation. CON0002963 In Children's Services use of Signs of Safety and Healing model. To be fully incorporated by January 2026 Page 169 of 288
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PROCUREMENT RISK Inherent Likelihood Inherent Impact Inherent score Failure to observe the required Procurement Regulations, Legislation and GCSOs in some instances of the council’s purchasing and contracting activity. The council’s devolved procurement model, in which some officers have Delegated Procurement Authority (DPA) to undertake procurement activity does not align with the most recent Scheme of Delegation and General Contract Standing Orders. Communications on procurement matters are not cascaded to the relevant officers and/or are unclear. 5 5 25 Residual Likelihood Residual Impact Residual Score 3 4 12 For regulated procurements, there is a risk of failure(s) in individual procurements, where aspects of the procurement procedures are not conducted as expected, and this could result in negative and costly impacts for the council, including legal consequences. There is also a risk that a significant proportion of the council’s current and ongoing expenditure has not followed a compliant procurement process that aligns with the governance outlined in this risk context, and therefore the council could be spending money in breach and disregard of its procurement duty. There is a risk of unauthorised approval of procurement activity. There is a risk that non-contracted suppliers remain enabled in our purchase to pay systems and are then incorrectly used for further requirements. Some procurement activity does not achieve best value and/or does not align with the council’s Plan for North Lanarkshire. CON0000100 Governance - Corporate Procurement Working Group - comprises a small number of Chief Officers and representatives with interest and skills to review, provide oversight, and assist in strategic decisions on matters pertaining to the council's procurement function. Meets quarterly. CON0000101 General Contract Standing Orders (GCSOs) Contract Standing Orders clearly define procurement roles and responsibilities and set out the procedures to be followed. These are subject to regular review. If there are significant changes these will be subject to consultation with stakeholders P&S, Corporate Procurement Working Group and Procurement Network CON0000108 Demand planning is a required component of the council’s Annual Procurement Report and requires data gathering from procuring service areas on expected regulatory procurements to be undertaken within the next two financial years. The Category Management approach facilities frequent conversations with the key officers in the Services Areas / contributors for this task. CON0000113 Regular Internal and External Audit of procurement activity and procurement related systems. Regular external assessment of procurement capacity and capability via the national Procurement Commercial Improvement Programme (PCIP). CON0000114 Comprehensive continuous procurement improvement plan in place with robust monitoring arrangements. Progress reported into CPWG CON0000914 Monitoring and reporting. Publication of Annual Procurement Report, including performance against a wide range of KPIs. Key Control CON0000915 Regular meetings with Scotland Excel: 1. Quarterly Executive Review between Scotland Excel Chief Executive and the council (Chief Officer (Assets and Procurement) + Procurement and Support Manager); and 2. Quarterly Business Review between Scotland Excel Account Manager and the council (Procurement and Support Manager + Category Managers). CON0002990 Procurement Strategy for the council: the latest revision of the Procurement Strategy was approved March 2025 setting out strategic objectives for procurement, strategy delivery actions and performance measures for financial year 2025-26. The Procurement Strategy is reviewed annually with consultation from the CPWG members. Performance of the Procurement Strategy is monitored and measured through the Annual Procurement Report, which is also presented to committee. Procurement Strategy is high level and provides the direction for all procurement related activities. Procurement Strategy is published on the council website and is shared with Scottish Ministers and Chief Officers. CON0002991 A devolved procurement model exists in the council, comprising category managers and procuring officers, with the predominant remit of leading or supporting Page 170 of 288
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strategic and regulated procurements, and management and maintenance of the council’s procurement registers and procurement toolkit. There is also an extension of officers across the Service Areas with various levels of procurement expertise, predominantly undertaking tactical and/or non- regulated procurement, and often with contract management responsibilities CON0002992 Policy, Procedures and Process: The council has a comprehensive procurement toolkit and supporting procedures, maintained by CPT and mandated through the councils GCSOs. This toolkit is in place to ensure a consistent approach in particular to regulated procurement activity, ensuring compliance with the governance of procurement, the associated general and specific duties, and mitigating procurement related risks. This toolkit should be used for all Regulated procurements, subject to exceptional circumstances. The toolkit is continuously under review and development to keep pace with changes and best practice. CON0002993 Delegated Procurement Authority: A DPA register, managed by CPT, has now replaced the previous Authorised Signatory register, managed by Finance Controls and Recs team, that held procurement permissions of officers across the council. The DPA Register can maintain each officer’s role and permissions (legation); this must be authorised by their Chief Officer. The DPA Register includes the status against the recommended awareness and training requirements for each officer. Where possible, the DPA permissions and levels should be applied within tender systems. Officers should not undertake any procurement activity if they are not assigned the requisite DPA. CON0002994 Financial Authorisation linked to purchase to pay. Authorisation of purchase orders and associated invoice payments. Authorisation maintained by Finance. CON0002995 Multiple systems used to facilitate tendering: Public Contract Scotland (PCS) portal; and (PCS-Tender). While both are considered to be fit for purpose, there is an opportunity to standardise practice and improve reporting and efficiency for the council by using PCS-Tender as the sole tendering system and PCS as the advertising platform this was the intention of the national development of these platforms. CON0002996 Training and skilled staff: Corporate Procurement Team (CPT) all team members have completed National Procurement Development Framework. This will be refreshed annually. New recruits to CPT will have academic qualifications/procurement competency relevant to their job requirements. CON0003047 Communications - Elected Members aware of Procurement activities and their responsibilities. CON0003049 All officers undertaking C&SM roles are aware of their responsibilities and have been provided with appropriate training. CON0003050 Services reminded that key aspects of contract and supplier management are complied with including the need to ensure that robust arrangements are put in place to enable accurate and up to date financial spend management information to be collated and reported to key stakeholders on a timely basis. Page 171 of 288
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SERIOUS ORGANISED CRIME, FRAUD AND CORRUPTION Inherent Likelihood Inherent Impact Inherent score There is a risk that NLC does not take, necessary action to prevent or adequately respond to Serious Organised Crime and other criminal activities. 5 4 20 Residual Likelihood Residual Impact Residual Score 3 3 9 CON0000156 Observe and action the National SOC Strategy known as Divert, Deter, Detect, Disrupt and participate in the tactical subgroups. This will include a questionnaire (prepared from the LA SOC Internal Audit Checklist) and circulated to NLCs SOC Internal Group Members CON0000157 Ongoing involvement in the Serious Organised Crime Multi-Agency Strategic Group (quarterly) CON0000158 Participation in West of Scotland SPOC Group CON0000159 NLC Serious Organised Crime Group Meeting Bi-monthly. NLC policies regularly reviews. SOC, and Cyber Crime session for frontline business Nov 2024. CON0000160 Corporate Procurement Advisory Note which details the introduction to measures in the procurement process to tackle Serious Organised Crime CON0000161 Training and development on good security practice including id badges etc.; in particular targeted at key frontline staff i.e. licensing and registration. CON0000162 Whistleblowing policy - mechanisms to report suspicious activity or behaviour - staff encouraged to report to line managers CON0000163 Scheme of Delegation defines clear reporting lines/responsibilities to avoid conflict of interests CON0000164 NLC Information Security Policy - compliance with policy, prevention of unauthorised access to PCs/laptops/remote devices (Corporate Risk Information Security and Information Governance) CON0000165 Chief Officer's Code of Conduct and disclosure of Chief Officer's conflicts of interests CON0000166 Employee Code of Conduct CON0000167 Councillors' Code of Conduct CON0000168 Liaison with Home Office Enforcement Officers in relation to sham marriages. Co-operative & co-ordinated approach to disclosure of information under section 29 of DPA. CON0000169 Gifts and Hospitality procedures - declaration for all Officers and Elected Members CON0000171 Fidelity Guarantee insurance provides cover for financial loss to specified limit. CON0000172 Through SOLAR, Police Scotland and SPOC Group, intelligence and information in general is shared between the multi agencies. CON0000173 SOC Group plans and corporate risk information evidence good controls which can minimise reputational damage. CON0000659 Document awareness via key staff attendance at the Document Awareness course delivered by Police Scotland. CON0001041 Engagement with Communities through 1/4ly Local Area Partnerships including via Community Matters briefings. CON0001404 NLC is a member of the National Anti-Fraud Network (NAFN), used to keep abreast of current frauds and scams which we risk being subject to. CON0001405 NLC undertake joint investigations with Police Scotland in respect of doorstep crime and intellectual property crime. CON0001406 Training delivered to front line staff with Police Scotland, including Business Gateway, Planning, Building Control, Protective Services and other frontline staff. CON0001516 Recruitment process mitigations include: 1. Identity checks. 2. Employment history - Standard application requests employment history. Contact will be made for current or last employer for reference. 3. Process to check for National and immigration (right to work) status. 4. All applicants complete a Criminal Convictions form, and where regulated employment a Disclosure/PVG will be required. Key Control CON0002888 Insider Threats - Guidance from Police Scotland via SOC Group. Key control is training module across all services which focuses on preventing infiltration by Serous Organised Crime group. Reporting in annual SOC report already in place CON0002889 NLC Website regularly updated re Serious Organised Crime Page 172 of 288
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BUSINESS CONTINUITY PLANNING Inherent Likelihood Inherent Impact Inherent score The council fails to meet expected service delivery standards and/or legislative or statutory requirements and provides a poor response to disruptive external and internal events which result in a loss of people, premise, suppliers or systems e.g. as a result of a pandemic, non- availability of staff and assets, fire, flood, cyber-attack or other failure event (either internally or externally i.e. cloud based). 5 4 20 Residual Likelihood Residual Impact Residual Score 5 3 15 CON0000183 Clear ownership of BCM risk and proven skill set CON0000184 Approved Corporate BCP now in place covering all Council services. Each service has their own Business Continuity Plan. As part of this each area has responsibility for annual testing of their plan(s). Additionally, Resilience Planning unit will seek assurance that this has been undertaken. (IT disaster recovery plan is managed by IT) CON0000185 BCP Champion within each Service is responsible for BCP development through their respective business functions, using standard methodology and documentation, with feedback to Resilience Planning Unit (RPU) and Risk Lead CON0000186 BCP Core Group established, and meeting regularly Chaired by member of the Resilience Planning Unit (RPU) with annual reporting to CMT and relevant Service Committee. CON0000673 Corporate Guidance for Business Continuity in place CON0000836 Corporate annual assurance return framework in place and completed by all Chief Officers; now covering annual testing and review of BCP's. CON0000847 Ongoing review and update of ICT DR & Service BC Plans plus bi-annual testing. Page 173 of 288
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RESILIENCE PLANNING Inherent Likelihood Inherent Impact Inherent score The council fails to meet expected service delivery standards and/or legislative or statutory requirements and provides a poor response to disruptive external and internal events which result in a loss of people, premise, suppliers or systems e.g. as a result of a pandemic, non- availability of staff and assets, fire, flood, cyber-attack or other failure event (either internally or externally i.e. cloud based). 5 5 25 Residual Likelihood Residual Impact Residual Score 2 5 10 CON0000187 Integrated Emergency Management (IEM) Methodology CON0000188 Corporate Resilience Management Team (CRMT) meets 4 times per annum CON0000189 Lanarkshire Local Resilience Partnership (LLRP) meetings chaired by Police Scotland Superintendent, most recently convened for Move to Critical and Severe Weather CON0000190 Regular co-ordinated testing with the other first responders for North Lanarkshire CON0000191 Participation in West of Scotland Regional Resilience Planning Partnership. CON0000192 Airwave Radios, Mobile Telephone Preference Action Scheme (MTPAS) Sims, Out of Hours Directory. CON0000193 Plans are reviewed regularly and when circumstances dictate necessary CON0000194 Training for key participants at council and resiliency partnership level CON0000195 Back up Emergency Response Centre (ERC) is [redacted] CON0000196 Key skilled staff in place CON0000197 Emergency Response Sites have high level of robustness re certain systems, infrastructures etc. CON0000198 Process in place to authorise emergency funding CON0000199 Plans are tested to comply with statutory requirements CON0000200 Council's and individual services' Business Continuity Planning arrangements. Each service has responsibility for their Business Continuity arrangements. CON0003134 Resilience stand by service has now been increased significantly and a further commitment that all newly appointed third tier officers are automatically enrolled in the standby arrangements. Page 174 of 288
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ICT OPERATIONAL CAPACITY Inherent Likelihood Inherent Impact Inherent score ICT Operations may not have the capacity/capability to support the Council and its partners in delivering Services, meeting Strategic Objectives, ensuring secure operations adopting technical innovation and facilitating change. 5 5 25 Residual Likelihood Residual Impact Residual Score 5 4 20 CON0000219 Technical Design Authority, Enterprise Architecture Governance Group and Data Governance Board enable oversight of this risk and associated controls and actions including review of skills and resources required Key Control CON0000220 Implementation of a 3-yearly cadence for publication of a Digital & ICT Strategy. CON0000221 Well established procurement processes enable robust selection of ICT partners CON0000222 Separate ICT DR Plans and Service BC Plans are up to date and there is bi-annual testing of ICT DR & of the Service BC Plans. CON0000223 Robust network design including firewalls, antivirus & antimalware systems and [redacted]. CON0000224 Use of automatic detective and preventative technologies [redacted] CON0000225 Access to ICT by individuals not employed by council is manged through accreditation formal onboarding and vetting process managed by the Council’s ICT function. CON0000226 Information Governance Framework including adherence with Scottish Government Resilience Framework CON0000227 Dedicated resource within ICT focussing on Programme, Change and Security management CON0000228 Corporate Project Management Methodology approach augmented by local PM approaches for specialist areas ensures consistency. CON0000229 Suppliers and contractors being managed appropriately; system exists. CON0000639 ICT operational procedures and guidance, including operations manual and solutions guide for each application. CON0001037 Development of critical friends list which includes PwC and Gartner and also professional memberships and procurement frameworks. CON0001038 Organisation structure regularly reviewed and workforce planning arrangement in place. Key Control CON0001039 Technical library for all solution documentation. Key Control CON0001040 Staff IT security awareness training modules CON0002897 Communications plan across all stakeholders (internal and external) CON0002898 Formalised IT assessments of suppliers Page 175 of 288
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INFORMATION SECURITY AND INFORMATION GOVERNANCE Inherent Likelihood Inherent Impact Inherent score There is a risk that Council data and/or information - including information processing systems - are compromised leading to a reduction of assurance of information confidentiality, integrity or availability. This may be caused by information, in whatever format, not being managed securely or that information governance arrangements across the Council and its ALEOs/partners is ineffective. 5 5 25 Residual Likelihood Residual Impact Residual Score 5 4 20 CON0000230 Appropriate Governance arrangements and groups are established, each with agreed Terms of Reference that are subject to annual review: Data Governance Board (DGB) provides a cross service strategic platform to address information management issues, and ensure lessons learnt from breaches and near misses. The Council’s SIRO chairs the DGB, acting as Executive Sponsor and advocate for the management of information governance at a senior level. Data Management Team (DMT) provides a cross service operational platform to raise compliance awareness, address operational information management issues and focus on ICT Security related compliance, and establish short life sub-groups as required to progress specific tasks. CON0000231 The mandatory post of Data Protection Officer ensures compliance with provisions of the DPA 2018 and UK GDPR on behalf of the council and its ALEOs. CON0000233 The framework of policies supporting the Digital and IT Strategy (i.e. Data Protection Policy, Payment Card Data Security Policy, Information Security Policy, Acceptable Use of IT Policy (and guidance), Records and Information Management Policy, and Records Management Plan) are well established in terms of ensuring the council has a suite of information governance policies to ensure that the council’s approach to data is effective and compliant in relation to data governance and the arrangements required to ensure effective arrangements are in place for the safe and secure collection, storage, use, and sharing of data, including processes to safeguard personal data and support data quality. Governed by the Data Governance Board, all policies (except the Records Management Plan) are reviewed every two years. In respect of the Records Management Plan, the council is not the keeper of this, and the council are informed when they are required to update this. In the meantime, the council does undertake an interim internal review each year. CON0000235 Information Governance/Security training and communications framework in place including mandatory e-learning courses for all staff in respect of Data Protection Act 2018 to be completed bi-ennially. Data Protection Essentials Information Security Awareness Records and Information Management. Data Protection Advanced (for staff who manage people and staff who regularly handle personal or sensitive information) These were developed by the DMT into toolbox training for non office-based staff. Compliance is monitored via DMT and reported quarterly via KPIs to Data Governance Board. Compliance is also monitored monthly through service management teams. CON0000237 The Records Manager acts as a consultant on all records and information compliance matters. CON0000238 Records Management Plan as required by the Public Records (Scotland) Act 2011 is in place. This includes ongoing review of records management plan in light of Public Records (Scotland) Act 2011. CON0000239 The Information Assets Register covers all mediums and identifies information asset owners and administrators. Access is regularly reviewed, controlled and monitored via the DMT. It will be moved to a new platform following audits to determine best mechanism and purpose reviewed in light of changes to management of data within the Council. CON0000240 Records retention schedule gives clear guidance to staff on the management and disposal of all formats of information CON0000241 Collaboration and communication tools for use on collaborative work and projects across services maintains confidentiality and security to small groups including deployment of new digital packages such as Microsoft Teams. CON0000242 Confidential wastepaper securely stored, removed and disposed of under a corporate shredding contract CON0000637 Information Risk Manager acts as an internal consultant for all information security compliance matters CON0000735 Corporate SARS recording and reporting process with associated guidance in place and communicated to relevant staff. Includes guidance on redaction and use Page 176 of 288
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of adobe acrobat pro redaction tool with services to ensure they have appropriate number of licences for use. CON0000848 Enterprise Architecture Governance Group ensures all technology proposals presented by Services comply with the mandatory Data Principles, with DP04 in particular focusing on protection of data from unauthorised use, disclosure or change. Key Control CON0000849 Annual PSN Compliance process Key Control CON0001383 Corporate and Service Business Continuity Plans in place and ongoing stress tested to inform priorities and decision making. CON0001384 Data Protection Policy confirms to services the requirement to have third party processing agreements in place where data processors have been engaged. CON0001385 Data Protection Policy confirms to services the requirement to have data sharing agreements in place where systematic and ad hoc data sharing is taking place with third parties. CON0001386 Secured Premises with secure storage and monitoring of security arrangements. CON0001477 To preserve records contained within it, the Corporate Records Stores have CCTV, Disaster Recovery Plan, Fire Evacuation Plan, security checks during building closures, fire and intruder alarms, fire doors, shelving in accordance with BSI guidelines, pest monitoring, temperature and humidity monitoring, boxing of all records, archival enclosures for records, reduction of UV light. Key Control CON0002050 Performance indicators are in place (approved by DGB) and reported quarterly. These allow performance to be measured and areas for improvement to be identified in respect of providing the DGB (and the council) with the relevant assurances in respect of data governance. An exercise is underway to review these indicators to ensure they remain fit for purpose in line with the DGBs updated terms of reference. CON0002051 A one council approach to data will unlock the potential of data to support delivery of The Plan for North Lanarkshire and Programme of Work by ensuring an accessible and single source approach to data that supports the organisation by providing insights and evidence that support decision making, planning, delivery, and continuous improvement as well as public reporting and transparency. CON0002060 PROTECTIVE Technical Cyber Controls: [redacted] CON0002061 DETECTIVE technical cyber controls: [redacted] CON0002062 RESPONSIVE Technical Cyber Controls: [redacted] CON0002063 RECOVERY Technical Cyber Controls: [redacted] CON0002070 Register of Data Processing Agreements, Data Sharing Agreements and Data Protection Impact Assessments is in place. Register is not fully up to date. DPAs, DSAs are recorded individually within Teams Channels. Further work will be carried out as part of the Corporate Data Protection Review. CON0002071 Software Asset Management process incorporated into the ITSM platform and informed by our Microsoft cloud management suite. This option chosen as more cost effective when compared to findings from the pilot Software Asset Management solution. CON0002417 Employee Service Centre processes are in place for managing overarching joiners/movers/leavers processes for employees, particularly with respect to relevant pre-employment check for new starts. CON0003158 Chief Officer Legal & Democratic is responsible for (SIRO role) and reports on Information Security and Data Protection at a Corporate Management Level Page 177 of 288
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DIGITAL AND IT STRATEGY Inherent Likelihood Inherent Impact Inherent score There is a risk that the Digital and IT Strategy, and the inherent technology and its replacement (and deployment of the replacement) cannot or does not sufficiently support the council in delivering the long-term vision and ambitions for digital community, digital economy and digital council (including the digital ambition) set out within 'The Plan for North Lanarkshire', or that it fails to keep pace with market change. 4 5 20 Residual Likelihood Residual Impact Residual Score 4 3 12 CON0000245 Maintenance of strategic relationships with selected suppliers. CON0000246 Contract Supplier monitoring and management arrangements in place to ensure delivery operates CON0000247 Enterprise Architecture Governance Board (EAGB), Data Governance Board (DGB) and Technical Design Authority (TDA) ensures and promotes a culture of governance that promotes the use of standards, principles and gated approvals where appropriate to ensure good financial management and resource usage in line with The Plan for North Lanarkshire. CON0000248 Corporate Project Management methodology and guidance ensures strong business cases are developed for the procurement of suitable technology. CON0000249 Ensure corporate procurement engagement and relationship facilitates effective route to market. CON0000250 Centralised control and/or monitoring of IT purchases, maintaining awareness on requirement and volumetric spends. CON0000650 Digital & IT Strategy documented, approved and reviewed for relevance on an annual basis. CON0000947 Digital vision, ambition and key principles approved by elected members Key Control CON0000948 ICT Digital roadmap and approved capital budget (2021 - 2026) Key Control CON0002096 Resource Planning - ensure appropriate processes are in place effectively deliver, monitor and report the categorisation, prioritisation and of work to resource plan. CON0002097 Skills Capability - Processes are in place to assess, forecast and monitor changing skill requirements, and that budgetary management is in place to accommodate. Skills matrix prepared and reviewed in line with Digital and IT Strategy. The Year 2 Workforce for the Future Plan has been submitted and takes cognisance of skills and aging demographics within the service CON0002895 Approval of Revised Digital & IT Strategy for period to 2027 at P&S 14 March 2024 Page 178 of 288
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TERRORISM Inherent Likelihood Inherent Impact Inherent score NLC fails to plan, prepare and therefore protect its employees, elected members, the public and communities. NLC fails to engage with the awareness provided by the UK Government, fails to provide a co-ordinated approach and fails to contribute to counter terrorism initiatives with partner agencies. 3 5 15 Residual Likelihood Residual Impact Residual Score 3 5 15 CON0000269 Observe and action the National Contest Strategy known as Protect, Prevent, Prepare and Pursue CON0000270 Participation in the tactical subgroups CON0000271 Ongoing involvement and quarterly meetings with Lanarkshire Multi-agency Strategy Group, dealing with counter terrorism. CON0000272 Buildings Security Protocol - arrangements at all NLC Properties [redacted] CON0000273 Counter Terrorism Group co-ordinates NLC approach CON0000274 Annual Insurer audits looking at fire and general security of selected high value buildings. CON0000275 Terrorism Insurance mitigates financial impacts of an event on council property assets. CON0000277 PREVENT - E&F risk based and targeted approach training for Head Teachers/Deputes with lead child protection responsibilities, assisted by Police Scotland. CON0000278 Emergency Plans through Events Management Plans for large scale events through SAG. CON0000640 Staff can report suspicious activity by using links on Connect (red button) together with a programme of awareness through Corporate Communications. CON0000641 "PREVENT" online training module has been developed and rolled out to staff. CON0000642 Communities’ engagement through Local Area Partnerships including via Community Matters briefings. CON0000643 Business Community engagement improves resilience and awareness through Business events and provision of information. This includes training for front line staff delivered by Police Scotland. CON0000644 Annual report to CMT then to P&S CON0001772 Public Partners aware of responsibilities how to comply communicated by NLC. This includes, letting or sub-letting property to a terrorist organisation and also holding community events. CON0001773 Adherence with New Protect Duty CON0002890 On-going engagement and participation with partners and multi agencies in scenario planning and training exercises (such as Safe Steeple). CON0002891 Martyn’s Law (Protect Duty) guidance and actions and compliance. CON0002892 Insider Threat Controls Training module developed from Police Scotland guidance. Engagement with services underway for module preparation and launch. CON0002893 Mobile App roll out on every council device. CON0003271 Awareness Third Sector and Faith Groups - To raise awareness of pertinent issues in relation to Counter Terrorism and encourage 2-way communication that is relevant and regular engagement with third sector and faith groups. Various delivery methods are used to maximise awareness & effectiveness, and these include (but not restricted to) - Interaction with community boards, Sharing information through established arrangements and at community board meetings CON0003272 Awareness Education, Children and Students: To raise awareness of pertinent issues in relation to Counter Terrorism and encourage 2-way communication that is relevant and regular engagement with Council and across North Lanarkshire with - Independent schools, Parent Councils, Independent childcare settings. Various delivery methods are used to maximise awareness effectiveness and these include (but not restricted to) - Weekly Education & Families bulletin, Parent Council and Parent Consultative Group meetings, Child Protection Committee, Head Teacher conferences. Page 179 of 288
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ENGAGEMENT AND CONSULTATION Inherent Likelihood Inherent Impact Inherent score NLC does not appropriately engage and consult with communities, partners and stakeholders in the shaping and delivery of services. 4 4 16 Residual Likelihood Residual Impact Residual Score 3 3 9 CON0000707 Corporate Community Ownership and Management Working Group and Leadership Group in place CON0000708 Working with Communities framework reviewed and updated CON0000709 Annual Reporting to Communities Committee, NLP Board and annual community empowerment report to communities under the terms of the Community Empowerment Act. CON0000710 Community Ownership panel and leadership Group to assess and make recommendations on CAT and Participation Requests CON0000711 New Community Ownership and Management of Assets policy approved June 2024 with implementation plan to streamline and improve approaches CON0000712 Charitable Leasing process included in new Community Ownership and Management of Assets policy approved June 2024. CON0000713 Specialised training including awareness of the approach, so that members, Council and partnership employees are equipped and supported to deliver. Training delivered re CAT, PB, LDP and also included within training portal. Community Co-ordinators are now in post in 9 community board areas. Further sessions planned on an ongoing basis CON0000714 Digital capability - via Digital NL digital solutions for communities. The Digital Inclusion Team ensuring community need is met and that digital capacity is available. Driving Digital locally agenda and work to establish local community led subgroups. Digital inclusion action emerging through development of the LOIPs CON0000715 Launch and campaign developed by Head of Communities, Head of Strategic Communications and Head of Asset and Procurement Solutions on Working with Communities operating model. Will include review changes to approach where deemed appropriate. Mainstream PB approach has been implemented across relevant services, and the position is reported annually to CoSLA and Scottish Govt. CON0002843 Participation in National Community Planning Authority which has all Scottish Local Authorities and Scottish Government. Allows identification and implementation of best practices and assists in adherence with regulations CON0002844 Participation in National PB officers Group, Community Safety Network, Nation Play Facilities Working Group, allows identification, sharing and implementation of best practice and assists in compliance with legislation, formal agreements and regulations CON0003168 Additional staff now in place (x2 full time posts) to focus on building capacity of local organisations to take on an asset CON0003169 Capital resources now available to groups submitting a successful application to take on an asset Page 180 of 288
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TACKLING POVERTY Inherent Likelihood Inherent Impact Inherent score There is a risk that North Lanarkshire Council does not contribute to reducing poverty in North Lanarkshire through failure to identify, manage, monitor and reduce the causes and effects of inequality and poverty in NL, we do not improve the lives of people in North Lanarkshire, or that we inadvertently take decisions or introduce policy that has unintended consequences. 5 5 25 Residual Likelihood Residual Impact Residual Score 5 4 20 CON0000717 Tackling Poverty Strategy/Annual Child Poverty Action Plan CON0000718 Resilient People Board along with the Wellbeing and Tackling Poverty Committee have oversight of the Council’s approach and strategy in this area. Replaces. The previous Tackling Poverty Board has been stood down following the announcement of the new Programme of Work 2028, by the CE and Council. The Tackling Poverty Board has been replaced by the Resilient People Board, which is chaired by Chief Social Work Officer, this Board will carry on with the role of the Tackling Poverty Board in line with the new PoW and work with the TPOAG to deliver the Tackling Poverty Strategy and LCPAR and the associated Action Plans. This approach offers the opportunity for a more integrated approach embedding and connecting work in support of the strategy and action plan with other key elements of the Councils POW with the intention of maximising impact. CON0000719 Tackling Poverty Officers Action Group with agreed terms of reference (inc IJB) CON0000720 Welfare Reform Officer's Group with agreed terms of reference (Inc IJB) CON0000721 Local Child Poverty Action annual report sets out proposal to support government to reduce targets CON0000722 Commitment to deliver the overall arching Tackling Poverty Strategy aligned with The Plan for North Lanarkshire and the Programme of Work. CON0000723 Multi-agency engagement and training developed, including on-line training to all partners involved in tackling poverty. Training delivered including via e-learning to key functions within NLC, NHS and Third Sectors. Maintains staff awareness. CON0000724 Tackling Poverty Officers AG Funding subgroup - will monitor the need and opportunities for Funding (internal/ external) and submit and ensure adherence with grant conditions. CON0000725 Food Poverty Working Group - Implement North Lanarkshire Council's Food Poverty Framework CON0000727 SAC and PEF funding and initiatives CON0000728 Council's Employability Programme including Supported Enterprise. Delivering support to unemployed residents including those who have recently been made redundant. CON0000729 Financial Inclusion Team provides advice, information and support to residents and support internal client facing services e.g. HSC, Housing and has been commissioned to provide a Cost-of-Living Helpline on behalf of the Council, funded by the IJB. CON0000730 NLC funds external services to provide information to reduce impact of poverty including welfare reform changes (inc CAB) CON0000731 Monitoring and reducing the level of rent arrears CON0000732 Maximising and monitoring of council income (housing benefit and council tax reduction scheme) CON0001423 Suicide prevention North Lanarkshire campaign. CON0001425 Financial Insecurity/Flexible budget which is to assist residents and groups who are adversely impacted by poverty (including significant shock events such as Covid-19, EU Exit, Cost of Living Crisis) CON0002920 Identified and agreed Tackling Poverty Drivers which are aligned to Tackling Poverty Strategy Page 181 of 288
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GOVERNANCE, LEADERSHIP AND DECISION MAKING Inherent Likelihood Inherent Impact Inherent score There is a risk that the council's governance arrangements will be impaired and/or unable to deliver on the shared ambition set out in The Plan for North Lanarkshire and associated Programme of Work and/or deliver best value services and/or financial sustainability while effectively fulfilling its governance and public accountability duties. 5 5 25 Residual Likelihood Residual Impact Residual Score 3 4 12 CON0000737 Development and approval of The Plan for North Lanarkshire CON0000739 Five complementary frameworks in place to support The Plan for North Lanarkshire and Programme of Work (Strategic Policy Framework, Strategic Performance framework including public performance reporting, Strategic Self-evaluation framework, Strategic Governance framework, Project Management Model) CON0000743 Code of Conduct for Elected Members. CON0000744 Code of Conduct for Chief Officers CON0000745 Code of Conduct for Employees supported by appropriate training programmes (highlighted in letter of employment, induction and disseminated via Intranet.) CON0000746 Scheme of Delegation (subject to annual review) and Scheme of Administration (reviewed as and when required) CON0000747 Financial Regulations and financial procedures CON0000748 Standing Orders amendments now means that Members have earlier sight of key committee reports ensuring longer oversight. CON0000749 Regular engagement between the Chief Executive & Members/political groups. Register of Members requests for officer attendance at political group meetings. CON0000750 Monitoring Officer Role provides oversight of conduct and enables management intervention when required. CON0000751 Whistleblowing Policy CON0000752 Corporate Risk Management arrangements CON0000754 Reporting - Officers skilled in producing a consistent quality level of reporting. Reporting template and guidance updated and implemented. CON0000756 Council staff resources, skills and numbers, aligned with the Plan CON0001042 Elected Member training programme via LearnNL (Elected Members Toolkit) CON0001456 Annual review and update of the Programme of Work is undertaken to provide Members with a composite overview of progress to date, along with the future roadmap to ensure strategy remains connected to delivery and the Programme of Work enables the ongoing delivery of projects, activities, and services in support of The Plan for North Lanarkshire. Key Control CON0001459 Strategy & Performance Manager post oversees the four supporting frameworks and project management model into one strategic support for business strategy and governance. Regular reporting on the supporting frameworks to elected members. Key Control CON0001460 Restructured Corporate Management Team to create a single integrated corporate forum including all Heads of Service, with revised Terms of Reference including strategic oversight of the Programme of Work and Delivering for Communities, and clear linkages to cascade and communicate with Service's SMTs and wider Operational Management Team (OMT) on a formal and regular basis. Key relevant areas of activity are - To develop, monitor and provide oversight of the activities and policies of the council. To maintain strategic oversight and direction of the council's Programme of work and The Plan for North Lanarkshire. To maintain strategic oversight of corporate governance arrangements. CON0001512 Annual Governance Statement (AGS) informed by (a) assurances provided by all Heads of Service to the Chief Executive that they have considered the corporate governance arrangements and the standard of internal financial controls in their area of responsibility and to the best of their knowledge, these have been, and are, working well and there are, in their opinion, no significant matters arising which would require to be raised specifically, and (b) an annual review for ensuring ongoing effectiveness of the council's governance arrangements. The AGS is signed off by the Chief Executive and the Leader, and included in the annual accounts in line with the Local Authority Accounting (Scotland) Regulations. Key Control Page 182 of 288
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CLIMATE CHANGE Inherent Likelihood Inherent Impact Inherent score There is a risk that NLC fails to positively contribute to the protection and development of a sustainable environment within North Lanarkshire, whilst mitigating further harm right now; NLC fails to become climate resilient. That we do not comply with legal obligations under the climate Change (Scotland) Act 2009 and related regulatory and legislative activities; We fail to identify and access other opportunities including grants that can maximise the benefits for the council and people of North Lanarkshire. 5 4 20 Residual Likelihood Residual Impact Residual Score 5 4 20 CON0000757 Revised Climate Plan which is strategy, boundaries, Leadership and governance. Will also include all deliverable key actions and revised delivery dates CON0000758 Active Travel and Access Strategy. Temporary owner and to re reassigned CON0000759 Air Quality Strategy CON0000762 Contaminated Land Strategy CON0000764 Food Growing Strategy (2021 - 2025) (Review Autumn 2025) CON0000768 Climate Change Governance continually reviewed and adapted to ensure effective and appropriate oversight. CON0000770 Procurement sustainability aspects required of suppliers through the Sustainable Procurement Duty. This is continually reviewed and enhanced. CON0000771 Flood risk management arrangements. This is continually reviewed and enhanced. CON0000772 Internal governance is supported and informed through membership of external forums e.g. Sustainable Scotland Network; Climate Ready Clyde; COSLA CON0000773 Clyde Valley Residual Waste Contract CON0000774 Assets review and rationalisation across NLC. CON0000775 Environmental Assets rationalised to ensure best use. CON0000776 Communications to residents and businesses across North Lanarkshire via social media channels etc to raise awareness and encourage action. The council have created and maintain their dedicated climate web pages CON0000777 Climate change effectively embedded into the Councils decision-making processes including project management, Climate Change Impact Assessments. CON0000778 Knowledge and awareness skills across senior managers and elected members CON0000779 Local Housing Strategy includes actions to address climate change issues. CON0000780 NLC staff resources and skill sets aligned with the strategic requirements of Climate Change activities. CON0000889 Through the continued review of the Councils Fleet, we will ensure that all vehicles purchased are in compliance with the most efficient vehicle emission standards and will also continue to increase the number of electric vehicles. CON0000893 Reporting to Internal and External parties CON0000911 Use of Building Energy Management Systems includes annual review of buildings performance across the estate; includes schools & corporate offices. CON0000912 Optimise external funding opportunities across broad range of climate related activities- energy savings projects, tree planting, EV charging, fleet changes CON0000913 LED street lighting CON0002598 Council will look to engage external partner to enhance access to low carbon fuel sources for vehicles across the Council area (EV charging & Hydrogen) CON0002600 In partnership with Scottish Power Energy Retail the Council will determine the feasibility to deliver an Eco Hub facility at the Bellshill depot site. CON0002601 Biodiversity Action Plan CON0003142 Polices conform with latest requirements including any regulatory amendments (via Climate View) CON0003143 Non-Domestic Energy Efficiency (NDEE) implemented across NLC Council Property (not housing) and School estate. CON0003274 Investigate the potential for a private/public partnership proposal to establish the best approach to deliver the Eco Hub at Bellshill Page 183 of 288
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POWER RESILIENCE (BLACK START) Inherent Likelihood Inherent Impact Inherent score NLC have inadequate arrangements in the event of complete failure of the national electricity grid. 5 5 25 Residual Likelihood Residual Impact Residual Score 4 5 20 CON0002444 Additional funding capital and revenue to support strategy implementation CON0002445 Liaison with all external partners though the Lanarkshire Multi Agency Co-Ordination Centre (MACC) located at the Police Scotland Offices, Windmillhill Street. CON0002446 Communication to General Public to provide reassurance that the event is being effectively managed to prevent/ limit social unrest. CON0002447 Communication arrangements to Members of the PRMT and operational support CON0002448 Communication arrangements to Strategic Partners - Police Scotland, NHS Lanarkshire etc. CON0002449 Volunteers from selected services across NLC provide assistance in delivering the Power resilience Plan CON0002450 Essential new equipment for delivery of Power Resilience Strategy, mobile generators, satellite radios, notice boards and various items for community organisations. CON0002451 Chief Officers buy in to Strategy CON0002543 Develop appropriate Power Resilience Strategy which will outline details of the Council response in the event of any Black Start event which will be targeted towards the preservation of life. CON0002544 Recovery time objectives for critical activities are included in BCP. CON0002545 Exercises relevant to Black Start to be delivered by Resilience Team. Page 184 of 288
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IMPROVING EDUCATIONAL OUTCOMES Inherent Likelihood Inherent Impact Inherent score There is a risk that current strategies and approaches do not improve attainment and achievement levels and reduce the poverty related attainment gap. (Excellence and Equity). 4 4 16 Residual Likelihood Residual Impact Residual Score 4 4 16 CON0002475 There is an overall SAC Plan which encompasses the strategy and outlines related initiatives to improve attainment and reduce the poverty related attainment gap with North Lanarkshire. This plan is informed by relevant research and has on-going monitoring built in to ensure best practice (new initiatives) will be incorporated into this plan. Ongoing engagement with the Attainment advisor who acts as the conduit between Scottish Government and the Local Authority CON0002476 Targeted allocation of additional staff. Clear processes in place to deploy additional staffing (via PEF and SAC funding) to provide additional support to improve outcomes and reduce poverty related attainment gap and impact of the pandemic. CON0002477 Implementation of refreshed quality assurance, planning and reporting processes to ensure a clear focus on self-evaluation and improvement, at all levels, complemented by proportionate arrangements for external scrutiny/quality assurance. (Validated self-evaluation processes). Regular progress reports provided to internal and external stakeholders including CMT, Elected Members and Scottish Government (financial and performance information). CON0002478 Creation and use of toolkits and processes that facilitate the effective interrogation, analysis and use of data to identify, track and monitor progress and to identify areas for improvement. This enables Head Teachers to identify individuals impacted by poverty and to quantify their attainment gap. A new service level data dashboard is in place using power BI. This will support head teachers to use data more effectively to inform improvement planning to raise attainment. CON0002479 Support all establishments to make effective use of these toolkits to identify, plan and deliver appropriate interventions and track and report on the impact of interventions in improving attainment, closing the poverty related attainment gap and meeting stretch aims. . CON0002480 Clear structure to drive and support curricular review including Develop the Young Workforce, Pathways programme and Curriculum Toolkit to reflect CFE core components and aspirations. There is on-going involvement in Inter authority networks to develop common strategies and to share approaches and prepare for outcomes of National Conversation. (ES, WP, ADES). New DYW strategy approved at Committee in Sept. 2025. This strategy outlines NLs approach to support all learners to achieve a positive post school destination. CON0002481 Establishment of networks and partnerships to improve outcomes for children and families (Empowering Our Clusters Model) West Partnership, Family Groups. Engagement in West Partnership workstreams will be reviewed in session 24/25 to maximise impact of involvement to maximise opportunities for collaborative improvement activity. Groups further reviewed in Sept. 2025 to better align participation with new strategic remits and staff available through the new service operating model. Notably, whilst the central team structure has increased, the SAC team has reduced - duties being prioritised and re-aligned to maximise impact. CON0002482 Interaction with the Tackling Poverty Officers Action Group to align support for identified children and families and address council priorities in relation to tackling poverty. Introduction of specific support for families whose children attend our ASN establishments, funded collectively through PEF. Continue to measure and report on the impact of this targeted support. CON0002483 Ongoing Recruitment campaigns for teachers and other key staff CON0002484 Establishment of policies and procedures designed to remove barriers and ensure all children and families have equal access to learning experiences e.g. Poverty Proofing Policies, Processes for Digital access, Parental engagement/family support policies. CON0002485 Ongoing engagement with Elected Members Page 185 of 288
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DIGITAL ADOPTION Inherent Likelihood Inherent Impact Inherent score That despite very considerable investment in new digital technology across the Council there is a risk that the organisation fails to create the right conditions for successful digital adoption across our employees and ultimately our service users. 5 4 20 Residual Likelihood Residual Impact Residual Score 4 4 16 CON0002796 Use of the council's strategic capital planning process to bid for fund for implementing technical solutions CON0002797 Strategic workforce plan that frequently considers the roles and requirements of the organisations and adapts as required. Details of all workforce planning initiatives are captured within the career pathways model. CON0002798 POW Digital North Lanarkshire - The sub-group tasked with developing and supporting a digital culture within the organisation has developed controls to both support and promote the adoption of digital technologies. Includes Digital, Culture, Knowledge and Leadership subgroups. Gartner were engaged on developing this control. CON0002799 PoW One Service - The sub-group tasked with developing and supporting workforce and culture within the organisation will develop controls to both support and promote the adoption of digital technologies. Includes workforce and culture sub-groups. CON0002868 Digital and IT strategy for 2024 to 2027 which aligns with organisational objectives supported across all stakeholders. Formal approval being at P&S 14 March 2024. CON0002869 Communications plan across all stakeholders (internal and external) CON0002870 An evolving Training and development plan both for all of organisation with training programmes for each user group CON0002871 Monitoring and reporting of uptake and advice to those not using the new technology/processes relevant to above. This will provide input to amending communications, training and development. Reporting framework in place via the PoW reporting schedule. Reporting to Finance and Resources committee in cycle 1. Monitoring via the Digital Culture, Knowledge and Leadership Group (every 4 weeks). CON0002872 New Change Management Framework which compliments the control Digital and IT Strategy CON0002873 Data Governance Board provides oversight in controls over the data from new digital processes. Controlling data in addition to new digital processes CON0003243 Implementation of Digital Culture Leadership and Knowledge action plan. Activities detailed until March 2026 and includes review of effectiveness, additional corrective tasks and also planning for further years. Page 186 of 288
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HOME SUPPORT SERVICE DELIVERY/SUSTAINABILITY Inherent Likelihood Inherent Impact Inherent score There is a risk that the council will be unable to provide adequate levels of Home Support to service users in North Lanarkshire. 5 5 25 Residual Likelihood Residual Impact Residual Score 4 5 20 CON0002735 Attendance Monitoring and Attendance Improvement Staffing levels and absences daily monitoring of locality teams to ensure sufficient skilled staff. Absence levels are entered in mySWIS and iTrent. These systems do not transfer this info to each other and requires double input. From Nov 2023 reports run to compare and now part of monthly monitoring process. Support and Attendance Team to support management team in the focus on reducing attendance absence CON0002737 Independent Home care Providers provide capacity to release in-house staff to focus on reablement CON0002738 Recruit in-house staff expressing interest to move to HAT CON0002739 Home Support Redesign of processes CON0002742 Staff training plans adhere with Care Inspectorate requirements CON0002743 New system for managing Home Support - Dynamic Scheduling Tool. Statement of Requirements and Tender for new system overseen by the Enterprise & Architecture Governance Group. Procurement of dynamic scheduling tool approved via delegated authority on 13 March. Implementation on-going position and escalation to Dynamic Scheduling Tool CM 2000 Project Board. DST will provide evidence for review of pool cars CON0002744 System (existing) to manage Home Support and includes "Hot phones". This system is to be replaced. CON0002745 Pool Cars sufficient to meet Home Support requirements and to have secure parking for them. CON0002746 Ensure that all Home Support chargeable visits are valid and appropriate use of financial resources CON0002747 Implementation of Supporting Attendance Policy CON0002748 Suitable numbers of appropriately trained staff. Home Assessment Team which to enable people to be supported to return home for the period of assessment. Living Well Service and staff to support people to remain at home previously called Longer Term Service Team. Reablement Team fully skilled and consistency best practice across all localities CON0002752 Complaints process in place. Includes regular reporting and escalation CON0003052 Living Well at Home (previously called Longer Term Service Team.) at full establishment Feb 2025. As and when vacancies occur recruitment will be undertaken. CON0003123 New NLC telephony system which will restore the number of phone lines back up to the number required CON0003124 Savings required over two years Page 187 of 288
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RAAC Inherent Likelihood Inherent Impact Inherent score Inability to manage the RAAC issue across NLC. This includes corporate and residential properties owned by NLC and individuals and families that are impacted 5 5 25 Residual Likelihood Residual Impact Residual Score 3 4 12 CON0003077 Working Group consisting of Chief Officers for Asset & Procurement Solutions and Housing Management and representatives from relevant functions is managing and co-ordinating actions. CON0003078 Regular Reporting to Policy and Strategy Committee, Housing Committee and CMT CON0003079 Internal process for residential property which aligns broadly with the Institute of Structural Engineers as limited guidance from UK/Scottish Governments CON0003080 Internal processes for corporate properties, which align broadly with the Institute of Structural Engineers, as limited guidance from UK/Scottish Governments CON0003081 Identification Desk Top exercise to rule in/ out properties across NLC’s corporate establishments and across the council’s housing ongoing. CON0003082 External specialist consulting structural engineer has been appointed to support RAAC work. Consultant will now look to undertake the following: Identify and classify RAAC presence. Prepare route map and prioritised action plan including estimated costs for remedial actions. Prepare recommendation and design inputs. CON0003083 Dialogue with tenants and residents potentially affected by this issue. Communications supported by corporate communications team. Tenants and residents given advanced notice of the reasons for the surveys and potential impacts or next steps and communications seeks to reduce disruption and worry for tenants re comms letter to owner occupiers. Suite of letters prepared. CON0003084 Corporate communications monitor any involvement in MSM articles and Social Media posts CON0003085 Funding Budget agreed to date - funded from Housing Revenue Account (HRA) Budgetary allowance but overall position cannot yet be determined for residential. Corporate property from Capital Programme. Will require further budgetary approval as and when there is a greater understanding actions and costs. CON0003086 Closure of corporate property of part of it when deemed necessary CON0003087 Closure and decant of tenants it deemed necessary ongoing none yet evacuated. CON0003088 Decant and rehouse tenants who have been evacuated (properties not always available in preferred area.) CON0003089 Open Market Purchase Scheme (OMPS) activities. New process implemented. Initial check, based on information held, is carried out before a survey of the property being considered is instructed. This new approach will provide the New Supply team with information to inform their decision on whether they will look to proceed with the survey and ultimately purchase of the property Implemented CON0003090 Advice from Kings Council guidance obtained on council liability especially on properties purchased under right to buy CON0003091 Peer review on works undertaken held with West Lothian Corporate Side CON0003092 Interim arrangements in place for entertainment events across North Lanarkshire CON0003093 Future location(s) for entertainment events in Motherwell this includes decision on Motherwell Theatre CON0003094 Staff aware of RAAC CON0003095 Group Insurance position clarified. [redacted] CON0003096 Provide information relating to Freedom of Information Request via Legal Services CON0003170 Compliance with Historic Scotland position on Motherwell Theatre CON0003234 Grant Scheme agreed and approved for owner occupiers of property that had been part of NLC residential estate CON0003235 Approved Protocol for dealing with RAAC across North Lanarkshire Properties (ALEO) Estate. Page 188 of 288
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DELIVERY OF THE APPROVED PROGRAMME OF WORK Inherent Likelihood Inherent Impact Inherent score There is a risk that the council will be unable to deliver the Programme of Work to 2028 in line with the supporting Single Integrated One Council Delivery Plan. 3 4 12 Residual Likelihood Residual Impact Residual Score 2 4 8 CON0003260 The existing senior management structure of the council (e.g. CMT / BMT / SMTs), which has been in place since January 2023, provides strategic oversight at various levels across the organisation with each having a distinct focus on an aspect of delivering the Programme of Work inter alia. CON0003261 As per the Scheme of Administration, the Policy and Strategy Committee have a key role to play to ensure the continuing commitment to delivering The Plan for North Lanarkshire through the Programme of Work and ensuring strategic oversight in terms of its ongoing development, co-ordination, and monitoring. As such, the Committee have ongoing oversight of related Programme of Work reports (i.e. that look back at the achievements to date, that review the current North Lanarkshire context, and that look forward at future plans) which are presented for due consideration in cycle 1 each year. CON0003262 To further enable the Policy and Strategy Committee to maintain their strategic oversight role of the overall Programme of Work to 2028 in relation to development, co-ordination, and monitoring of The Plan for North Lanarkshire and to keep under review such programmes as the Committee considers necessary to achieve the councils long-term aims and objectives, a six monthly update report on delivery of the Programme of Work is presented for due consideration in cycle 3 each year. CON0003263 The seven Programmes of Work are supported by six Programme of Work Strategic Boards whose role is to maintain a big picture focus on ensuring the Programme of Work (i.e. the collective portfolio of supporting programmes, projects, and activities) is developed and delivered in a way that ensures ongoing alignment to the councils vision of inclusive growth and prosperity for all (as set out in The Plan for North Lanarkshire). These Boards act as a bridge between the policy direction set out by the Programme of Work and its delivery by providing the strategic direction for delivery of the Programme of Work. In doing so, each Board provides the overall direction, leadership, and senior management overview of all priority projects and activities considered essential to achieving its critical success factors. All Boards have a Terms of Reference. CON0003264 A Senior Responsible Officer (SRO) (i.e. a Chief Officer and member of the councils Corporate Management Team) is responsible for delivery of each Programme of Work and for chairing the Programme of Work strategic Boards. Each Board also has a depute Chair and other Chief Officers who are core members of the Board and have decision making roles. CON0003265 A single integrated one council Delivery Plan has been implemented from April 2024 to enable ongoing monitoring of Programme of Work delivery throughout its lifespan. A schedule of regular monitoring and reporting is in place in respect of all stakeholder audiences to ensure ongoing oversight throughout the lifecycle of the Plan. CON0003266 The Delivery Plan is supported by a Reporting Schedule for each Board which sets out reports to committee to enable Elected Members oversight at service committee in respect of operational delivery and for them to carry out scrutiny in line with their role as set out in the Scheme of Administration. CON0003267 A regular review process will continue to support the Programme of Work to 2028. This will ensure the council continues to (a) be able to adapt the Delivery Plan to changing circumstances, (b) absorb the impact of major unpredictable situations in order to keep plans relevant and the timescales therein realistic, and (c) assess incremental changes and impacts arising from updates to the results for the 28 Health Check Indicators. Page 189 of 288
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ENTERPRISE CONTRACT MANAGEMENT Inherent Likelihood Inherent Impact Inherent score NLC is unable to or to fully realise the ambitions for the phased approach to delivery of the Enterprise Contracts as the agreed approach for delivering significant additional value that feeds into the wider economic growth ambitions. These include enhanced social value, comprehensive asset maintenance and life cycle management and the linking of all related service activities and contracts together to enable strategic development, interconnected end to end delivery and programming of investment priorities. 4 5 20 Residual Likelihood Residual Impact Residual Score 2 5 10 CON0003275 Contract Performance and Assurance Team with suitable level of skills in place and responsible for contract governance and assurance and instructing all parties on deliverables. CON0003276 Elected Member and Senior Management Team scheduled reporting in place. CON0003277 Contingency Planning which can be enacted in response to market or supplier failure at any stage during the contract life cycles. This has identified alternative routes to market and also contained within service contingency plans. Financial review of suppliers carried out on an annual basis. CON0003278 Social Value tracker and monitoring in place which will be subject to performance management through schedule 9 of the contract and management monitoring through schedule 10. CON0003279 Intelligent Client function has responsibility for managing the relationship, monitoring performance, undertaking oversight and assurance for all of council. Remit, exact roles, and responsibilities have been developed, documented and implemented CON0003280 Enhanced contract management arrangements, proportionate to the size and scale of these contracts and reflecting good practice, developed, formally documented, and communicated to the team appointed to manage this contract. CON0003281 Procurement engagement and assessment process for the non-exclusive element of the Enterprise Contracts (Core Projects) is developed, fully documented, and clearly communicated to, and properly implemented by, the team appointed to manage the contract. CON0003283 Performance Handbook to support delivery and monitoring of KPIs and SPIs (Strategic Performance Indicators) Is live and agreed for both Contracts and to be reviewed on an annual basis. Page 190 of 288
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Appendix 3 - Corporate Risk Benchmarking North Lanarkshire Council (April 2025) South Lanarkshire Council (September 2024) Edinburgh City Council (March 2025) Fife Council (January 2025) Falkirk Council (October 2024) Renfrewshire Council (November 2024) 1 Home support service delivery/ sustainability National Care Service Child/Adult Protection Health Deterioration National Care Service Delivery of homeless duties 2 Information security and governance Information governance Information Governance and Data Management Ineffective Information Governance Health and Social Care Transformation Financial Sustainability 3 ICT operational capability Inability to maintain infrastructure, assets and properties in a well-maintained condition Cyber ICT Failure Cyber Security Successful Cyber Attack 4 Enterprise Contract (Mobilisation) The council fails to deliver the outcomes of the Economic Strategy Housing Pressures and Resultant Risks Roads and Transportation Infrastructure Failure Delivery of Major Capital Investments including Growth Deal Reducing inequalities 5 Human resources (workforce planning) Lack of capacity and skills to meet increased service demands Workforce Supply Workforce Challenges Social Work and Social Care Recruitment and Retention Pressures Workforce planning, recruitment and retention 6 Public protection Public Protection Organisational Culture Inability to Ensure Public Safety and Protection Public Protection: Harm to Adults/Children Strategic sustainable planning for people and assets 7 Procurement risk Procurement Risk Financial Control Legal and Regulatory Compliance Failure Financial Sustainability - need for recurring savings Global environmental sustainability and route to Net Zero 8 Governance, leadership and decision-making Regulatory compliance Ongoing Legislative Requirements Poor Corporate Governance and Leadership Leadership, Decision Making, and Governance Migration and asylum related impacts 9 Health and Safety Health and Safety Health and Safety Failure to Effectively Discharge Statutory Health and Safety Obligations Health, Safety, and Wellbeing Economy 10 RAAC Council inherits commercially unviable retail premises Asset Management Loss of Key Buildings Premises Compliance (including Legionella, Asbestos, and RAAC) Asset management - ongoing financial sustainability 11 Business continuity planning Increase in adverse weather Organisational Sustainability Including Transformation Educational Inequality / Widening Attainment Gap Sustainable Growth 12 Terrorism Industrial Action Context (UK Government Counter Terrorism Strategy) Elected Members - Failure to comply with Council Governance and Code of Conduct Anti-Terrorism 13 Home to school transport delivery/ sustainability Market capacity in local third and private sector markets. Society (Economic/Social/Geographic) Financial instability Housing Standards – possible changes to fire safety Page 191 of 288
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14 Resilience planning Resilience Planning Resilience Increased inequality Resilience – Partnerships and Business Continuity Management 15 Serious organised crime, fraud and corruption Council operations are affected by fraud, theft, organised crime and cyber attacks Serious Organised Crime and Fraud Ineffective Transformational Shane Agenda / Stategic Planning Services to Asylum Seekers 16 Tackling poverty Unable to provide required support to reduce cost of living impacts in SL Economic Downturn Inclusive and Sustainable Economic Growth in Fife Poverty – impacts on individuals and families 17 Power resilience (Black Start) Emergency response commitments Interdependency Effectiveness Failure to Address Climate Change Gender Based Violence (GBV) 18 Climate change Climate Change Climate Change Climate Change – Delivery of Climate Declaration and Plans 19 Digital adoption Failure to conduct statutory impact assessments Managing Information/Disinformation 20 Improving educational outcomes Failure to deliver outcomes of IJB Essential Learning 21 Financial sustainability Budget Gap across medium term 22 Digital and IT strategy IT development does not secure efficiencies 23 Engagement and consultation Failure to deliver the outcomes of the Community Plan 24 Delivery of approved programme of work Failure to achieve the outcomes of the Council Plan SFRS Unwanted Fire Alarm Signal Policy Historic childhood abuse Inability to effectively provide accommodation for homeless / refugee resettlement The council fails to deliver objectives of the Community Wealth Building Strategy Page 192 of 288
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1 North Lanarkshire Council Report Adult Care and Social Work Committee Does this report require to be approved? Ref Date ☒ Yes ☒ No 2/09/25 Quality Assurance Annual Report From Morag Dendy, Chief Officer (Planning, Performance, and Quality Assurance) E-mail DendyM@northlan.gov.uk Telephone Executive Summary The role of Quality Assurance includes a broad spectrum of activity both internally across social work services, and, in partnership with our commissioned services. Assurance and Governance underpins our key functions whilst aligning our work to the Council’s Plan for North Lanarkshire and the five-year Programme of Work 2023-2028. Throughout 2024/2025, the Quality Assurance Team have participated in Strategic Planning meetings, influencing and shaping future priorities and approaches aligned with the University Health & Social Care (UHSCNL) Strategic Commissioning Plan 2023 – 2026 and the priorities outlined within the associated Programme of Work. The health and social care environment in which we operate remains challenging and sharing of best practice and solution focused ideas are integral to ensure the people of North Lanarkshire receive good quality support to help meet their outcomes. Our commitment is to provide an annual report on activity carried out in the preceding year. The purpose of this report is to update Committee on our Quality Assurance activity over the annual period of 1 April 24 to 31 March 25. Recommendations It is recommended that the Adult Care and Social Work Committee: (1) Note and endorse the contents of the report. (2) Remit the report for information to the Integration Joint Board (3) Remit the report for information to the Audit and Scrutiny Panel (4) Remit the report for information to the Education, Children and Families Committee. Item 11 Page 193 of 288
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2 1. Background 1.1 This report highlights Quality Assurance activity over the period 1 April 2024 to 31 March 2025. It outlines how work has progressed in areas which includes Contracts & Contract Management Framework, Procurement, Back to Basics – Getting it Right for Everyone, Safe Staffing, Market Facilitation, Review of Registered Social Landlords, Duty of Candour, In House Monitoring, Social Work Risk Management, ASW Governance Subgroup for Registered Managers, Participation & Engagement and Carers. 1.2 Full detail of these activities is included in Appendix One. 2. Report Contracts 2.1 The Quality Assurance Team are responsible for coordinating and facilitating all procurement activity across social work. This is in partnership with our corporate procurement colleagues, who provide the framework and legal basis to ensuring that decisions taken are in line with legislation including the Procurement Reform (Scotland) Act 2014. 2.2 Over the past year, Quality Assurance have continued to ensure consistency across purchased services and that contractual arrangements have clearly defined terms and conditions. This has ensured that expectations are clearly outlined and there is a basis for contract monitoring to take place. This enables the quality of services being provided to people to be evaluated. Arrangements range from national frameworks to Individual Placement Agreements which balance quality against cost to achieve overall best value for services purchased to support people. Contract Management Framework 2.3 Adherence with the contract management framework is an integral component of the processes in place to demonstrate commissioned services are adhering to terms and conditions and that outcomes and best value are achieved. Contract monitoring is a means to identify unmet need and inform future strategic planning and commissioning. 2.4 The Contract Management Framework was also the focus of a recent internal audit of Quality Assurance. Findings were positive, with only minor recommendations for improvement. As a result of the audit, feedback from stakeholders and new legislation, further enhancements have been made: The Plan for North Lanarkshire Priority Improve the health and wellbeing of our communities Ambition statement (12) Ensure our residents are able to achieve, maintain, and recover their independence through appropriate supports at home and in their communities Programme of Work Resilient People Page 194 of 288
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3 • Contract Management Framework process has been made clearer with roles & responsibilities outlined for both QA staff and providers • Monitoring prioritisation assessment (MPA) modified to more clearly identify service-related risk • Analysis of quarterly return submission documented, and feedback is now given to providers • Closure date introduced for acceptance of quarterly & annual return submissions to enhance compliance • Information added to capture the principles of safe staffing legislation 2.4.1 We reported last year that we planned to produce a Quarterly Commissioned Services Performance Report. This was implemented as of 1st April 2024, to provide useful information to operational colleagues to assist in supporting people to make a choice of care provider based on the available intelligence. The report also enables the Quality Assurance Team to monitor performance, patterns, themes and trends in relation to areas such as notifications of concern, engagement & participation, Care Inspectorate Grades, Tier Ratings and compliance with annual/quarterly provider returns. 2.4.2 During the reporting period we started to provide information which assists Locality Teams in supporting people to identify their choice of care provider. All providers on the SDS Framework are included within the Performance Benchmark Tool, as are up to date contact details. Alongside each provider on the SDS Framework, we have included performance information which gives indicators to the quality of care being provided to people. We strive to ensure information is up to date. Benchmarks include Care Inspectorate grades, contract monitoring Tier indicating associated risk level and evaluation score at the time of entering the framework. Procurement 2.5 Quality Assurance continued to lead on procurement activity for all social work services in collaboration with colleagues within Corporate Procurement, Service Leads and Locality Social Work Teams, to ensure joined up planning, clear procurement processes and subsequent contract monitoring arrangements. This ensured that all commissioned contract work delivered best value, in accordance with Procurement Reform Scotland Act 2014 and the Procurement (Scotland) Regulations 2016. In House Monitoring Framework 2.6 Throughout 2024 a Test of Change for the newly developed In House Monitoring Framework continued within Home Support (Living Well at Home). The review and evaluation of the In-House Monitoring Framework commenced in December 2024 and those who had been involved in the development of this, and the participants of the Test of Change provided feedback on what worked well and what further developments could be embedded within the approach. Feedback consisted of individual meetings and group workshops. 2.7 The Senior Management Team have agreed the roll out of the revised In-House Monitoring Framework and a programme of activity will commence in April 2025. Market Facilitation 2.8 The health and social care sector continued to experience a variety of challenges. These challenges are expected to continue for some time. The Quality Assurance team continues to promote, stimulate and support market facilitation, and our approach is based on strategic intervention, relationship building, light touch intervention and Page 195 of 288
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4 supporting beneficial new relationships and activities that lead to resilient and sustainable approaches. In turn this leads to continuous improvement, improved ways of working and an active learning cycle, whereby planning impacts on delivery, review and learning. Engagement & Participation 2.9 In September 2024 the University Health and Social Care Engagement and Participation Strategy was launched alongside the Growth Pot Fund. Quality Assurance were involved in both the drafting of, and raising awareness of, the strategy and its ambitions. During the year work to collate examples of best practice to support staff across the service to further engage with those involved in services, was undertaken by Quality Assurance, in partnership with Planning and Performance colleagues. Back-to-basics to getting it right for everyone 2.10 Over the past year within Adult Health & Social Care Services, we have been working on the development of an enabling approach that supports the move from our work on back-to-basics to getting it right for everyone, as we recognise the landscape of health and social care is changing and services, supports and responses need to change to continue to improve the lives of people who live and work in North Lanarkshire. We have sought to adopt a human learning approach by trying different ways to focus more on people and less on systems and processes, and use resources to their best effect, to make the most positive impact on peoples’ lives. 2.11 Over the coming year we will further develop specific plans and service developments: as this is a whole system approach, we anticipate there will be a lot to focus on and much change across services, supports and responses that are needed to achieve and sustain change. Safe Staffing 2.12 The Health and Care (Staffing) (Scotland) Act 2019 (HCSA) came into effect on 1st April 2024. The purpose of this legislation is to establish a statutory framework to ensure appropriate staffing levels in health and care settings. North Lanarkshire Council have responsibilities as a provider of care and support and as a placing authority. 2.13 Quality Assurance supported both commissioned and in-house services with the implementation of the Act throughout the reporting period, by facilitating two dedicated working groups. 2.14 Quality Assurance have devised the Health and Care (Staffing) (Scotland) Act 2019 Annual Report for Social Work Services. Duty of Candour 2.15 All health and social care services in Scotland have an organisational duty of candour. This is a legal requirement which means that when certain types of incidents happen, the people affected understand what has happened, receive an apology, and the organisation learns how to improve for the future. 2.16 North Lanarkshire Council reviewed and modified its Duty of Candour reporting procedures during 2024/25. Throughout January, February & March 2025 Locality Page 196 of 288
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5 Social Work Managers, Senior Social Workers and Registered Managers participated in awareness raising sessions to enhance understanding of the circumstances when Duty of Candour would be considered; and the stages involved in the procedure. 2.17 The Duty of Candour notification procedure now includes two stages, which are: • Part 1 Possible Duty of Candour incident (Initial Notification) • Part 2 Managing the Duty of Candour Process 2.18 The intention underlying the introduction of the two-stage process is to enable internal monitoring and analysis of when Duty of Candour has been considered but not activated. It is envisaged that this data will contribute to organisational learning. Review of Registered Social Landlords 2.19 Since the summer of 2023, Quality Assurance has been leading on the review of five Registered Social Landlords who provided thirteen sheltered & very sheltered developments across North Lanarkshire. These services were funded to provide housing support, using Supporting People funding. This funding stream was discontinued around 2016/17, leading to mainstream social work funding being accessed pending review. This review has now concluded, and North Lanarkshire Council no longer commission or fund these Registered Social Landlords. Adult Social Work Subgroup – Registered Managers 2.20 An Adult Social Work Subgroup for Registered Managers was established in 2025. This group meet eight weekly, and the chair is the Quality Assurance Service Manager or delegated person. This group reports through the ASW Governance Group and its purpose is to ensure robust governance and oversight across Registered Services. Social Work Risk Management 2.21 Quality Assurance have oversight of the social work risk register and are responsible for quarterly & annual reporting, compliance audits and for the facilitation and coordination of the Social Work Risk Forums. Quality Assurance participate in Corporate Risk Management Team meetings, and cascade appropriate information through the correct forums. 2.22 Risk Champions and Facilitators act as points of contact for risk management matters within social work and promote risk awareness across the service. 3. Measures of success 3.1 Measures of success are contained within Appendix One of this report. 4. Supporting documentation 4.1 Appendix 1: Quality Assurance Annual Report 2024/25 Morag Dendy Chief Officer (Planning, Performance, and Quality Assurance) Page 197 of 288
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6 5. Impacts 5.1 Public Sector Equality Duty and Fairer Scotland Duty Does the report contain information that has an impact as a result of the Public Sector Equality Duty and/or Fairer Scotland Duty? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact? If Yes, has an assessment been carried out and published on the council’s website? https://www.northlanarkshire.gov.uk/your-community/equalities/equality- and-fairer-scotland-duty-impact-assessments Yes ☐ No ☐ 5.2 Financial impact Does the report contain any financial impacts? Yes ☐ No ☐ If Yes, have all relevant financial impacts been discussed and agreed with Finance? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact? 5.3 HR policy impact Does the report contain any HR policy or procedure impacts? Yes ☐ No ☐ If Yes, have all relevant HR impacts been discussed and agreed with People Resources? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact? 5.4 Legal impact Does the report contain any legal impacts (such as general legal matters, statutory considerations (including employment law considerations), or new legislation)? Yes ☐ No ☐ If Yes, have all relevant legal impacts been discussed and agreed with Legal and Democratic? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact? 5.5 Data protection impact Does the report / project / practice contain or involve the processing of personal data? Yes ☐ No ☐ If Yes, is the processing of this personal data likely to result in a high risk to the data subject? Yes ☐ No ☐ If Yes, has a Data Protection Impact Assessment (DPIA) been carried out and e- mailed to dataprotection@northlan.gov.uk Yes ☐ No ☐ 5.6 Technology / Digital impact Does the report contain information that has an impact on either technology, digital transformation, service redesign / business change processes, data management, or connectivity / broadband / Wi-Fi? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact? Page 198 of 288
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7 Where the impact identifies a requirement for significant technology change, has an assessment been carried out (or is scheduled to be carried out) by the Enterprise Architecture Governance Group (EAGG)? Yes ☐ No ☐ 5.7 Environmental / Carbon impact Does the report / project / practice contain information that has an impact on any environmental or carbon matters? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact? 5.8 Communications impact Does the report contain any information that has an impact on the council’s communications activities? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact? 5.9 Risk impact Is there a risk impact? Yes ☐ No ☐ If Yes, please provide a brief summary of the key risks and potential impacts, highlighting where the risk(s) are assessed and recorded (e.g. Corporate or Service or Project Risk Registers), and how they are managed? 5.10 Armed Forces Covenant Duty Does the report require to take due regard of the Armed Forces Covenant Duty (i.e. does it relate to healthcare, housing, or education services for in-Service or ex- Service personnel, or their families, or widow(er)s)? Yes ☐ No ☐ If Yes, please provide a brief summary of the provision which has been made to ensure there has been appropriate consideration of the particular needs of the Armed Forces community to make sure that they do not face disadvantage compared to other citizens in the provision of public services. 5.11 Children’s rights and wellbeing impact Does the report contain any information regarding any council activity, service delivery, policy, or plan that has an impact on children and young people up to the age of 18, or on a specific group of these? Yes ☐ No ☐ If Yes, please provide a brief summary of the impact and the provision that has been made to ensure there has been appropriate consideration of the relevant Articles from the United Nations Convention on the Rights of the Child (UNCRC). If Yes, has a Children’s Rights and Wellbeing Impact Assessment (CRWIA) been carried out? Yes ☐ No ☐ Page 199 of 288
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Quality Assurance Annual Report 2024/2025 APPENDIX 1 Page 201 of 288
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1 1. Introduction The role of Quality Assurance includes a broad spectrum of activity both internally across social work services, and, in partnership with our commissioned services. Assurance and Governance underpins our key functions whilst aligning our work to the Council’s Plan for North Lanarkshire and the five-year Programme of Work 2023-2028. Throughout 2024/2025, the Quality Assurance Team have participated in Strategic Planning meetings, influencing and shaping future priorities and approaches aligned with the University Health & Social Care (UHSCNL) Strategic Commissioning Plan 2023 – 2026 and the priorities outlined within the associated Programme of Work. Quality Assurance have strengthened the governance structure and reporting arrangements around the Strategic Commissioning Plan Programme of Work. These sit alongside and compliment structures already in place across UHSCNL. The purpose of the structure is to ensure oversight of inter-related programmes, projects and activities. Last year we reported on the expanded remit of Quality Assurance and the additional staffing resource that had been aligned. We believe that we met our key deliverables. Our achievements include the evaluation of the In-House Monitoring Framework and subsequent roll out; a review of Duty of Candour Procedures and delivery of training across Locality Teams; completion of a review of Registered Social Landlords, collation of information for inclusion in the CSWO report; development of a care opinion newsletter; the launch of the Engagement & Participation Strategy; and the organisation of the annual Committed to Carers Event. The bigger part of our work focuses on social work procurement and contract monitoring. The range of contracts that have been procured, and further development of our contract management framework are detailed within this report. Some key functions of the Quality Assurance Team were subject to audit and the findings shared. We are delighted to report that the areas of work audited reflected compliance with good practice principles and defined expectations. Much of the focus of Quality Assurance during this reporting period has been supporting our Registered Services and an Adult Social Work Subgroup for Registered Managers commenced. A safe staffing working group continues to explore best practice and develop standardised tools to evidence compliance with the Guiding Principles of the newly implemented Health and Care (Staffing) (Scotland) Act 2019. The Quality Assurance Team supported Home Support (Living Well at Home) to introduce a performance monitoring framework to ensure accountability across all grades of staff. The team also facilitated workshops and briefings to assist in expanding the knowledge of Care Inspectorate Quality Frameworks and self-evaluation tools. In line with the principles of self-directed support, people can exercise as much choice and control as they wish, around their support arrangements. Quality Assurance support this through ensuring that teams are equipped to facilitate discussions around choice of support options. Performance is now being captured through the introduction of a Quarterly Performance Report and Benchmark Tool for commissioned services. We have progressed new social work induction processes, social work self-evaluation, the reframing of risks and policy development has commenced. Test of change sites have been identified for social work self-evaluation, prior to roll out. Page 202 of 288
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2 Extensive work was carried out in relation to new legislation around reporting requirements under the Health and Care (Staffing) (Scotland) Act 2019 Act. We also supported Housing and Early Years colleagues with the aim of ensuring a consistent approach across North Lanarkshire Council to safe staffing reporting. Over the past year Quality Assurance have supported the work around our transformational change programme, Phase One Back to Basics, which is now embedded across our locality teams. As we enter Phase 2 Getting it Right for Everyone, we remain engaged and connected to the principles underlying the approach. The activities reported in this annual report reflect our commitment to on-going improvement and that people can influence and shape decision making. 2. Contracts The Quality Assurance Team are responsible for coordinating and facilitating all procurement activity across social work. This is in partnership with our corporate procurement colleagues, who provide the framework and legal basis to ensuring that decisions taken are in line with legislation including the Procurement Reform (Scotland) Act 2014. Our approach to procurement activity reflects Scottish Government best practice guidance including Procurement of Care and Support Services, and the Public Procurement Strategy for Scotland 2023 to 2028. We seek to ensure that we are acting in accordance with the principles of ethical commissioning. As a learning organisation, we continue to modify and adapt our procurement journeys to inform and secure best value, to provide care and support to people across North Lanarkshire. Following the awarding of contracts throughout 2024/2025, our internal procurement end to end process has been revised and modified to reflect what worked well and what improvements and enhancements could be made to ensure that future services are influenced, shaped and aligned to the Plan for North Lanarkshire, the Strategic Commissioning Plan and other key health and social care priorities and ambitions. The Quality Assurance Team have participated in additional procurement awareness training during this reporting period and more bespoke training is planned for August 2025. An invite will be extended to operational colleagues to take part in this training, in response to feedback from previous tendering activity. It is envisaged that the modifications made to the end-to-end procurement journey and the involvement in bespoke procurement training will assist operational colleagues to devise service specifications, which describe the service required and the outcomes to be achieved. We continued to work closely with our partners at Scotland Excel. Through Scotland Excel, we operate the National Care Home Contract, the Children's Residential Care and Education including Short Break, Services and Fostering & Continuing Care contracts from Scotland Excel. Scotland Excel have committed to redesigning the National Care Home Contract, as since its development in 2013 there have been significant changes to the social care environment. It is envisaged that redesign will be more reflective of the current social care landscape, which includes challenges such as the inexperience of the workforce, staff recruitment and retention, cost of living impacts and changing demographics/more complex needs of the care home population at the time of admission. Page 203 of 288
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3 Over the past year, Quality Assurance have continued to try and ensure consistency across purchased services and that contractual arrangements have clearly defined terms and conditions. This has ensured that expectations are clearly outlined and there is a basis for contract monitoring to take place. This enables the quality of services being provided to people to be evaluated. Arrangements range from national frameworks to Individual Placement Agreements which balance quality against cost to achieve overall best value for services purchased to support people. Tables 2a and 2b below illustrate that as of 31 March 25, 98% of all social work spend had a formal contracting arrangement in place. This figure remained consistent with 2023/2024, when we reported 98%. Two organisations are currently out of contract and subject to review during the reporting period. The review findings are under consideration and previous funding agreements are being honoured during this time. Quality Assurance continue to progress with arrangements to ensure all spend has contractual and legal agreements in place; however, it should be noted that due to the fluidity of contracting and commissioning, achievement of 100% compliance may not always be possible. Table 2a 98% 2% No of Contracts 2024/2025 Contracts in Place In Development 98% 2% No of Contracts 2023/2024 Contracts in Place In Development Page 204 of 288
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4 Table 2b There are currently 310 contracted provider organisations, a decrease of seven from the figure reported last year and as highlighted above. The number of out of authority care homes being utilised has increased by 7 and it can be determined that this is not due to lack of availability within North Lanarkshire, as there have been no capacity issues throughout the reporting period. People accessing care homes out of authority are doing so due to their choice to locate close to family. There has been a reduction in the cross-border provider organisations we contract with. It can be seen from the graphs above that non framework self-directed support has increased, and non-traditional respite packages have decreased. 3rd sector and voluntary providers have increased by 1. We encourage these providers to join our SDS Framework. The number of care homes within North Lanarkshire we contract with remains unchanged since last year and this is also the case with Self Directed Support (SDS Framework). 10 4 27 12 141 3 10 2 7 4 9 9 4 61 0 20 40 60 80 100 120 140 160 3rd Sector / Voluntary Advocacy Care Home (NLC) Care Home Cross Border Care Home Out of Authority Carers Network Fostering & Continuing Care Mental Health Misc Non Framework Self Directed Support Non Traditional Respite Residential Schools Secure Services Self Directed Support Spread of Providers 2023/2024 11 4 27 3 148 10 10 2 7 5 8 10 4 61 0 20 40 60 80 100 120 140 160 3rd Sector / Voluntary Advocacy Care Home (NLC) Carers Network Care Home (Out of Authority) Care Home (Cross Border) Fostering & Continuing Care Mental Health Misc Non Framework Self Directed Support Non Traditional Respite Residential Schools Secure Services Self Directed Support Spread of Providers -2024/2025 Page 205 of 288
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5 3. Contract Management Framework (CMF) The two most recent Quality Assurance Annual Reports (2022/23 & 2023/2024) provided updates on developments and enhancements to the contract management framework. From the cyclical changes implemented, and throughout the 2023/24 reporting period, the Quality Assurance team evaluated the impact of the changes. Various methods of evaluation were utilised, including an on-line meeting with commissioned services. Other methods included a Quality Assurance presentation at one of the SDS Provider Development Sessions, feedback from Internal Audit, on-going discussions at team meetings and through the findings of senior officers’ use of the framework, findings from service manager sampling and compliance checks. This approach reflects one of a learning organisation and focuses on our overarching aims, which include monitoring our commissioned services to enable effective partnership working, early intervention and the targeting of resources to improve the experience of people. Adherence with the contract management framework is an integral component of the processes in place to demonstrate commissioned services are adhering to terms and conditions and that outcomes and best value are achieved. Contract monitoring is a means to identify unmet need and inform future strategic planning and commissioning. The main changes made to the contract management framework and as highlighted in 2022/2023 & 2023/2024 annual reports are as follows: - - Introduction of an Engagement & Participation Toolkit - Quarterly & annual returns being specific to the model of service - Monitoring Visit report template introduced to improve on consistency and the impact from monitoring In January 2025 Quality Assurance arranged a feedback session focusing on the changes made to the contract management framework. Over 40 providers attended. Feedback was used to further build on developments to avoid duplication of reporting or collation of unnecessary information. The outcome was an improved and more relevant framework. In March 2025 Quality Assurance facilitated a further session on the contract management framework at one of the SDS Provider Development Days. Feedback was positive and promoted enhanced understanding and awareness. The Contract Management Framework was also the focus of a recent internal audit of Quality Assurance. Findings were positive, with only minor recommendations for improvement. As a result of the audit, feedback from stakeholders and new legislation, further enhancements have been made: • Contract Management Framework process has been made clearer with roles & responsibilities outlined for both QA staff and providers • Monitoring prioritisation assessment (MPA) modified to more clearly identify service-related risk • Analysis of quarterly return submission documented, and feedback is now given to providers • Closure date introduced for acceptance of quarterly & annual return submissions to enhance compliance • Information added to capture the principles of safe staffing legislation The revised MPA can be seen below in two parts (Table 3a & 3B) It is based on a confidence rating and focuses on assessment areas which indicate the potential risk of lower-than- Page 206 of 288
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6 expected standards of care and support being provided. Outcomes are nuanced and determined based on narrative provided by Senior Officers who have additional context as to circumstances, as well as established relationships with providers. This approach is balanced with an element of standardisation. Table 3a Table 3b Page 207 of 288
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7 The MPA outcome indicates the tier level and associated frequency of monitoring required by Quality Assurance Senior Officers. See below: - Each Tier suggests a minimum monitoring frequency as set out in Table 3c below Table 3c STATUS INDICATED MONITORING LEVEL Red Significant concerns in relation to service performance, contract compliance. TIER 4 Contract monitoring visit frequency – 1 to 4 weekly. Amber Moderate concerns in relation to service performance, contract Compliance TIER 3 Contract monitoring visit frequency – variable, at least quarterly but no more than monthly. Yellow Minor concerns identified in relation to service performance and contract compliance TIER 2 Contract monitoring visit frequency – variable, at least bi-annually but no more than quarterly. Green Service performance, contract compliance and engagement are satisfactory. TIER 1 Contract monitoring visit frequency – annually in most cases. Page 208 of 288
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8 Table 3c The on-going improvements to our contract management framework ensure that due diligence is consistently and clearly documented and decisions are based on facts and evidence. This safeguards North Lanarkshire Council from potential reputational or financial consequences. Table 3c highlights Tier Levels as reported at the end of 2023/2024 and for the same time in 2024/2025. Tier 4 services have increased in this reporting period from 0% to 5%. However, it is positive that the risks are known to the team, as this ensures these can be mitigated with the appropriate interventions. When comparing the lower tier ratings (1 & 2) across both reporting periods, there was a 3% reduction from 2023/2024 and for Tiers 3&4 there was a 2% increase from 2023/2024. Overall, most providers were tiered within the lower Tier rating categories. This is positive as the intensity and frequency of Care Inspections, and our monitoring activity has been enhanced. Quality Assurance are mindful of the challenges being experienced within the sector and are pleased to report that in spite of the challenges evidence highlights an improved quality of care from 2023/24. Tier 1 Tier 2 Tier 3 Tier 4 Q4 2024 to 2025 74% 16% 5% 5% Q4 2023 to 2024 68% 25% 8% 0% 0% 10% 20% 30% 40% 50% 60% 70% 80% Commissioned Services Q4 Tier Ratings 2023/2024 & 2024/2025 Q4 2024 to 2025 Q4 2023 to 2024 Page 209 of 288
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9 Commissioned Services Quarterly Performance Report – We reported last year that we planned to produce a Quarterly Commissioned Services Performance Report. This was implemented as of 1st April 2024, and it is intended to provide useful information to operational colleagues to assist in supporting people to make a choice of care provider based on the available intelligence. The report also enables the Quality Assurance Team to monitor performance, patterns, themes and trends in relation to areas such as notifications of concern, engagement & participation, Care Inspectorate Grades, Tier Ratings and compliance with annual/quarterly provider returns. The format of the Commissioned Services Quarterly Performance Report has continued to change and develop in response to feedback from Localities. Feedback indicated it would be helpful for Localities to receive updates following submission of Notifications of Concern about provider performance. We introduced a feedback section within the Notification of Concern Form. We also track the timescales for feedback to be provided. Levels of Engagement and Participation have continuously increased. Over the reporting period we engaged with the following: Table 3d Supported people Staff Relatives/ carers Other Amount 146 276 134 48 0 50 100 150 200 250 300 No of people engaged with as at 31/03/2025 Supported people Staff Relatives/ carers Other Q1 3 11 2 0 Q2 43 80 32 18 Q3 68 109 60 20 Q4 32 76 40 10 0 20 40 60 80 100 120 No of people engaged with during each quarter 2024/2025 Page 210 of 288
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10 We continue to measure the impact of this engagement. Some examples are shown below: - Table 3e GP is now based within the Care Home one day a week. Provider ensured consistency and improvement in staffing arrangements. Manager arranged a meeting with the family to outline the staffing arrangements and to provide reassurance around their concerns The need to provide information about people’s likes and dislikes in Agency staff induction and handovers was agreed. This has been added to the service development plan. Previous concerns around prearranged GP appointments. Discussed concerns with the management team Concerns around inadequate staffing levels at night raised by family Discussion took place with the manager who confirmed safe staffing levels were in place Some carers are better than others Senior Officer discussed with manager and asked for follow up Agency staff who do not know the residents Information relayed to the manager Page 211 of 288
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11 Performance Benchmark Tool – During the reporting period we started to provide information which we hope will assist Locality Teams in supporting people to identify their choice of care provider. All providers on the SDS Framework are included within the Performance Benchmark Tool, as are up to date contact details. Alongside each provider on the SDS Framework, we have included performance information which gives indicators to the quality of care being provided to people. We strive to ensure information is up to date. Benchmarks include Care Inspectorate grades, contract monitoring Tier indicating associated risk level and evaluation score at the time of entering the framework. 4. Regulatory Activity Table 4a below details an analysis of the key question “How well do we support people’s wellbeing?”. The data has been extracted from Tables 4b and 4c below. North Lanarkshire Care Homes performance measures lower than Scotland wide care homes, in that 72% of grades of 4 and above were awarded. Scotland wide care homes achieved 76.6% of grades of 4 and above. From the figures below it would appear that North Lanarkshire care homes seem to have an overall average of grades ranging between adequate and good. An improvement area would be to start to focus on why very few care homes are achieving good or above grades. 132 Scotland wide care inspections are reported below for the period 1st April 2024 – 31st March 2025. Please note some care homes have not been inspected or have not been inspected under this key question. Table 4a - Please note North Lanarkshire care homes are not included in the overall Scotland wide figures. How well do we support people’s wellbeing Number of Care Homes Assessed Grades Awarded Percentage North Lanarkshire Care Homes (Table 4b) 25 0 x Excellent 5 x Very Good 13 x Good 4 x Adequate 0 x Weak 0 x Unsatisfactory 3 x Not Assessed 0% 20% 52% 16% 0% 0% 12% Scotland Wide Care Homes (Table 4c) 107 3 x Excellent 38 x Very Good 41 x Good 17 x Adequate 1 x Weak 0 x Unsatisfactory 3% 35% 38% 16% 1% 0% Page 212 of 288
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12 7 x Not Assessed 7% Table 4b As of 31st March 2025, there were 27 care homes within North Lanarkshire. 24 of the care homes had been assessed by the Care Inspectorate against their key question of, ‘How well do we support people’s wellbeing?’. None of the care homes assessed achieved the highest grade of ‘Excellent’, however 29.1% of care homes achieved ‘Very Good’. How well do we support people's wellbeing? How good is our leadership? How good is our staff team? How good is our setting? How well is care and support planned? Very Good 3 2 1 2 0 Good 15 13 9 6 9 Adequate 5 7 3 5 2 Weak 4 3 0 3 2 Unsatisfactory 0 1 1 0 0 0246810121416 Care Inspectorate Grades -North Lanarkshire based Care Home as at 31/03/2024 How well do we support people's wellbeing? How good is our leadership? How good is our staff team? How good is our setting? How well is care and support planned? Very Good 7 4 4 1 0 Good 13 7 14 13 11 Adequate 4 7 3 2 4 Not assessed 3 9 6 11 12 0 2 4 6 8 10 12 14 16 Care Inspectorate Grades -North Lanarkshire based Care Home as at 31/03/2025 Page 213 of 288
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13 The majority of care homes were assessed as ‘Good’ or better against this question, totalling 54.1%. It is positive to note that the number of care homes assessed as Very Good has increased from 11.1% in 2023/2024. The care homes who were assessed as ‘Very Good’ were Blair House, Carrickstone, Darroch, Highgate, Kirknowe, Rosepark and Summerlee. Of the 27 care homes within North Lanarkshire, 15 were assessed under key question ‘How well is care and support planned?’ Of the 15 assessed, 73% received a grade of ‘Good’. During the reporting period, no care homes within North Lanarkshire were subject to Large Scale Investigations. From 1st April 2024 to 31st March 2025 there were a total of six care homes within North Lanarkshire, who at periods, had a voluntary moratorium applied to all new admissions. These were Avondale, Darroch, Carrickstone, Milbrae, Parksprings and Woodside. Out with Avondale, whose moratorium was applied due to a change in contract, the remaining five care homes were for reasons of weak Care Inspectorate grades and the findings from monitoring carried out by Quality Assurance. The duration of these moratoriums was a maximum of three months with some being removed with one or two months. Cumbernauld Care Home had an enforced moratorium due to weak Care Inspectorate grades. Improvements were quickly embedded by the Provider and the moratorium to new admissions was removed within three months. It is important to note the application of a moratorium to new admissions is to enable the care homes to focus on progressing identified improvement areas. Page 214 of 288
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14 Table 4c Care Homes in Scotland (excluding North Lanarkshire): North Lanarkshire Council currently has 313 people placed within 122 care homes that are located elsewhere in Scotland. Contract Monitoring activity is carried out by the host authority where the care home is geographically located, although care management responsibilities remain with North Lanarkshire Council for the individuals placed. Individual Placement Agreements are implemented for individuals and these agreements detail the basis for care and support. North Lanarkshire Council are notified of any Large-Scale Investigation activity or potential scenarios which may lead to the closure of the home e.g. Care Inspection Enforcement Action, Liquidation etc. How well do we support people's wellbeing? How good is our leadership? How good is our staff team? How good is our setting? How well is care and support planned? Excellent 0 1 0 1 0 Very Good 39 40 15 9 13 Good 56 44 34 37 38 Adequate 30 27 19 12 25 Weak 2 2 1 2 1 0 10 20 30 40 50 60 Care Inspectorate Grades -Care Home as at 31/03/2024 (excluding NLC) How well do we support people's wellbeing? How good is our leadership? How good is our staff team? How good is our setting? How well is care and support planned? Excellent 4 2 0 1 0 Very Good 58 36 45 20 22 Good 58 44 50 49 41 Adequate 18 25 17 15 23 Weak 1 2 2 0 0 Not assessed 9 39 34 63 62 0 10 20 30 40 50 60 70 Care Inspectorate Grades -Care Home as at 31/03/2025 (excluding NLC) Page 215 of 288
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15 Table 4d How well do we support people's wellbeing? How good is our leadership? How good is our staff team? How good is our setting? How well is care and support planned? How well do we support Children and Young People's Rights and Well-Being Care and Support Environment Staffing Management and Leadership Excellent 3 0 2 0 0 0 0 0 0 0 Very Good 32 21 21 1 12 1 2 0 2 1 Good 12 15 10 1 10 1 0 0 0 1 Adequate 7 6 6 0 6 0 0 0 0 0 Weak 1 1 2 0 1 0 0 0 0 0 Not assessed 6 18 20 59 32 0 0 2 0 0 0 10 20 30 40 50 60 70 Care Inspectorate Grades -Self Directed Support including Care at Home as at 31/03/2025 Page 216 of 288
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16 Table 4e Self-Directed Support (SDS) including Care at Home: Across the services on the SDS Framework a total of 38 Care Inspections took place using the current inspection methodology. There remain two services whose last inspections were carried out in accordance with a previous inspection approach. How well do we support people's wellbeing? How good is our leadership? How good is our staff team? How good is our setting? How well is care and support planned? Excellent 1 0 0 0 0 Very Good 27 16 7 1 7 Good 16 20 9 2 9 Adequate 3 8 1 0 3 Weak 2 2 2 0 2 0 5 10 15 20 25 30 Care Inspectorate Grades -Self Directed Support including Care at Home as at 31/03/2024 Page 217 of 288
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17 The table above outlines 61 services with their current grades under each Key Questions as of 31st March 2025. This table highlights that for Key Question 1 ‘How well do we support people’s wellbeing?’ Three services received a grade of ‘Excellent’. These services were Active Care and Support Services, Potential Living (VAMW) and Support for Ordinary Living (SOL). A grade of ‘Very Good’ was received by 58.1% of services and 21.8% of services inspected received grades of ‘Good’ or above. For the key question ‘How well do we support people’s wellbeing?’, one service received a grade of ‘Weak’. This service was Aspire West Support Service Care at Home. Of the 61 services, 29 were inspected by the Care Inspectorate against the key question ‘How well is care and support planned?’. Of these, 41.3% received grades of ‘Very Good’ and 34.5% received grades of ‘Good’, or above. It should however be taken into consideration that a further two services have grades of ‘Very Good’ under Quality of Care and Support from the previous Care Inspectorate approach. This means that 45.1% of services inspected received grades of ‘Very Good’. During the reporting period no SDS Framework services were subject to Large Scale Investigations. From 1st April 2024 to 31st March 2025 there were a total of six SDS Framework services within North Lanarkshire, at periods, that had a voluntary moratorium applied to supporting any new people. These were Aspire, Ayrshire Children’s Service, Cera Care, Enable, Invercare and Home Instead. Out with Home Instead, whose moratorium was applied due to a change in contract, the remaining five SDS Framework services were for reasons of weak Care Inspectorate grades and findings from monitoring carried out by Quality Assurance. Care 1 Professional had an enforced moratorium due to weak Care Inspectorate grades. When taking into consideration timescales for moratoriums being applied, SDS Framework services were in place for considerably longer than care homes with an average period being approximately six months. Page 218 of 288
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18 5. In-house Monitoring Framework Throughout 2024 a Test of Change for the newly developed In House Monitoring Framework continued within Home Support (Living Well at Home). The review and evaluation of the In-House Monitoring Framework commenced in December 2024 and those who had been involved in the development of this, and the participants of the Test of Change provided feedback on what worked well and what further developments could be embedded within the approach. Feedback consisted of individual meetings and group workshops. The evaluation highlighted the need for a greater focus on engaging with people to inform self-evaluation improvement plans during Stage One of the process. Furthermore, the timescales and documentation/tools have benefited from slight modifications in response to what people told us during the engagement and evaluation. The Senior Management Team have agreed the roll out of the revised In-House Monitoring Framework and a programme of activity will commence in April 2025. Prior to roll out, briefing sessions will be facilitated by Quality Assurance for Registered Managers and Service Managers/Locality Social Work Managers, who are scheduled to participate in the process throughout 2025/26. Services in scope are Locality Support Services, Integrated Day Services and the Children’s Residential Houses. Two localities from Home Support (Living Well at Home) will recommence the cycle as of April 2025 as they achieved Tier 1 status. The remaining four localities continue to engage with Quality Assurance six weekly, to monitor progress of improvement plans, due to them being assessed as Tier 2 status. Prior to roll out of the In-House Monitoring Framework, the Quality Assurance Team will facilitate Improvement workshops for Registered Page 219 of 288
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19 Managers and their teams, which will focus on self-evaluation, quality frameworks and the tools to assist in this process. Page 220 of 288
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20 6. Market Facilitation The health and social care sector continued to experience a variety of challenges, which have been mentioned throughout this report. These challenges are expected to continue for some time. The Quality Assurance team continues to promote, stimulate and support market facilitation, and our approach is based on strategic intervention, relationship building, light touch intervention and supporting beneficial new relationships and activities that lead to resilient and sustainable approaches. In turn this leads to continuous improvement, improved ways of working and an active learning cycle, whereby planning impacts on delivery, review and learning. Work with Enterprise & Communities Team - The Quality Assurance Team continued to liaise with colleagues across the council to identify and support initiatives to assist providers to flourish, remain sustainable and deliver excellent care and support to people across North Lanarkshire. There is a plan for Quality Assurance and Enterprise & Communities to jointly visit a variety of care homes and SDS Framework providers supporting people at home. The aim of these visits will be to hear directly from providers what the challenges are and to identify ways in which the council can support long term sustainability and growth. A report will be made available following the programme of visits which will take place throughout 2025/26. Care Academy - Quality Assurance continued to participate in the work activity of the Care Academy which consists of representatives from North Lanarkshire Council, South Lanarkshire Council and NHS Lanarkshire. The overall vision for the Care Academy is to: Develop a robust, sustained, vibrant Care Academy attracting and developing a diverse workforce for health and care services in Lanarkshire and promoting the sector as a rewarding choice for careers. Increase awareness and engagement about the Care Academy across all partners and organisations, to support people from our communities, working in our communities. The aims of the Care Academy are to: 1. Create the health and social care workforce for the future that best serves the needs of people living in Lanarkshire. 2. Contribute to addressing deprivation and inequalities across Lanarkshire to help people live their lives to the fullest. 3. Provide pathways to fair work, meaningful employment, and progression across the breadth of health and social care. Page 221 of 288
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21 4. Build a strong talent pipeline to meet future demand and reduce skills shortages within the health and social care sector across Lanarkshire. Further Roll Out of Funding to Support Workplace Scheme- Quality Assurance are currently planning, through the Care Academy to further build on an initiative whereby funding was provided by North Lanarkshire Council to Lanarkshire Care Partners, who deliver care at home services to people across North Lanarkshire. This workplace scheme has already achieved the following: - • 8 North Lanarkshire jobseekers secured paid work. • Over 500 hours of work were paid at a rate above SLW. • Approx.152 CPD points accrued. • SCQF level 5 qualifications gained in Emergency First Aid at Work and Moving and Assisting People. • 7 people finished the placement scheme and are qualified to fill gaps in the Health and Social Care workforce. • 5 offers of employment were made by us to people who would not have been on our recruitment radar without the work-placement scheme. • Approximately £1000 increase in revenue to local businesses contracted to deliver some of the scheme training. Other Care Academy Priorities - Quality Assurance have also been involved in a variety of other deliverables identified by the Care Academy, including the development of micro businesses within Adult Health & Social Care, development of local market facilitation plans, engagement with the principles of the Community Wealth Building and exploring options for funding to support training and wellbeing across the sector Impact of Increase in Employer National Insurance Contributions - Adult service colleagues liaised with providers to consider individual, unique and collaborative ways of minimising the impact of the increase in employer national insurance contributions. Meetings have taken place to ensure a solution focused approach to this. Provider Capacity Portal – Last year we reported that we would be rolling out a new portal whereby SDS Framework Providers would be able to report their capacity to deliver work. This roll out took place following an initial test of change. Feedback has been positive from providers and locality teams, in that the original aim to minimise the time impact for all, has been achieved through this reporting system. 7. Carer and carer focused organisations The Quality Assurance team participated in a range of carer focused work over the year, including a large-scale procurement exercise, monitoring of the commissioned carer focused organisations, engagement and participation focused activity, involvement in Carers Week and development work with the wider carer support network. The second annual Commitment to Carers event in North Lanarkshire was also organised and Page 222 of 288
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22 facilitated by Quality Assurance and supported by the commissioned carer organisations, again demonstrating the excellent partnership ethos to support carers locally. The Quality Assurance team continued to be influential in ensuring that North Lanarkshire maintained and further developed the long-standing positive record of engagement and participation and strong relationships with carers, and carer focused organisations. Over the reporting year Quality Assurance continued to engage with unpaid carers and carer focused organisations, to build on progress to date, and upon the intent set out in both the national Carers Strategy and the North Lanarkshire Carers Strategy 2024-2027. Quality Assurance led in certain areas of this work, offered support and guidance in other areas, and had an assurance overview throughout. Carers in North Lanarkshire are subject to the many challenges faced by unpaid carers nationally – around accessing breaks from caring, the hidden costs of caring, and issues with accessing replacement care are widely known and recognised, but solutions can be harder to identify. National Census information confirms that more people are having to provide unpaid care. In North Lanarkshire there is an ageing population of unpaid carers, and resources remain limited, whilst needs are infinite. Quality Assurance were involved in influencing and shaping how to best meet these challenges in a sustainable and innovative way, and the local carer experience over the past year continues to be significantly more positive than the findings and statistics reported nationally. This was evidenced through Quality Assurance monitoring and engagement with carers. In line with legislative requirements, a Procurement Exercise, led by Quality Assurance took place in late 2024 to identify carer focused organisations who would work in close partnership with UHSCNL to meet the needs and outcomes of unpaid carers locally. The UHSCNL financial commitment to support carers within this Tender was £18 million and involved significant engagement with carers and other stakeholders, resulting in key areas identified as being: • Adult Carer Support and Adult Carer Support Plans • Carer Information, Advice, Campaigning, Engagement and Participation • Dementia specific caring • Hospital Discharge related caring. • Support for Young Carers The successful bidders were: • Lanarkshire Carers • North Lanarkshire Carers Together (NLCT) Page 223 of 288
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23 • Alzheimer’s Scotland • Getting Better Together • Action for Children Young Carers Support Project Funding was also provided for: PAMIS – to offer a Family Support Service for families caring for individuals with profound, complex, and multiple disabilities, where specialist knowledge was required. HOPE for Autism - to support children, adults, and family carers, where Autism or Neurodivergence is a feature. Quality Assurance monitoring ensured continued strategic fit, best value, positive impact, and an outcome focused approach. Quality Assurance were also involved in the commissioning of North Lanarkshire Disability Forum (NLDF) - to deliver on the Engagement and Participation Strategy 2024 -2027. Engagement across seldom heard communities and organisations resulted in the voices of previously “hidden” carers also coming to the fore. Through a separate Tender led by Quality Assurance, the Adult Carer Advocacy remit was re-aligned to an Advocacy provider organisation, having previously been hosted by NLCT. Quality Assurance continued to be involved in both governance and operational activity around the Community Solutions programme, facilitated by Voluntary Action North Lanarkshire (VANL). A range of engagement and participation activities aimed at all carers, but with a focus on underrepresented individuals, groups, or communities, including carers from minority ethnic communities and LGBTQI+ communities and involving Quality Assurance, was progressed throughout the year. Funding was made available by Quality Assurance, for an Equalities post within NLCT, and this augmented a similar existing post within Lanarkshire Carers. Quality Assurance were involved in assessing funding applications across a variety of funding streams, including Carer Breather, VANL Community Mental and Well Being Fund, NLDF Growth Pot, and NLC Grant Awards Programme. The range of CVS organisations, including those with an age-related, or condition specific focus, continue to have a role in direct, or indirect, support to carers as well as supported people. Monitoring and quality evaluation regarding carer support across these organisations took place throughout the year to ensure that we continue to have a strong focus on approaches that are carer and supported people led. Page 224 of 288
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24 Quality Assurance continued to be involved in governance structures and strategic forums, involvement in improvement areas, consultation, and co- production, with identified actions that further engagement and participation in our day-to-day practice. 8. Commitment to Carers Event The 2nd annual Commitment to Carers Event took place in Motherwell in May 2024, following on from the inaugural event in Bellshill in 2023. The event saw a number of carers and young carers delivering keynote addresses on various caring related topics. The event, hosted by UHSCNL also served as the official launch of the North Lanarkshire Carers Strategy 2024 -2027. As part of the movement towards ever greater carer engagement and participation, responsibility for the annual Commitment to Carers Event has now passed from UHSCNL to NLCT, with the 3rd annual event continuing to have a focus on celebrating the impact of caring and carer focused activity, and is scheduled for November 2025, at the Chryston Community Hub. 9. Participation and Engagement Quality Assurance were instrumental in the progress made over the year to increase the capacity to enhance engagement and participation, across our communities, and amongst supported people and unpaid carers. This work continued over the year, in line with Ambition Statement 19, in the Plan for North Lanarkshire (Improve engagement with communities and develop their capacity to help themselves.) This is also priority within UHSCNL Strategic Commissioning Plan and is critical to ensuring: • We involve people in the decisions that affect their wellbeing. • Improvement comes from feedback on the experiences of services and supports. • Our services and supports continue to be based on what matters to people. • We have a continued focus on person centred approaches to embed the wider approach to Getting it Right for Everyone. The key ambitions of our continued investment to engage supported people, unpaid carers and communities is to: • Improve communication and increase connections • Increase awareness of what matters to people Page 225 of 288
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25 • Increase capacity for early intervention and prevention During 2024-25 the investment and focus to ensure that the voices of supported people were strengthened, gathered pace. The consortium of North Lanarkshire Disability Forum (NLDF), Lanarkshire Links (LL) and Voice of Experience Forum (VoEF), worked together to engage with supported people and support active participation. To help facilitate this, Quality Assurance provided a Growth Pot managed by NLDF. Across 2024-25 there were two rounds of Growth Pot funding that generated 55 applications and 20 awards totalling just over £80,000 to community organisations. The fund reached minority ethnic groups, rural communities and those who experience disability, mental health issues and addictions. The North Public Partnership Forum comprises 3 local forums in North Lanarkshire: Cumbernauld; Kilsyth and Villages; Northern Corridor. During the calendar year the forum decided to change their name to Lanarkshire North Partnership Forum to better represent the areas in North Lanarkshire in which they operate and as part of a review of their core functions. Over the last 12 months the forum’s views have been sought on a range of topics from health colleagues including Effective Prescribing, Pharmacotherapy and Treatment Escalation Plans. Quality Assurance participated in the forum and acted as a conduit to help facilitate progress, resolve issues and link to operational colleagues. In September 2024 the University Health and Social Care Engagement and Participation Strategy was launched alongside the Growth Pot Fund mentioned above. Quality Assurance were involved in both the drafting of, and raising awareness of, the strategy and its ambitions. During the year work to collate examples of best practice to support staff across the service to further engagement with those involved in services and supports was undertaken by Quality Assurance, in partnership with Planning and Performance colleagues. The Strategy for Carers 2024 – 27 was developed with carers and carer organisations and led by Quality Assurance. Carer related work is reported on in a previous section. Similarly, Quality Assurance support to Voluntary Action North Lanarkshire, (VANL) who oversee the Community Solutions programme, and the Children, Young People and Family Network is contained in another section of this report. Quality Assurance helps facilitate a broader reach within communities and supports opportunities for people to engage in what matters to them in North Lanarkshire. Engagement with localities builds community capacity, through anchor organisations and Community Consortia provide leadership and co-ordination of activities. The commissioning of Care Opinion in adult health and social care sought to ensure that there were opportunities online for adults, children and young people to feedback on their experiences and raise any concerns across the commissioned and funded services in North Lanarkshire. Quality Assurance has a coordination role in relation to Care Opinion. Page 226 of 288
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26 Care Opinion - Care Opinion is an independent, non-profit, web-based feedback platform where people can submit their experiences of health and social care services whether positive or negative. Comments are moderated and forwarded to the relevant service who can respond directly. 2024/2025 saw the introduction of a Care Opinion Newsletter produced by Quality Assurance. This has enabled feedback to be shared across networks and promotes the use of Care Opinion. The Care Opinion Newsletter celebrates positive feedback, highlights any lessons learned and is published quarterly. 10. Communications Quality Assurance have a key function within the area of communication. This includes the following responsibilities: - • Overseeing and updating North Lanarkshire Council (Social Work) and UHSCNL websites • Governing social work resources, policies and procedures held on our SharePoint site • Owners and administrators of Viva Engage – which includes responding to queries and sharing updates in relation to Subject Access Requests and Resources, Policies & Procedures • Quality Assurance Newsletter • Care Opinion Newsletter and administration of the stories received by UHSCNL Quality Assurance Newsletter During the reporting period the newsletter was refreshed and published three times. Having reviewed our Quality Assurance communications and the number of views from social work staff it was decided that a Quarterly Commissioned Services Report would be published. More information is available about this report under Contract Management Framework. Social Work Induction Talent and Organisational Development (TOD) initially developed a Social Work Induction Platform. Quality Assurance have continued to expand this with a specific focus on how we practice within North Lanarkshire. Various social work representatives have contributed to the development of this. Quality Assurance will continue to host a forum for ensuring on-going review. The current Social Work Induction Platform has been shared with IT Leads who will update accordingly. This work will progress during 2025/26. The focus from Quality Assurance will be to develop a standardised and localised induction programme which will concentrate on learning, development and reflective practice at key points, following commencement in a new post. Page 227 of 288
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27 11. Information Governance Quality Assurance had oversight to ensure that information was dealt with to the highest standards, ensuring fairness, consistency, and security. The Information Governance Framework supports in fulfilling these responsibilities. The team coordinate: • Subject Access Requests (SARs), including reviews, complaints from the Information Commissioner’s Office (ICO). • Quarterly SAR statistics. • Freedom of Information (FOISA) requests, including reviews and complaints from the Scottish Information Commissioner. • Data Protection Impact Assessments (DPIAs). • Data Protection Act (DPA) or Schedule 2 requests. • Annual ICO statistics. • Quarterly Corporate Key Performance Indicators (KPIs). The benefits of Information Governance for the council includes but is not limited to, enhanced data security, regulatory compliance, improved data quality, risk management, cost reduction, efficiency and accountability. Quality Assurance consult with the Freedom of Information Team and Data Protection Team, who guide internal processes in accordance with legislation. There was a continued focus on coaching, mentoring and training of locality administrative staff and field workers, in relation to SARs and SARs recording. This followed from the review and update of SAR’s recording systems. SARS statistics 2024/2025 The upcoming focus and development within Social Work Information Governance will focus on monitoring and tracking across all social work teams. 114 63 290 341 208 0 50 100 150 200 250 300 350 400 CASES AT START OF APRIL 2024 CASES AT END OF FEBRUARY 2025 TOTAL NUMBER OF SARS RECEIVED: TOTAL NUMBER OF SARS CLOSED: TOTAL NUMBER CLOSED ON TIME: SAR Information as at 31/03/2025 Page 228 of 288
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28 12. Procurement Quality Assurance continued to lead on procurement activity for all social work services in collaboration with colleagues within Corporate Procurement, Service Leads and Locality Social Work Teams, to ensure joined up planning, clear procurement processes and subsequent contract monitoring arrangements. This ensured that all commissioned contract work delivered best value, in accordance with Procurement Reform Scotland Act 2014 and the Procurement (Scotland) Regulations 2016. Quality Assurance support individual’s rights to determine the way they receive support, and this includes the right to select a provider who is not on any of our contract frameworks. On these occasions, and following due diligence checks of the preferred provider, Individual Placement Agreements (IPA’s) are created to ensure there is a shared basis between North Lanarkshire Council and the Provider for the delivery and manner of support. In the past year, 56 citizens of North Lanarkshire chose this route for support. Table 12a - Procurement activity for contracts under £50,000 undertaken in 2024/2025. Provider Contract Overview Service Area / Procurement Category Total Value of Contract (Excl VAT) Contract Start Date Contract End Date Commercial Strategy Sourcing Route Disabled Enabled Ltd: Access Panel North Lanarkshire Provision of advice and guidance in supporting and ensuring accessibility across North Lanarkshire buildings and the built environments Adult Social Work Services £4,684 01/04/2024 31/04/25 Re-Procurement Proposal for Funding SACRO Provision of an individual service using a mentoring Children, Families and Justice Social £49,995.00 01/06/2024 30/06/2025 Re-Procurement Proposal for Funding Page 229 of 288
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29 approach, which is a way of helping and supporting individuals with issues they might be facing both practically and emotionally. Work Services Ten for Zen Provision of the mindfulness sessions online and in person service users could develop skills, which is a way of helping and supporting individuals with issues they might be facing both practically and emotionally Children, Families and Justice Social Work Services £32,850.00 01/04/2024 31/03/2026 Re-Procurement Proposal for Funding Lanarkshire Counselling &CBT Centre (LCCC Scotland Ltd) Provision of counselling services, in person, virtually and by telephone, service users have the opportunity to Adult Social Work Services £33,600.00 01/04/2024 31/03/2025 New Requirement Proposal for Funding Page 230 of 288
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30 address problematic areas in their lives with a trained counselling professional. Yoga Through the provision of the yoga and breath work in person sessions, service users have the opportunity to reduce stress, improve mental and physical health and improve coping skills. Children, Families and Justice Social Work Services £5,190 01/04/2024 31/03/2025 New Requirement Proposal for Funding Wise Group An on-line service that assists people to develop life skills. It is a secure flexible service for people being supported by a range of Justice Services and can count Children, Families and Justice Social Work Services £31,506 01/04/2024 31/03/2025 Re-Procurement Proposal for Funding Page 231 of 288
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31 towards the other activity element of a community payback order Families Outside A support service for families in North Lanarkshire who are affected by imprisonment Children, Families and Justice Social Work Services £56,188 01/04/2024 31/03/2025 New Requirement Proposal for Funding PAMIS Family information, advice, and support service for families in situations where a family member has a significant level of disability - profound and multiple learning disability (PMLD). Adult Social Work Services £36,500.00 01/04/2024 31/03/2025 Re-Procurement Proposal for Funding Shelter Scotland Provision of Specialist Housing Advocacy Service Adult Social Work Services £25,000.00 01/07/2024 31/03/2025 Re-Procurement Proposal for Funding Page 232 of 288
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32 Improvement Service Provision of independent support from the improvement service to offer workshops, consultation and engagement to help direct a review of family support. Children, Families and Justice Social Work Services £5,000.00 09/09/2024 01/06/2026 New Requirement Proposal for Funding Deaf Services Lanarkshire Provision of support to reduce inequalities for people with a sensory impairment Adult Social Work Services £10,000 01/02/2025 31/07/2025 Re-Procurement Proposal for Funding Barnardo’s Scotland To provide a Missing Persons Service across the North Lanarkshire to children and young people who have been reported missing to Police Scotland. Children, Families and Justice Social Work Services £50,000 16/02/2024 15/02/2025 Re-Procurement Proposal for Funding Page 233 of 288
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33 Care Opinion The purpose of the Care Opinion Subscription is to: • Provide an innovative model which assists and enables the Subscriber to fulfil their public engagement involvement responsibilities; • Enables the Subscriber to compare feedback on the Care Opinion website across local services using alerts and push reporting to provide access to performance management information for staff, managers, partnership, elected officials and key Social Work £35,936 01/11/2024 31/10/2027 Re-Procurement SLA Page 234 of 288
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34 stakeholders including public partners; • Provide evidence about the quality of services provision which can be used to support relevant standards in relation to quality and participation of people who use services. Table 12b - Procurement activity for Contracts over £50,000 undertaken in 2024/2025. Contract Title Contract Overview Total Value of Contract (Excl VAT) Service Area Contract Start Date Contract End Date (Excl Extensions) Advocacy Services for Children & Young People Due to new legislation to be introduced by Scottish Government during the early part of 2025, it is necessary to grant a direct award for 12 months to the current provider. This will enable the service to develop and take cognisance of the new legislation. A subsequent open tender will take place in 2025/2026. Provision of advocacy services to children and young people is in support of their rights as individuals as set out in the United Nations Convention on the Rights of the Child (UNCRC), which aims to support children in all areas of their lives. £241,000.00 Children, Families and Justice Social Work Services 03/03/2025 28/02/2026 Page 235 of 288
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35 Befriending Service The aim of this support is to provide additional resource to Children’s Services Planning Partnerships to provide the right support at the earliest time to children, young people and families. This also supports the ambitions of the Promise; to provide flexible and responsive support, enabling more children to remain loved and supported within their own families and develop resilience, self-esteem, address isolation and build effective relationships. £361,591.80 Children, Families and Justice Social Work Services 01/10/2024 30/09/2025 plus 2 one- year extensions available Community Alarm replacement - Analogue to Digital UHSCNL and NLC have invested significantly in early intervention and supported self-management for over a decade, with support for change and investment across all sectors which focus on wellbeing. The Community Alarm Service is a key part of supporting self-management with technological advancements creating the opportunity to move from a crisis response service to being more proactive and preventative. Telephone lines in the UK are being upgraded to digital technology. The process of migrating to digital telephone lines has already started. The rollout was scheduled to be completed by the end of 2025, when analogue telephone services in the UK will be switched off and replaced by digital systems using internet protocol (IP) technology £495,000.00 Social Work 17/02/2025 31/03/2025 Community Alarms Individuals who have been provided with telecare equipment from NLC, Social Work, such as community alarm and assistive technology must have their equipment updated to continue to receive a safe and reliable service. £249,970.00 Adult Social Work Services 20/05/2024 16/11/2024 Community Living Support The service helps to ensure those residents of North Lanarkshire, who require support to maintain their tenancy, are enabled to do so. The low-level support available contributes to good health and wellbeing and can reduce any need for higher level support. £1,209,960.00 Adult Social Work Services 01/06/2024 31/05/2027 Page 236 of 288
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36 Direct Payment Support Services The service will provide independent support and advice for people wishing to consider or actively employ staff directly to meet their social work budget using a direct payment option 1. £415,788.00 Adult Social Work Services 06/01/2025 05/01/2028 Distress Brief Intervention (DBI) The overarching aim of the DBI service is to provide a framework for improved inter-agency co-ordination, collaboration and co-operation across a wide range of care, settings, interventions and community supports, towards the shared goal of providing a compassionate and effective response to people in distress improving experience and outcomes for those experiencing distress and those providing support. Pan Lanarkshire with North Lanarkshire as the lead procuring partner. £1,917,960.00 Adult Social Work Services 01/04/2024 31/03/2026 Domestic Abuse An inclusive domestic abuse service for any person affected by abuse aligned too Equally Safe £1,384,492.00 Social Work 01/06/2025 30/05/2029 Early Help & Family Support To provide early help and take a preventative approach to providing support to families who need it. This is an opportunity to connect services locally and improve access to family support through earlier and more effective response to need. £4,080,000.00 Education 01/04/2024 31/03/2026 plus 1 year extension available Flexible Framework for Self-Directed Support - Entry Point 4 Flexible Framework with Providers to support the critical Service Delivery to Children, Young People and Adults who have been assessed as requiring support to design, develop and achieve real lives in line with the Social Care (Self Directed Support) (Scotland) Act 2013 £820,000,000.00 Adult Social Work Services 01/04/2025 31/03/2031 Independent Advocacy Services (Adults) Independent advocacy supports people to have their voices heard and their rights and interests protected. Independent advocacy is a positive force in influencing social change, with the work and ethos of advocacy underpinned by a person-focused and human rights framework. The importance and benefits of independent advocacy are now widely recognised and woven into the fabric of health and social care provision and legislation in Scotland. Advocacy for carers and for people affected by drug and alcohol £3,507,405 Adult Social Work Services 01/03/2025 28/02/2028 plus 2 one- year extensions available Page 237 of 288
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37 misuse are now also incorporated into the requirements of the contract. Multi Agency Risk Assessment Conferences (MARAC) Provision of effective management, co-ordination and administration of Multi Agency Risk Assessment Conferences (MARAC), on behalf of North Lanarkshire Council and North Lanarkshire Health and Social Care Partnership £253,325.00 Children, Families and Justice Social Work Services 01/07/2024 30/06/2026 plus 2 one- year extensions available Mental Health Peer Support and Short-Term Mental Health Support Service Mental health and wellbeing service that provides support to residents of North Lanarkshire experiencing mental health challenges. Lot 1 – Peer Support Service with Info Service Lot 2 – Short-Term Support Service. £3,081,204 Adult Social Work Services 01/03/2025 28/02/2029 Support for Unpaid Carers and Young Carers To provide support to unpaid adult carers and \ or young carers, across North Lanarkshire. The service(s) procured will be instrumental in helping North Lanarkshire Council meet statutory requirements and duties as outlines in the Carers (Scotland) Act 2016 and Self-Directed Support (Scotland) Act 2013, specifically around support to carers. Lot 1: Direct Carer Support and breaks from caring, Lot 2: Carer Information, Advice and Campaigning Services and breaks from routine from routine, Lot 3: Condition specific Carer support (Dementia), Lot 4: Post Discharge Carer Support, Lot 5: Young Carers £16,380,000.00 Adult Social Work Services 01/03/2025 28/02/2028 plus 3 one- year extensions available. National Shared Alarm Receiving Centre (ARC) Framework is a single supplier framework and will provide the participating members a mechanism to procure a technology solution to contribute to a smooth transition from the current analogue connections to digital connections within their Alarm Receiving Centres. £412,183.00 03/03/2025 02/03/2027 plus 2 one- year extensions available Page 238 of 288
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38 Bairns Hoose Underpinned by the UNCRC, Bairns Hoose promotes a child-centred, trauma-informed and multi-agency approach that supports children recover from abuse. £102,640.00 Children, Families and Justice Social Work Services 01/10/2024 30/09/2025 Missing Persons To provide a Missing Persons Service across the North Lanarkshire to children and young people who have been reported missing to Police Scotland. £290,000 Children, Families and Justice Social Work Services 15/02/2025 14/02/2027 plus 2 one- year extensions available Provision of information and advice service for (Autism) To provide a bespoke service to persons, families, communities and professionals who are affected by or work with Autism. £62,500.00 Adult Social Work Services 01/04/2025 30/09/2025 Provision of support for people affected by Huntington’s Disease A bespoke service to persons, families, communities and professionals who are affected by or work with Huntington’s Disease. Tripartite agreement with North Lanarkshire Council, South Lanarkshire Council and NHS Lanarkshire. North Lanarkshire Council is the lead. £398,898 Adult Social Work Services 01/04/2025 31/03/2028 Page 239 of 288
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39 13. Ethical Commissioning The Scottish Government’s Adult Social Care Ethical Commissioning policy team commissioned the Institute for Research and Innovation in Social Services (Iriss) to work with a range of partners, on developing an implementation plan with priorities, to ensure that ethical commissioning and procurement principles became a reality. One of the priorities identified by the group was for better support for commissioners and to work on developing training and a qualification for commissioners. As part of the project, Iriss ran an Action Learning Set for commissioners. The aim was to develop support for commissioners and others involved in implementing ethical commissioning and procurement. A group of 15 local authority commissioners were invited to meet monthly from August 2024 to January 2025 for discussions with input from expert speakers. Quality Assurance were part of this group. Local commissioners shared their experiences, challenges and priorities for support and any training needs. The group provided a space for learning, development and support with the move to ethical commissioning, and for commissioners to hear about current developments and improvements in commissioning policy and practice, working together on identifying priorities for future support. The outcomes were: • Commissioners have increased knowledge, skills and confidence in their commissioning practice. • The Scottish Government Adult Social Care Ethical Commissioning team and partners have a clearer sense of commissioning as a distinct profession and the skills and knowledge required to commission ethically. • Scottish Government and partners have a foundation on which to build future and more formalised training in partnership with larger training focussed organisations. Scottish Living Wage Last year we reported that most Providers had indicated they were either already accredited as or were willing to become Scottish Living Wage employers. This trend continues, with 96% of 96% 4% Providers Paying Scottish Living Wage at at 31/03/2025 YES % N/A % 96% 4% Providers Paying Scottish Living Wage as at 31/03/2024 YES % N/A % Page 240 of 288
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40 Providers who deliver a direct care & support service paying the Scottish Living Wage. The remaining 4% of Providers provide non-care related services (such as domestic & catering staff) or are within the cross-border category, whereby the Scottish Living Wage does not apply. 14. Adult Support & Protection (ASP) Quality Assurance have a remit across social work in supporting commissioned services to respond in accordance with Adult Support & Protection legislation and North Lanarkshire Council policies and procedures. Quality Assurance also have a role in the identification of any patterns and themes which may indicate wider systemic concern. As a direct link to commissioned services, Quality Assurance promote best practice in relation to Adult Support & Protection. Over the reporting period, Quality Assurance continued to maintain links with adult services colleagues to ensure ASP activity was considered in day-to-day practice. Quality Assurance continue to have representation in the following ASP forums and contribute to: • Learning & Development • Monitoring & Reporting • Lanarkshire Wide Care Home Task Force Group • Weekly Care Home ASP Review Quality Assurance were also involved in a National Learning Review involving the closure of a Care Home. Representation will continue within a focus group driving forward local recommendations that arose from the Learning Review. 15. Social Work Risk Management Quality Assurance have oversight of the social work risk register and are responsible for quarterly & annual reporting, compliance audits and for the facilitation and coordination of the Social Work Risk Forums. Quality Assurance participate in Corporate Risk Management Team meetings, and cascade appropriate information through the correct forums. Risk Champions and Facilitators act as points of contact for risk management matters within social work and promote risk awareness across the service. Representatives from the Quality Assurance Team participated in a two-day accredited Institute of Risk Management (IRM), Essentials of Enterprise Risk Management Course. Participation assisted Quality Assurance to continue to progress the reframing of social work risks, to ensure that these are fluid, dynamic, specific and relevant to the current environmental context. Risk Champions and Facilitators continue to engage with risk owners to provide awareness and support to reframe risks. This approach ensures that our work priorities are focused on the correct areas. Risk continues as a standing agenda item at the ASW Governance and Social Work Leadership meetings and there is a plan for live risks to be discussed and reviewed by leadership teams within these forums. 16. Registered Social Landlords Since the summer of 2023, Quality Assurance has been leading on the review of five Registered Social Landlords who provided thirteen sheltered & very sheltered developments across North Lanarkshire. These services were funded to provide housing support, using Supporting People Page 241 of 288
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41 funding. This funding stream was discontinued around 2016/17, leading to mainstream social work funding being accessed pending review. Quality Assurance engaged with all stakeholders during 2024/2025 to hear their views in relation to the proposal to discontinue housing support services and move to Retirement Housing. Advocacy were involved to ensure representation for those who required this. Following the engagement sessions, it was agreed that NLC would no longer commission or fund the staffing associated with the legacy model. This was to ensure that all those living within the services under consideration could have choice and control over who delivered their care and support in line with SDS principles. Two of the five Registered Social Landlords (RSL’s) involved transitioned from sheltered/very sheltered housing to other models in April and July 2024 respectively, and positive outcomes were reported following the change. The remaining three RSL’s continued to finalise their transition plans and in early 2025 one moved to a new model. For the remaining two RSL’s direct funding from NLC has ceased. However, one of these RSL’s elected to join NLC’s Self-Directed Support including Care at Home Framework to enable them to provide care and support utilising individual budgets should people chose them as a provider. We will continue to engage through monitoring activity. Following the conclusion of this review there is confidence that individuals are receiving the right support at the right time. 17. Care Home Governance & Assurance Following review of the enhanced clinical and care oversight arrangements for care homes reported last year, there has been continued support commissioned through the Care Home Assurance and Support Board and the Care Home Collaborative Group. The Collaborative Group combined what was previously two separate subgroups - the Care Home Governance Group and the Care Home Healthcare Framework Implementation Group. An initial gap analysis of the implementation of the Healthcare Framework and follow up review have been progressed meaning that the separate Implementation Group was disbanded. The Safety Huddle Multi-Disciplinary Forum which has continued to build on good practice embedded during the pandemic, has been further stepped down to fortnightly meetings. The focus of work has been reviewed and refined to include the ratings for each Care Home within North Lanarkshire. Adult Support and Protection escalations have also been included in discussions. These further enhancements maximise the effectiveness of the arrangements in place, to ensure systems and processes enable intelligence to be shared between agencies, to identify and allow support to be provided to care homes at risk. Actions are agreed collaboratively to provide an immediate response to safeguard residents. Quality Assurance participate in the Collaborative Group and the Safety Huddle and play a part in influencing the assurance and governance arrangements through a social work lens. Quality Assurance have been involved in the on-going review of the Healthcare Framework Gap Analysis, and it is envisaged that enhanced awareness raising across care homes of the framework and what providers and people can expect, will be a focus of activity throughout 2025/26. Quality Assurance introduced a working group with providers, to understand the Healthcare Framework. The meetings were initially beneficial, as historically Care home managers did not always engage with opportunities to participate in formal governance meetings. However, with consensus, these meetings have since been disbanded as the group felt it had achieved its purpose. Page 242 of 288
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42 18. Care Home Managers Meeting Quality Assurance continued to co-ordinate Care Home Managers Meetings as a support for Care Home Managers. Meetings, hosted in a local care home setting, have continued, with the aim to have them quarterly. The meetings give the opportunity to share ideas, good practice initiatives and common provider concerns. There is an ongoing input and update from a range of professionals involved in supporting care homes. Meetings over the reporting period have included topics such as Adult Support & Protection, promoting continence care, promotion and use of care opinion, pharmaceutical updates, the healthcare framework and safe staffing legislation. The Associate Medical Director, attended the meeting in August 2024 to brief the group on the Serious Adverse Event Review (SAER) 19. Complaints Quality Assurance retains an overview role in terms of complaints regarding Social Work service provision. Quarterly reports on complaints activity are reported through our governance structures. The annual summary and analysis of complaints received over the period 2024/2025 is attached as Appendix 1. 20. Duty of Candour All health and social care services in Scotland have an organisational duty of candour. This is a legal requirement which means that when certain types of incidents happen, the people affected understand what has happened, receive an apology, and the organisation learns how to improve for the future. An annual report capturing Duty of Candour activity is a requirement of the Council and the report for 2024/2025 is attached as Appendix 2. 21. Safe Staffing The Health and Care (Staffing) (Scotland) Act 2019 (HCSA) came into effect on 1st April 2024. The purpose of this legislation is to establish a statutory framework to ensure appropriate staffing levels in health and care settings. A review of procurement, contracts and contract monitoring processes took place prior to the implementation of the Act. There has been recognition from Scottish Government, Care Inspectorate and all Local Authorities that the reporting requirements for Local Authorities are currently vague and therefore in the lead up to the first annual report, there remained new and emerging guidance being shared. Reassurance has been provided, that due to the lack of clarity, the Care Inspectorate on behalf of the Scottish Government, will carry out an analysis of reports following receipt, with clearer guidance and a reporting template to be made available for annual reports due in 2026. Quality Assurance worked collaboratively with the Care Inspectorate throughout the year, participating in the HCSA Implementation Group, which is facilitated by the Safe Staffing Programme and was launched in August 2024. This group meets every two months and provides a forum for stakeholders to share experiences, good practices, and areas for improvement. Whilst the group is ongoing, discussions are underway about its future direction after the current reporting period. Page 243 of 288
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43 Quality Assurance continued to support both commissioned and in-house services with the implementation of the Act throughout the reporting period, by facilitating two dedicated working groups. North Lanarkshire Council have responsibilities as a provider of care and support and as a placing authority. • Commissioned Services Working Group This group was established prior to the Act’s implementation. Its aim was to share best practices and discuss potential risks. Feedback from participants indicated that attending the group was beneficial and helped them feel more prepared. Following the implementation of the Act, the group continued to meet for several months, creating a collaborative platform where services could share experiences, including examples of good practice and areas for improvement. • In-House Registered Services Working Group This group was formed in November 2024 and initially met monthly, before transitioning to a bi-monthly schedule. It continues to be well attended by registered managers, and feedback indicates that the group is valuable in supporting ongoing learning, knowledge exchange, and the sharing of best practices. • The group has developed an assurance tool which is based on the guiding principles of the Act, and it is intended to document evidence of how the principles of the Act influence staffing arrangements. This tool is being used across all NLC registered services. • Throughout 2025/2026 staffing contingency plans and staffing level tools will continue to be developed. The Health and Care (Staffing) (Scotland) Act 2019: Annual Report for Social Work Services is attached as Appendix 3. 22. North Lanarkshire Registered Services Care Inspectorate Activity: Annual Report 2024/2025 Quality Assurance have oversight of Care Inspectorate activity, and this enables the monitoring of individual services and organisational patterns, themes and trends. An annual report has been produced capturing findings over the reporting period see Appendix 4. 23. Getting it Right for Everyone (GIRFE) Quality Assurance were represented on the GIRFE Facilitation Group, which is tasked with ensuring that the wider principles of the national approach to GIRFE were embedded within day-to-day practice across North Lanarkshire. GIRFE is about providing a more personalised way to access help and support when it is needed. GIRFE places the person at the centre of all the decision making that affects them, with a joined-up consistent approach, regardless of the support needed at any stage of life. GIRFE is intended to inform the future practice model of all health, social care and public sector professionals, and shape the design and delivery of services, ensuring that people’s needs are met. Work to embed the 5 GIRFE principles, as noted below is ongoing and the GIRFE Facilitation Group had a lead role in raising awareness of these and seeking to ensure that these are reflected in operation day to day. Page 244 of 288
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44 • I have the information I need to make decisions about my life, in a way that works for me, and I am supported to understand what options are available to me, and trusted to know what is right for me • the people who support me take the time to listen and understand me as a person and we consider my whole life when making decisions about my life • I know that I can be clear about what matters to me, and I trust that my choices will be respected and understood by the people who support me • if I need to access services or support, I am treated with kindness, dignity and respect at all times. • the people I am involved with work together with me and each other to share information, in a way that is accessible to me and develop a clear understanding of how to support my wellbeing The GIRFE approach applies equally to existing supports and services, as well as to innovation, with some exciting innovations underway. A Getting it Right for Everyone Approach has now been embedded within North Lanarkshire as our local means of meeting the aspirations of the national approach. 24. Back-to-basics to getting it right for everyone Over the past year within Adult Health & Social Care Services, we have been working on the development of an enabling approach that supports the move from our work on back-to-basics to getting it right for everyone, as we recognise the landscape of health and social care is changing and services, supports and responses need to change to continue to improve the lives of people who live and work in North Lanarkshire. We have sought to adopt a human learning approach by trying different ways to focus more on people and less on systems and processes, and use resources to their best effect, to make the most positive impact on peoples’ lives. Through the learning as management strategy (also known as Human Learning System) approach, we have been working with academic and national partners, including Healthcare Improvement Scotland, to make learning and experimentation a key driver in our work. A key element of the learning approach has been the development of a Whole System Enabling Approach strongly embedded within each of the six localities, which supports a place-based model. Overarching this work has been making sure that when people contact our services the response is quick and effective, with a focus on helping people to help themselves first. Our Enabling Approach has helped us understand and consider how all parts of the Health & Social Care system interact and influence each other. Our desire is to continue to support people to thrive by providing targeted services that are tailored to reflect their diverse needs. Keeping people central to the decisions that affect them is key and has helped us plan actions that support positive outcomes for those who access our services. Over the coming year we will further develop specific plans and service developments: as this is a whole system approach, we anticipate there will be a lot to focus on and much change across services, supports and responses that are needed to achieve and sustain change. 25. Trauma Informed Practice There is a Scotland wide vision of a trauma informed and responsive workforce and services. This approach recognises the impact of trauma and adversity on individuals and seeks to prevent further harm, support recovery, address inequalities and improve life chances. Within Page 245 of 288
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45 North Lanarkshire, a Trauma Informed Practice Oversight Group was established, with representatives drawn from across the wider Health and Social Care service, including Quality Assurance. The remit of the group is focused on ensuring that the principles of Trauma Informed Practice are embedded in day-to-day practice, and that our buildings and spaces also reflect and support a Trauma informed approach. Examples of the role of Quality Assurance in supporting this approach include, but are not limited to: Three recently concluded adult Tenders (Adult Advocacy, Support for unpaid Carers, and Peer Support, Mental Health) were all developed in line with Trauma Informed Practice. The services commissioned through these Tenders, as well as other local CVS organisations who provide information\ advice \ support to citizens of North Lanarkshire, were, for the most part, involved in an initial Trauma Informed Awareness session, facilitated by the Trauma informed Practice Lead. The overall intention is that Trauma Informed Practice becomes embedded into everyday practice, not just within Health and Social Care, but across partner organisations also. The next step in this process will be to link with framework support provider organisations and promote the opportunity to participate in Trauma Informed Practice awareness raising sessions, again with the expectation, that Trauma Informed Practice is further embedded within these organisations also. Work will also continue to embed Trauma Informed Practice across the services delivered by UHSCNL. 26. Policies and Procedures Work has continued to progress in relation to Social Work Policies and Procedures. Quality Assurance are the SharePoint site owners for these, and editing rights are restricted to the team. During the reporting period there has been a Policies & Procedures Working Group established with representatives from across social work. The aim of this group was to agree the file path for central storage and easy access. Furthermore, policy control documents would be attached to ensure that policy owners, review dates and version control were available and up to date. Thereafter the plan was for Quality Assurance to host a Policy Review Group to ensure social work policies remain consistent with changes in legislation and practice. This work was paused due to a variety of findings which made it difficult to establish a suitable file path due to use of language and gaps and duplication in policies and procedures. Several discussions and presentations have taken place with the Senior Leadership Team and colleagues in Legal Services and Corporate and there is now a plan to progress with the devising and implementing of policy statements, rather than working directly from National Guidance. These policy statements will guide and govern all safe operating procedures for local services. This work will be carried out in phases commencing with Registered Services. 27. Care Home Physical Activity Initiative UHSCNL funded an initiative with the Burns Gym which has meant that over the reporting period, Burns Gym has successfully expanded and enhanced its virtual fitness programme, delivered weekly via Zoom, for care homes across North Lanarkshire. 23 out of 27 homes participated in this imitative. Joe and Tony Burns have effectively engaged residents, significantly improving their physical, social, and mental well-being. Participation has increased, and feedback continues to highlight the programme’s positive impact. Page 246 of 288
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46 From the latest evaluation report some of the key Statistics have been identified and these include: Physical Health Improvements: Mobility improved in 50% of participating homes. Strength and balance improved in 40% of homes. Falls reduced in 20% of homes. Social Engagement: 72% of homes reported increased social interactions. Emotional Well-being: Improved mood reported in 80% of homes. The link to the report is below for more information. NLC 12 Month Evaluation Report.docx 28. Adult Social Work Subgroup – Registered Managers An Adult Social Work Subgroup for Registered Managers was established in 2025. This group meet 8 weekly, and the chair is the Quality Assurance Service Manager or delegated person. This group reports through the ASW Governance Group and its purpose is to ensure robust governance and oversight across Registered Services. The group aims are to: • Ensure good governance and oversight across service delivery • Work collaboratively as registered managers team • Source/agree solutions that promote good outcomes • Identify and agree actions that improve the quality of care and support and reduce the risk of harm • Ensure robust systems and processes are in place to reporting through various governance routes • Support a culture of self-evaluation; refection; shared learning; improved practice • Plan and support the inspection process through the development of improvement plans Initial feedback is that this forum is well received and Registered Managers feels that it gives them focused time to discuss and plan improvement work with their peers. There are plans in place for Duty of Candour, Engagement & Participation & Infection Control to be future focus sessions. 29. Social Work Scotland Contracts & Commissioning Practice Network Quality Assurance participate in quarterly Social Work Scotland Contracts & Commissioning Practice Network. The team lead on a Care Home subgroup which explores some of the national issues, initiatives and best practice. This group feed back to the main membership. Page 247 of 288
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47 Quality Assurance also facilitated a session on VAT Holding Companies as requested by the Chair. 30. Quality Assurance Planned Developments This report has covered Quality Assurance activity undertaken during the period 1 April 2024 to 31 March 2025 and highlights progress made in key activities noted in the last reporting period. Several developments outlined below are in progress or planned for the period 2025/2026 and we will provide updates in future reports. Quality Assurance Planned Developments • Work with operational colleagues to influence and shape future procurement and service specifications • Establish clearer end to end procurement processes • Revamp contract mobilisation procedures • Working with commissioned services to support/mitigate the impact of the NI changes. • Finalise Social Work Induction • Further develop support for Carers • Progress with Policy Statements/ Policy Review Group/File Path • Roll out of Social Work Self Evaluation following test of change • Complete programme of In-House Monitoring • Build on engagement and participation toolkit to embed throughout all aspects of our work • Embed Programme of Work Governance Structure & Reporting Procedures • Oversight and support in relation to Care Inspectorate complaints for registered services • Sampling/Quality check/Feedback relating to Elected Members/Parliamentary enquiries • Complete reframing of risks on social work risk register. Change the ethos of review. • Participate in National Care Home Learning Review/Progress Recommendations for Quality Assurance • Establish quarterly reporting structure for expressions of dissatisfaction & Care Inspectorate activity for Registered Services • Progress Care Academy deliverables Page 248 of 288
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48 Annual Complaints Report 2024-2025 Social Work [Adults and Education, Families & Justice] Introduction This report provides an overview of Social Work’s performance in terms of handling complaints received between 1 April 2024 and 31 March 2025 which covers both Adults and Education, Families & Justice services. This report describes how complaints have been managed by social work services, details the number and nature of complaints received during the year and demonstrates our commitment to learning and improvement. Complaint Process We always aim to provide the highest possible quality of service to all members of our communities and are committed to ensuring accountability and transparency. We recognise there are times when we get things wrong and fail to meet the expectations of those who use our services. We welcome feedback as it provides information that helps us to learn from complaints and shape and improve the way services are delivered. Complaints are viewed as a positive communication tool and are actively encouraged. As per the Scottish Public Services Ombudsman [SPSO] definition, we regard a complaint as any expression of dissatisfaction, by one or more members of the public, about our action or lack of action, or about the standard of service provided by us or on our behalf. Anyone can make a complaint, either verbally or in writing, face to-face, by phone, letter or email. People are directed and encouraged to use the North Lanarkshire Council online portal to make a complaint but retain the right to use any of the aforesaid options. A two-stage statutory social work complaints process was introduced on 1 April 2017, which harmonised complaint handling processes across all council services. The process is as follows: • Stage one – ‘frontline resolution’: we will always try to resolve complaints quickly, within five working days, and in exceptional circumstances extend for a further five days. • Stage two – ‘investigation’: if people remain dissatisfied with our stage one response, they can escalate their complaint to stage two. Complaints that are complex or need detailed investigation from the outset can be looked at immediately at stage two. These complaints will be acknowledged within three working days and a written response provided within twenty working days; this can be extended in exceptional circumstances. Appendix 1 Page 249 of 288
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49 Following completion of the complaints process, if the person remains dissatisfied, they can ask the SPSO to consider their complaint further. We always advise of this entitlement and provide contact details. Complaint activity [overall] Overall, 263 complaints were received in the reporting period, an increase of 58 [28%] from 2023-2024 when 205 complaints were recorded. Notably, 34% of all adult services complaints were in relation to home support services. A breakdown of locality complaints is undernoted: Education, Families & Justice 103 complaints were received in relation to Education, Families and Justice services across 2024-25, an increase of five [6%] from last year. The undernoted summarises locality complaint activity for Education, Families and Justice services across 2024-2025. Adult Social Work Services 160 complaints were received in relation to adult services across 2024-25, an increase of 59 [54%] from 2023-2024. The undernoted summarises locality complaint activity for Adult Social Work Services in 2024-25. 14 18 21 16 7 17 10 Airdrie Bellshill Coatbridge Cumbernauld Motherwell Wishaw H.Q. Education, Families & Justice Services 57 16 9 19 19 28 12 Airdrie Bellshill Coatbridge Cumbernauld Motherwell Wishaw H.Q. Adult Social Work Services Page 250 of 288
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50 All localities had increased complaint activity in the reporting period. However, Airdrie and Bellshill recorded notably high increases over 2024-2025 – Airdrie, a 62% increase, Bellshill, a 100% increase. Increased complaints were attributable to dissatisfaction about home support services in the areas. However, Bellshill complaints are still relatively low – they recorded eight in 2023-2024 and 16 2024-2025. Management actions were deployed to consider this increase more fully, and consequently, home support complaints decreased in quarter four. Performance Indicators The Complaints Standard Authority, in conjunction with the Scottish Public Services Ombudsman developed a suite of four mandatory performance indicators in association with the Local Authority Complaint Handlers Network on which we are represented. These indicators [undernoted] are a valuable source of information as they help to identify recurring or underlying issues, derive/drive learning from complaints and highlight potential areas for improvement. • Indicator One: the total number of complaints received. • Indicator Two: the number and percentage of complaints at each stage that were closed in full within the set timescales of five and 20 working days. • Indicator Three: the average time in working days for a full response to complaints at each stage. • Indicator Four: the outcome of complaints at each stage. Education, Families & Justice – Performance Information Indicator One - 103 complaints were received in relation to Education, Families and Justice services across 2024-25 Indicator Two/Three: Compliance with target statutory timeframes to complete complaint. Undernoted graphics depict adherance to statutory timeframes. At Stage 1, 57% were met within 5 working days, a further 38% were met with an agreed extension [within 10 working days], and 5% were outwith response target time. Average number of days to issue response: 6 working days. At Stage 2, 56% were met within 20 working days, a further 24% required an agreed extension, and 20% were outwith reponse target time. Average number of days to issue response: 34 working days. Page 251 of 288
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51 Indicator four - Complaint Outcomes “Outcome” refers to whether a complaint was upheld, not upheld, partially upheld or resolved. At Stage One, 33% of all complaints were not upheld, with the remaining 66% recording a positive outcome for the complainant. At Stage 2, 36% were not upheld, 64% recording a positive outcome. The volume of Education, Families and Justice complaints since 2020-2021 has remained stable, with little variation in the number of complaints between 2021-2022 and 2024-2025. Cause of Complaints [Stage 1 Cause of Complaints [Stage 2] Page 252 of 288
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52 Adult Social Work Services – Performance Information Indicator One - 160 complaints were received in relation to adult services across 2024-25. Indicator Two/Three - Compliance with target statutory timeframes to complete complaint. Undernoted graphic depicts adherance to statutory timeframes: At Stage 1, 53% met statutory response times, 26% met statutory timeframes within 10 days, 21% breached target timeframe. Average number of days to issue response: 6 working days. At Stage 2, 72% were met within 20 working days, a further 18% required an agreed extension, and 10% breached target timeframe. Average number of days to issue response: 23 working days. Indicator 4 - Complaint Outcomes “Outcome” refers to whether a complaint was upheld, not upheld, partially upheld or resolved. 54% of complaints at Stage 1 were not upheld, with the remaining 46% recording a positive outcome for the complainant. At Stage 2, 37% of complaints were not upheld, 63% had a positive outcome. 35 53 11 Stage 1 Upheld Not upheld Partially upheld 7 148 9 Stage 2 Upheld Not upheld Page 253 of 288
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53 Adult Social Work Service complaints show variation in the number received between 2021- 2022 and 2024-2025. The increase in complaints throughout 2024-2025 are commensurate with increased home support complaints. Cause of Complaints Stage 1 Stage 2 Learning from Complaints [Both Services] The learning from all social work complaints this year have highlighted: • The importance of good communication and mutually respectful interactions. • The need to ensuring that those who use our services and their carers have appropriate information. • Ensure that service quality is met. • The need to improve information and advice for those who need to contact and seek support from social work services. • Importance of reviews carried out regularly. • Ensure that we comply with Human Rights. Page 254 of 288
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54 • Update support plans accurately. • Confirm social work planned intervention with person. • Adherence to timeframes. • Assure that all staff are appraised of procedural/process change. Outcomes are often specific to the complaint and complainant, but when there are organisational learning points that influence policy or procedure, it is necessary to ensure that learning outcomes are cascaded and acted upon. Individual learning points are handled directly with the complainant and through supervision with members of staff. More general learning points are cascaded through supervision with team members and discussion at team meetings. 31% of all social work complaints indicated that there were no learning outcomes, whilst 34% were attributed to communication/staff attitude as the principal cause of complaints. 19% related to other issues as mentioned above, with 16% unrecorded on the system. 54 [34%] of Adult Social Work Services were in relation to home support services in this reporting period. We recognise the importance of learning from complaints and acknowledge that having a learning outcome recorded is an area that requires attention. We understand that complaints help organisations learn more about the experiences of people who use their services, and that complaints can be helpful to enable us to provide a person-focused service. While learning from complaints remains a non-mandatory performance indicator by the Scottish Public Services Ombudsman, they are interested in any systemic changes that are made following a complaint. Going forward, we will work directly with our locality teams to ensure that accurate recording and learning from complaints is embedded in practice to ensure quality services are delivered. Scottish Public Services Ombudsman The SPSO considered nine complaints throughout 2024-2025 six of which they decided not to follow up, with one complaint withdrawn by the complainant. One complaint awaits a decision, whilst the final complaint, the Council were instructed to issue a new stage two response. Child Friendly Complaints Procedure The SPSO launched the Child Friendly Complaints Procedure in July 2024. This procedure aims to ensure that children’s rights, under the United Nations on the Rights of the Child, [UNCRC] are met through a child-centred complaint process. Their principal aim was to co- 74, 34% 67, 31% 40, 19% 35, 16% Learning from Complaints Communication No learning Service Improvement Outcome unrecorded Page 255 of 288
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55 design this alongside children and young people and implement a public sector complaints procedure that meets children’s rights and needs. The SPSO continue to work in collaboration with local authorities to develop good practice guidance through the national complaint handlers’ group, of which officers from Quality Assurance are members. Within North Lanarkshire, a core group meets to co-design and trial our Child Friendly Complaint Process, which is modelled on national guidance. Quality Assurance officers have met with senior managers from Education, Families and Justice to discuss and to distribute draft guidance and FAQs from the SPSO. Care Opinion Care Opinion is a non-profit organisation, web-based feedback platform funded mainly through subscriptions from health and care organisations. At present, 500 health and social care organisations use Care Opinion across the UK. People submit stories to share their experiences of health and social care services. These can be both positive and negative, are moderated by Care Opinion staff, and quickly forwarded to the relevant area of service who can respond directly to the story. We recognise the importance of feedback; it is considered integral to quality improvement. For staff, it gives an opportunity to see the system and the service provided through the person’s eyes. Care Opinion – Key statistics • 471 stories were shared on Care Opinion 1 April 2024 – 31 March 2025 • 84% of stories received a response from the service within 7 working days, with circa 60% within one working day. • 80% of all stories shared have a zero-criticality rating, whilst 1% have a strongly critical rating. 18% have a low to moderate criticality rating. • Circa 83% of stories posted refer to NHS Lanarkshire services, whilst the remaining 17% refer to social care and third sector partners that are included in the UHSCPs subscription. To further support the use of Care Opinion as a vehicle to promote feedback on services, our revised Contract Management Framework asks all contracted providers, through their quarterly monitoring return, to report on their use and promotion of Care Opinion as a method of seeking feedback. We are also expanding the service tree to incorporate commissioned organisations if they wish to be included within the UHSCP subscription. Over the course of the past year, several third sector organisations, mainly those specific to our partnership with Voluntary Action North Lanarkshire, have been added to the subscription. Training Training on the system, where complaints are recorded continues to be delivered virtually through a video. This is a helpful aide memoire, but we recognise that additional support around recording and managing complaints is required and have agreed a programme of learning events to support locality teams to further enhance their approach to complaint handling. Page 256 of 288
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56 Quality Assurance Quality Assurance senior officers provide training and support to social work managers and teams in relation to the complaint handling process. A suite of letter templates is available, which provide guidance on model answers, trauma informed and best practice when engaging with complainants. Complaints are often routed directly through the Quality Assurance team who acknowledge receipt and assign complaints to the relevant service manager. New guidance was recently issued that instructs that all Stage 2 responses are routed through the social work complaints mailbox prior to issue, with all being sense checked by the Quality Assurance Senior Officer. In doing so, we ensure that all stage 2 complaints are compliant with the Complaint Handling Procedure. A single agency learning review was commissioned to consider a serious complaint. The outcome and findings are still be determined. Complaints that relate to both health and social work/social care services are routed through the relevant lead organisations complaints process, but there is an integrated approach to resolution and any joint learning outcomes are shared. Conclusion The principal cause of complaints continues to identify poor staff communication, staff attitudes and quality of service. This is further reflected within the learning outcomes, which indicate the need to improve communication, practice and approach to those using social work services. As a service we are committed to improving learning from complaints, which is also one of the key performance indicators, which in the future may be reportable to the SPSO. We will place further emphasis on the need to ensure that all complaints are dealt within identified timeframes, with clear communication of outcomes. Although 100% of complaints that were sent directly to social work were acknowledged by the due dates, only 58% overall were completed within statutory timeframes, with no need for an extension. Complexity of issues, new processes, staffing, IT systems and very tight time frames for resolution were the contributory factors in failure to complete all complaints within time. Improvement in these areas is expected in 2025-2026. Further actions – 2025-2026 Several key actions have been identified to strengthen our approach whilst dealing with complaints including using the learning to improve the quality of experience for those who use our services. Many are continuing or legacy commitments made in former years but remain valid objectives. The key actions are: 1. We will, over the course of 2025 -2026, sense check and proof-read all stage 2 complaints to ensure that the procedures are understood and followed. Legacy action that is on-going. 2. We aspire to ensure that logging actions and learning from complaints is done consistently to support the improvement of services that support people across our communities. 3. We develop a programme of reflective learning sessions across teams - Complaint activity and learning remain an agenda item in team meetings and links across services and localities are maintained with Quality Assurance who will review complaint activity as required. Learning sessions were delivered as requested in 2024-2025 and will continue in 2025-2026. Page 257 of 288
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57 4. We will continue to promote Care Opinion as one of the key mechanisms for engaging with members of the public and to generate meaningful feedback. Further resources have been deployed to assist with this activity – a one-page newsletter/precis of Care Opinion will be drafted and circulated to all social work staff to support further usage and promotion of Care Opinion. 5. Where possible, we will secure system training to all members of management support teams who now have responsibility for logging and tracking complaints. 6. We will offer complaint handling training as a refresher session, or for training for new staff. Training sessions are offered on an ad hoc basis, and as required by individual teams. 7. A further legacy action from 2023-2024 is the roll out and implementation of Child Friendly Complaints Handling Procedures. The SPSO have now indicated that Child Friendly Complaint Handling will not be a separate procedure, but practice guidance is necessary to ensure that the rights of children and young people, conferred by the UNCRC, are protected. Page 258 of 288
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58 Duty of Candour Report: 2024-2025 All health and social care services in Scotland have an organisational duty of candour. This is a legal requirement which means that when certain types of incidents happen, the people affected understand what has happened, receive an apology, and the organisation learns how to improve for the future. An important part of this duty is that we provide an annual report about the organisational duty of candour in our services. This report describes how our organisation, North Lanarkshire Council, has operated the organisational Duty of Candour during the time between 01 April 2024 and 31 March 2025. If you have any questions or would like more information about North Lanarkshire Council, please feel free to contact us at: barrym@northlan.gov.uk When Must Duty of Candour be Activated? Duty of Candour must be activated as soon as reasonably practicable after becoming aware that an unintended or unexpected incident occurred in the provision of the health, care or social work service were, in the reasonable opinion of a registered health professional (not involved in the incident) that: (a) the incident appears to have resulted in or could result in any of the outcomes mentioned below (b) the outcome relates directly to the incident rather than to the natural course of the person’s illness or underlying condition. The relevant outcomes are as follows: • the death of the person. • permanent lessening of bodily, sensory, motor, physiologic or intellectual functions(including removal of the wrong limb or organ or brain damage) (“severe harm”). Harm which is not severe harm, but which results in one or more of the following: • an increase in the person’s treatment. • changes to the structure of the person’s body. • the shortening of the life expectancy of the person. • an impairment of the sensory, motor, or intellectual functions of the person which has lasted, or is likely to last, for a continuous period of at least 28 days. • the person experiencing pain or psychological harm which has been, or is likely to be, experienced by the person for a continuous period of at least 28 days. The person requires treatment by a registered health professional to prevent: Appendix 2 Page 259 of 288
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59 • the death of the person. • any injury to the person which, if left untreated, would lead to one or more of the outcomes mentioned above. How many incidents happened to which the organisational duty of candour applies? In the last year, there have been no incidents notified to Quality Assurance, where the organisational duty of candour applied. Information About Our Policies and Procedures North Lanarkshire Council reviewed and modified its Duty of Candour reporting procedures during 2024/25. Throughout January, February & March 2025 Locality Social Work Managers, Senior Social Workers and Registered Managers participated in awareness raising sessions to enhance understanding of the circumstances when Duty of Candour would be considered; and the stages involved in the procedure. The Duty of Candour notification procedure now includes two stages, which are: / Part 1 Possible Duty of Candour incident (Initial Notification) / Part 2 Managing the Duty of Candour Process The intention underlying the introduction of the two-stage process is to enable internal monitoring and analysis of when Duty of Candour has been considered but not activated. It is envisaged that this data will contribute to organisational learning. Duty of Candour Reporting procedures and awareness raising sessions have been added to the North Lanarkshire Council Social Work Induction that all social work staff complete within the first four weeks of employment. Duty of Candour training and information is available to North Lanarkshire Council staff on-line at Duty of candour | Turas | Learn Where something has happened that may trigger the organisational Duty of Candour, our staff report this to Social Work Quality Assurance. Quality Assurance initiate contact with the reporter to plan, guide and support the process Duty of Candour Procedure. What have we learned? Duty of Candour discussions and reflections have taken place during the awareness raising sessions and have demonstrated the benefits of interactive learning and peer discussion when considering whether the Duty of Candour criteria has been met. North Lanarkshire Council Social Work will embed a refresher Duty of Candour training programme utilising this method, in turn complementing and enhancing e-learning. We believe that our modified Duty of Candour reporting process provides operational social work staff with the opportunity to explore and consider in full, improvement actions from unintended incidents. Furthermore, it enables North Lanarkshire Council Senior Managers to have confidence that we are fulfilling our legal and morale responsibilities as defined within the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 (The Act) and The Duty of Candour Procedure (Scotland) Regulations 2018. Training and Support for staff All new social work & social care staff within North Lanarkshire Council learn about the organisational Duty of Candour at induction and subsequent refresher sessions. Page 260 of 288
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60 We know that serious mistakes can be distressing for staff as well as people who receive care and support and their families. We therefore promote access to North Lanarkshire Council Employee Assistance Programme for those who have been affected by an organisational Duty of Candour incident. Support for relevant persons Where a relevant person (i.e., children, adults, families, etc.) is affected by the incident that activated the organisational duty of candour, we provide links to wellbeing support services. Page 261 of 288
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61 Appendix 3 Health and Care (Staffing) (Scotland) Act 2019: Annual Report for Social Work Services Under section 3(2) of the Health and Care (Staffing) (Scotland) Act 2019 (“the Act”), every local authority and integration authority must have regard to a number of listed factors when planning or securing the provision of a care service from a third party: • the guiding principles in the Act (section 1 of the Act); • the requirement on care service providers to have regard to the guiding principles (section 3(1) of the Act); • the duty on care service providers to ensure appropriate staffing (section 7 of the Act); • the requirement on care service providers with regard to training of staff (section 8 of the Act); • the requirement on care service providers to have regard to guidance issued by the Scottish Ministers (section 10 of the Act); • the duties on care service providers under Chapter 3 of Part 5 of the Public Services Reform (Scotland) Act 2010, for example with regard to registration of care services; and • the duties on care service providers under Chapter 3A of Part 5 of the Public Services Reform (Scotland) Act 2010, for example with regard to the use of any prescribed staffing methods or staffing tools. Note that the Health and Care (Staffing) (Scotland) Act 2019 inserted chapter 3A into the Public Services Reform (Scotland) Act. Section 3(6) of the Act states that relevant organisations must publish information annually on the steps they have taken to comply with the requirement in section 3(2) regarding the planning and securing of care services and any ongoing risks that may affect their ability to comply with this requirement. The information in this report relates to the financial year, 01 April 24 to 31 March 25, and will be published by 30 June 25. Page 262 of 288
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62 To enable the collation of the information published, a copy of the report has been sent to the Scottish Government hcsa@gov.scot. Page 263 of 288
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63 Declaration Name of local authority / integration authority: North Lanarkshire Council Report authorised by: Name Alison Gordon Designation Chief Social Work Officer (Children, Families, Justice and Integrated Services) Date: 23 June 2025 Details of where the report will be published: NLC and UHSCP website(s). Information Required 1. Please detail the steps you have taken as an organisation to comply with section 3(2) of the Health and Care (Staffing) (Scotland) Act 2019: 3(2) In planning or securing the provision of a care service from another person under a contract, agreement or other arrangements, every local authority and every integration authority (within the meaning of section 59 of the Public Bodies (Joint Working) (Scotland) Act 2014) must have regard to— (a) the guiding principles for health and care staffing, and (b) the duties relating to staffing imposed on persons who provide care services— (i) by virtue of subsection (1) and sections 7 to 10, and (ii) by virtue of Chapters 3 and 3A of Part 5 of the Public Services Reform (Scotland) Act 2010. To comply with section 3 (2) of the Health and Care (Staffing) (Scotland) Act 2019 North Lanarkshire Council worked closely with the Care Inspectorate, the Scottish Government, our commissioned Registered Services and key social work staff. Education, training, scoping roles & responsibilities Prior to the enactment of the legislation in April 2024 our Social Work Quality Assurance team led on the research around the requirements of the act, focusing on the impact to Commissioned Services and to North Lanarkshire Council in meeting the responsibilities outlined for Local Authorities. Our engagement activities included: Page 264 of 288
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64 - North Lanarkshire were one of ten authorities involved in the Scottish Government pilot – HSCP Chapter Testing Summary Report - Focus Groups & Peer Learning for Commissioned Registered Services. Sessions included education and the sharing of best practice evidence sources surrounding the 8 Guiding Principles, wellbeing of staff, staff training and the Staffing Method Framework. - Hosted Care Inspectorate Face to Face & On-line Education Sessions for Social Work staff. This raised awareness of the act to ensure social work staff were aware of the responsibilities of providers and Local Authorities. - Introduced as a standing agenda item at Adult Social Work Governance, Senior and Social Work Leadership Team Meetings and our (cross care group) Social Work Workforce Meeting. In doing so preparation and implementation of the legislation was given strategic priority. - Quality Assurance Newsletter. Quarterly updates were provided across social work in relation to the new legislation and how we were preparing for its implementation. Links to the Care Inspectorate Safer Staffing Hub were shared as was training available through the SSSC Open Badge route or alternatively Turas. Procurement & Contracting Our Social Work Quality Assurance Team, in partnership with operational colleagues, are responsible for procuring and contracting of Registered Commissioned Services. Prior to 1st April 2024 they liaised with our Corporate Procurement Team to review contracts which for Registered Services includes: - National Care Home Contract (NCHC) – 25 Care Homes with nursing and 1 Care Home Residential are commissioned within North Lanarkshire. Scotland Excel own and manage this contract through the National Care Home Contract. - North Lanarkshire Council did not plan or secure care homes between 1st April 2024 to 31st March 2025. - Self-Directed Support (SDS) Framework including Care at Home Services – This framework is owned by North Lanarkshire Council. It is a ten-year framework effective from 2021, and it will expire in 2031. There are annual entry points for tender submissions from organisations meeting the criteria however in 2024 tender submissions were invited from December 2024 with the contract being effective as of 1st April 2025. We will report on new services added to the SDS Framework in 2025/2026. Page 265 of 288
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65 - As of 31st March 2025, the SDS Framework for Care at Home Services included 58 services. These services are accessed by Adult Health & Social Care, Children & Families & Justice. Breakdown below of the number of services available to support adults, children and older adults. Adults Children Older Adults 49 19 38 - Children's Residential Care and Education, including Short Break, Services – 2 different organisations from the framework are provide services within North Lanarkshire. This contract is owned and managed by Scotland Excel. - North Lanarkshire Council did not plan or secure any services under this contract between 1st April 2024 to 31st March 2025. - Fostering and continuing Care - 2 services are commissioned within North Lanarkshire. This contract is owned and managed by Scotland Excel. - North Lanarkshire Council did not plan or secure any services under this contract between 1st April 2024 to 31st March 2025. - Individual Placement Agreements – Where an individual chooses to be supported by a non-commissioned service or out of authority/cross borders, placements are agreed through North Lanarkshire Council by utilising an Individual Placement Agreement. The findings from the review of the National Care Home Contract, the SDS Framework for Care at Home services and Individual Placement Agreements, all of which are utilised when planning and securing services, confirmed that no modifications were required to legislative requirements. This was due to the Health and Care (Staffing) (Scotland) Act 2019 legislation/guidance stating that there is no requirement to stipulate the actual name of the legislation. The need to comply with the Care Inspectorate Standards and all legislation relevant to social care form part of our contract monitoring approach. As part of the procurement journey and overall evaluations the guiding principles of the act and person specific training plans are considered in reference to meeting people’s unique outcomes. Care Inspectorate registration details and current grades awarded for each of the Key Questions are also taken into consideration. Contract Monitoring The Social Work Quality Assurance Team have oversight of all commissioned Registered Services for Adult Social Work, Children & Families and Justice services. Page 266 of 288
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66 Monitoring arrangements are in place, and these have been modified to include information around staffing arrangements and the key components of the staffing method framework, the guiding principles of the act including staff wellbeing and stakeholder feedback. During monitoring visits, the Quality Assurance Team engage directly with stakeholders to ensure that their views are being taken into consideration when decisions are made about staffing. A request is made to the Care Inspectorate to extend an invitation to a representative from the Quality Assurance Team to enable them to participate in the feedback session. This approach ensures information about staffing is known timeously. Care Inspectorate grades, requirements and areas for improvement are monitored and taken into consideration when risk assessing the commissioned services and the level of monitoring required. When a placement is being made in a non-commissioned service including out of authority and cross borders, due diligence processes are in place that includes liaison with the host authority and the appropriate regulator e.g. Care Inspectorate. This enables oversight of safer staffing compliance issues. 2. Please detail any ongoing risks that may affect your ability to comply with the duty set out in section 3(2). North Lanarkshire Council have a Self-Directed Support (SDS) Framework including Care at Home Services. This is a 10-year framework with annual entry points, as referenced above. This framework has been live since 2021 and will continue until 2031. Exploration and consideration are in process to make changes to the tendering evaluation process to evidence inclusion of the provider’s responsibilities under the Act. This will feature within future entry points. Subsequent modifications arising will be informed in collaboration with procurement legislation and best practice, which may result in limitations to the scope of change applied throughout this period. The Care Inspectorate do not define training requirements for a provider at the time of registration. Staff training is determined by the needs of the people being supported which is a fluid and dynamic process. To include training requirements as part of any competitive tendering process may not achieve the desired outcome as a result. North Lanarkshire Council take a person-centered approach to the expectations of providers to update their training plans as and when the needs and aspirations or people change. Monitoring visits carried out by our Social Work Quality Assurance Team capture any gaps as defined by the population at that time. Page 267 of 288
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67 North Lanarkshire Registered Services Care Inspectorate Activity: Annual Report 2024/2025 Appendix 4 Page 268 of 288
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68 Annual Report for North Lanarkshire Adult Services Care Inspectorate Activity for 2024/2025 Introduction North Lanarkshire Council currently operate a range of registered services, namely Locality Support Service (Disability), Home Support Service and Integrated Day Services and Residential Children’s Houses. All are delivered over the six localities: Motherwell, Wishaw, Coatbridge, Airdrie, Bellshill and Cumbernauld. These services are regulated by the Care Inspectorate and inspection frequency is determined by risk rating based on the Care Inspectorate scrutiny tool. Purpose of Report The purpose of this report is to provide an overview of care inspection activity for NLC in- house services during the reporting period 1st April 2024 and 31st March 2025. This report provides details of the most recent care inspection activity, including grades awarded, requirements, areas for improvement, areas of strength and good practice and highlights any patterns or themes emerging. Care Inspectorate Grading System The table below outlines the grading system used by the Care Inspectorate to determine grades for each of the key questions and quality statements. Grades range from unsatisfactory (1) through to excellent (6). The In-House Services being reported on fall under three different quality frameworks which are as follows: - Locality Support Services & Integrated Day Services – A quality framework for support services (not care at home) - Home Support Service & Community Alarms – A quality framework for support services (care at home including supported living models) Key Question 4 as stated below is not assessed for this service type. EXCELENT 06 VERY GOOD 05 GOOD 04 ADEQUATE 03 WEAK 02 UNSATISFACTORY 01 OUTSTANDING OR SECTOR LEADING MAJOR STRENGTHS IMPORTANT STRENGTHS, WITH SOME AREAS FOR IMPROVEMENT STRENGTHS JUST OUTWEIGH WEAKNESSES IMPORTANT WEAKNESSES – PRIORITY ACTION REQUIRED MAJOR WEAKNESSES – URGENT REMEDIAL ACTION REQUIRED An evaluation of excellent describes performance which is sector leading and supports experiences and outcomes for people which are outstandingly high quality. This is a demonstrable track record of innovation, effective practice and/or very high- quality performance across a wide range of its activities and from which others could learn. We can be confident that excellent performance is sustainable and that it will be maintained. An evaluation of very good will apply to performance that demonstrates major strengths in supporting positive outcomes for people. There are very few areas for improvement. Those that do exist will have minimal impact on people’s experiences and outcomes. While opportunities are taken to strive for excellence within a culture of continuous improvement, performance evaluated as very good does not require significant adjustment. An evaluation of good applies to performance where there is a number of important strengths which, taken together, clearly outweigh areas for improvement. The strengths will have a significant positive impact on people’s experience and outcomes. However improvement are requirement to maximise wellbeing and ensure that people consistently have experiences and outcomes which are as positive as possible. An evaluation of adequate applicates where there are some strengths, but these just outweigh weaknesses. Strengths may still have a positive impact by the likelihood of achieving positive experiences and outcomes for people is reduced significantly because key areas of performance need to improve. Performance which is evaluated as adequate may be tolerable in particular circumstances, such as where a service or partnership is not yet fully established, or in the midst of major transition. However, continues performance at adequate level is not acceptable. Improvements must be made by building on strengths while addressing those elements that are not contributing to positive experiences and outcomes for people. An evaluation of weak will apply to performance in which strengths can be identified but these are outweighed or compromised by significant weaknesses. The weaknesses, either individually or when added together, substantially affect peoples’ experiences or outcomes. Without improvement as a matter of priority, the welfare or safety of people may be compromised, or their critical needs not met. Weak performance requires action in the form of structured and planned improvement by the provider or partnership with a mechanism to demonstrate clearly that sustainable improvements have been made. An evaluation of unsatisfactory will apply when there are major weaknesses in critical aspects of performance which require immediate remedial action to improve experiences and outcomes for people. It is likely that people’s welfare or safety will be compromised by risks which cannot be tolerated. Those accountable for carrying out the necessary actions for improvement must do so as a matter of urgency, to ensure that people are protected, and their wellbeing improves without delay. Page 269 of 288
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69 - Residential Children’s Houses – A quality framework for care homes for children and young people and school care accommodation (special residential schools) Care Inspectorate Activity Locality Support Services Locality Support Service is a service for adults aged 16-65 with a learning disability, physical disability or long-term condition who require support to achieve their identified goals or outcomes, build confidence or maximise independence to lead healthier, safer, happier lives. This service is well connected and can support and signpost people to access services within their community including employment/voluntary opportunities, health improvement groups and further education courses. There were no care inspections within Locality Support Services during the reporting period. For details of grades and last inspection dates please refer to Table Appendix A. Integrated Day Services Integrated Day Services provide support for adults over 65, who often have complex and overlapping needs that require support from both health staff and social care staff. Support is offered either through the outreach, respite at home service, or support within the Integrated Day Service. The service is provided by both Social Work and Health staff, who work in partnership to ensure good quality support is provided. There were no care inspections within Integrated Day Services during the reporting period. Dates of the last inspections can be seen in the table Appendix B. Page 270 of 288
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70 Community Alarm Service The community alarm service provides urgent assistance to people living within their own homes who experience emergencies like taking ill or falling. People who choose to have the service are provided with an alarm unit connected to their phone system. When activated, a call is automatically made to the response centre where the staff will clarify the nature of the emergency. Staff will then alert family members or send trained community alarm staff or contact emergency services. This service operates 24-hours a day, 365 days a year, for people who are resident within North Lanarkshire area. There is currently a small charge for this service. Within the reporting period there were no inspections for this service. The table in Appendix C, highlights the core information in relation to the Community Alarm Service. Home Support Services Home Support is a service for individuals with complex health and care needs who require support to be as independent as they can be within their own homes. There are six In-House Home Support services across North Lanarkshire - Wishaw, Motherwell, Bellshill, Coatbridge, Airdrie and Cumbernauld. Airdrie Home Support were inspected three times during the reporting period. August 2024, 13 November 2024 and again on the 8 January 2025. On the 9 August 2024 the inspection focussed on 4 key questions: “How well do we support people’s wellbeing?” “How good is our leadership?” “How good is our staff team?” “How well is care and support planned?” All four key questions were awarded grades of weak (2) From this inspection requirements and areas of improvement included: Improvement and management of missed visits, reviews to be held no later than six monthly and support plans to be updated following reviews, to ensure that visits take place at the times specified, support plans reflect good practice, are person centred and outcome focussed. (see table on Appendix D) A further inspection took place on 13 November 2024 which focussed on two of the four requirements which were made on 28 September 2023. These were missed visits and reviews. It was evident that there were improvements in the number of reviews being carried out and systems had been implemented to ensure visits took place as scheduled. These requirements were then recorded as being met. The remaining two requirements from 28 September 2023 were then extended further to 6 January 2025. On the 8 January 2025 a further inspection focussed on the two outstanding requirements wand the following key questions: “How well do we support people's wellbeing” “How good is our leadership” “How well is our care and support planned” Page 271 of 288
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71 The requirements were met at this inspection and the 3 key questions above were graded adequate (3). This highlighted improvement particularly around care planning and consistent, organised visits. Bellshill Home Support were inspected on 18 April 2024 with four key questions being assessed. “How well do we support people’s wellbeing?” “How good is our leadership?” “How good is our staff team?” “How well is care and support planned?” All questions were graded Good (4) which highlighted an overall improvement in the grades from the previous inspection where grades of Adequate (3) were awarded for all key questions. Feedback reflected improvements to supervision frequency, observational monitoring and staff training. Coatbridge Home Support were inspected on 27 September 2024 with four key questions being assessed. “How well do we support people’s wellbeing?” “How good is our leadership?” “How good is our staff team?” “How well is care and support planned?” All questions were graded Adequate (3). This was an improvement on the grades awarded at the last inspection where three key questions (KQ 1, 2 and 5) were graded weak (2). Some progress was recognised from the last inspection. However there remained two of the three requirements which had not been met. These were: care plans to be person centred and outcome focussed and reviews to be carried out 6 monthly. During this inspection four of the eleven previous areas for improvement were noted as having been met. Some other areas were consolidated into new areas of improvement. These were to ensure that all staff, including management, access the relevant training appropriate to their role and apply this training in practice. A robust system was to be developed for managing complaints and to ensure that people are involved in contributing to their reviews. (See Appendix D) Feedback reflected that the staff induction process was thorough and had been developed, direct observations were taking place and staff received feedback. Supervision was taking place, recorded with follow up action and the training matrix was up to date and noted when refresher training was due. Cumbernauld Home Support was inspected on 11 September 2024 with four key questions being assessed. “How well do we support people’s wellbeing?” “How good is our leadership?” “How good is our staff team?” “How well is care and support planned?” Page 272 of 288
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72 Although two of the three requirements had been met since the last inspection no regrading took place. Therefore, grades of Adequate (3) remained for all four key questions. Feedback reflected improvements in training, supervision and audits of support reviews. A follow up inspection on 27 January 2025 focused on outstanding requirements and areas for improvement. The requirement for personal support plans being up to date, accurate, and reflective of good practice remained unmet. Additionally, there remained an area for improvement around action plans and supervision records as these had not been fully addressed. More time was required for the improvements that had been made to be embedded in practice. Feedback reflected that the care and support provided was good and positive changes continued to be implemented by the management team. Motherwell Home Support was inspected on 15 August 2024 with four key questions being assessed. “How well do we support people’s wellbeing?” “How good is our leadership?” “How good is our staff team?” “How well is care and support planned?” Three key questions were awarded grades of weak (2) however the key question “How well do we support people’s wellbeing?” was graded adequate (3). These grades were lower than those awarded previously. Requirements and areas for improvement were made. (See table Appendix D) A follow up inspection took place on 26 March 2025 and improvements had been noted. Three key questions were assessed. “How good is our leadership”, “How good is our staff team” and “How well is care and support planned” All three key questions were regraded to adequate (3). All requirements and areas for improvement had been met highlighting progress in these areas. Wishaw Home Support was inspected on 15 October 2024 with four key questions being assessed. “How well do we support people’s wellbeing?” “How good is our leadership?” “How good is our staff team?” “How well is care and support planned?” Grades of good (4) were awarded for all four key questions. The three areas noted for improvement at the last inspection were assessed during the October 2024 inspection and all three had been met. These included: improving the quality of care plans: the management of falls: ensuring prompt referrals to the appropriate professionals, when required. Areas of improvement from the October 2024 inspection included ensuring that action plans were fit for purpose and SMART (specific, measurable, achievable, realistic and time-bound) Page 273 of 288
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73 and focused to ensure a culture of continuous improvement. Review reports were to be shared with the appropriate people. Feedback reflected that there is good communication across the staff team, good management oversight and staff are supported within the workplace. Residential Children’s Houses North Lanarkshire Council Residential Children’s houses offer accommodation, care and protection to children and young people generally aged 12 to 18, who cannot, for a variety of reasons, live in the community with their parents, extended family or substitute families. There are currently 5 North Lanarkshire Residential Houses in 5 areas within North Lanarkshire: Buchanan Street, Fort Street, Cambusnethan, Forrest Street, Fort Street and Main Street. All 5 residential houses were inspected within the reporting period. More detail can be found in Appendix E. Buchanan Street Residential House was inspected during the reporting period on 5th December 2024. One key question was inspected: “How well do we support children and young people's rights and wellbeing?” This key question was graded adequate (3). An area for improvement included development of staff practice, particularly around trauma informed practice. A further area for development noted the need for collective discussions and decision-making forums to be developed with young people. The management of medication and associated procedures were an area for improvement and management meetings were to be held, to continue to develop the service. The two requirements made from the previous inspection were both met within the timescales highlighting improvements in the quality assurance processes, incident reports were recorded accurately and risk assessments and safe plans for young people were detailed. More detail can be found in Appendix E. Feedback reflected that young people felt well cared for, there was good oversight of risk for young people and personal plans were outcome focused. Cambusnethan Residential House was inspected during the reporting period on 12th June 2024. One key question was inspected: “How well do we support children and young people's rights and wellbeing?” This key question was graded adequate (3) The previous requirement made at the last inspection was met within the timescales. This highlighted improvement with the admissions and matching procedures. Three previous areas for improvements from the last inspection were also met. Three new areas for improvement were made in the inspection of 12th June 2024. These included the need for improvement in staff training in relation to children’s specific needs, to develop child friendly and SMART personal plans and to continue to review staffing levels. Feedback reflected that the home worked well with partner agencies to support young people, there were some positive outcomes for young people and support for families was very good. Page 274 of 288
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74 Forrest Street Residential House was inspected during the reporting period on 18 August 2024. One key question was inspected: “How well do we support children and young people's rights and wellbeing?” This key question was graded good (4). The areas of improvement made from the previous inspection were met at this inspection and three new areas for improvement were made at the inspection of 18 August 2024. More detail can be found in Appendix E. Feedback reflected that risk was reduced for most young people, the staff group were skilled and experienced, and all young people had personal plans which detailed their needs and wishes. Fort Street Residential House was inspected during the reporting period on 25 February 2025. One key question was inspected: “How well do we support children and young people's rights and wellbeing?” This was graded 4 (good). There was one area of improvement made at this inspection suggesting personal plans should be SMART (specific, measurable, achievable, realistic and timebound). Feedback reflected that young people had meaningful relationships with staff and managers. Additionally, it was noted that staff worked proactively to support young people, relationships with family and friends were actively promoted and young people were supported and enabled to make informed choices and decisions for themselves. A previous area of improvement made was met at this inspection as there was evidence that action was taken to improve incident records ensuring that they held accurate information and good evidence of debriefs. The de-briefs were proactively undertaken by the manager, who sought to explore and understand learning for all involved. Main Street Residential House was inspected during the reporting period on 31 January 2025 with one key question inspected “How well do we support children and young people's rights and wellbeing?” This key question was graded good (4). There was one area of improvement made suggesting that personal plans should be SMART (specific, measurable, achievable, realistic and timebound). The previous four requirements made were all met at this inspection. Conclusion From carrying out an analysis of recent inspection activity across Registered In-House services, 15 inspections are noted to have been carried out between 1 April 2024 to 31 March 2025. From the 24 services reported on, 6 home support and 5 residential children’s houses services have been inspected. Page 275 of 288
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75 From the inspections carried out during the reporting period a common theme identified for all home support services, was the need for care plans to be developed, ensuring that they were person centred, and outcome focussed. Another common theme identified was to ensure that reviews were taking place 6 monthly. Themes emerging from the 5 children’s residential houses were staff training, specifically focusing on children’s needs and ensuring that personal plans were SMART. Further information can be found in the appendices below. Page 276 of 288
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Appendix A Locality Support Services CI Status 76 Locality Support Service Date Inspection Took Place How well do we support people's wellbeing? How good is our leadership? How good is our staff team? How good is our setting? How well is care and support planned? Overall Grade Awarded Requirements Areas for Improvement Areas of Strength Airdrie 16/05/2023 VERY GOOD - 5 VERY GOOD - 5 NOT ASSESSED NOT ASSESSED NOT ASSESSED VERY GOOD - 5 None None Support is consistent by high quality staff ensuring positive experiences and outcomes Bellshill 23/06/2023 VERY GOOD - 5 VERY GOOD - 5 NOT ASSESSED NOT ASSESSED NOT ASSESSED VERY GOOD - 5 None None Good planning with people to ensure support is person centred. Good joint working with partnership agencies and skilled staff. Coatbridge 26/05/2023 VERY GOOD - 5 VERY GOOD - 5 VERY GOOD - 5 NOT ASSESSED VERY GOOD - 5 VERY GOOD - 5 None None People are supported well to build friendships and community links with good high-quality support provided. Cumbernauld 25/09/2023 VERY GOOD - 5 VERY GOOD - 5 NOT ASSESSED NOT ASSESSED NOT ASSESSED VERY GOOD - 5 None None Support is consistent by high quality staff ensuring positive experiences and outcomes. Motherwell 07/07/2023 VERY GOOD - 5 VERY GOOD - 5 NOT ASSESSED NOT ASSESSED NOT ASSESSED VERY GOOD - 5 None None People are well supported with experienced staff and Good supportive management team. Wishaw 12/06/2023 VERY GOOD - 5 VERY GOOD - 5 NOT ASSESSED NOT ASSESSED NOT ASSESSED VERY GOOD - 5 None None Good communication between people, families and the service. People are supported to have high quality positive experiences and outcomes. Page 277 of 288
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Appendix B Integrated Day Services CI Status 77 Integrated Day Service Date Inspection Took Place How well do we support people's wellbeing? How good is our leadership ? How good is our staff team? How good is our setting? How well is care and support planned? Overall Grade Awarded Key Questions Inspected outwith New Framework Requirements Areas for Improvement Areas of Strength Harry Walker - Airdrie 27/07/2023 VERY GOOD - 5 ADEQUATE - 3 VERY GOOD - 5 VERY GOOD - 5 VERY GOOD - 5 N/A By the closing date, which will be notified by the Care Inspectorate in 2024, the provider must comply with their legislative responsibility to submit an annual return. To ensure continuous improvements the provider should develop an improvement plan. Sir John Mann - Bellshill 12/01/2024 VERY GOOD - 5 VERY GOOD - 5 VERY GOOD - 5 NOT ASSESSED GOOD - 4 GOOD - 4 N/A None People should be supported to gain and maintain their independence to ensure people feel empowered and in control. This is to ensure that care and support is consistent with the Health and Social Care Standards (HSCS) which state that: 'I am empowered and enabled to be as independent and as in control of my life as I want and can be.' (HSCS 2.2).This area for improvement was made on 30 January 2024. • People were supported by long term staff who knew them well • People enjoyed attending the service and talking to staff and peers • Various activities were on offer everyday to stimulate people both physically and mentally • Both hot and cold nutritious meals on offer everyday. Coatbridge 14/04/2024 VERY GOOD - 5 GOOD - 4 VERY GOOD - 5 GOOD - 4 GOOD - 4 N/A There were no requirements 1. To develop an improvement plan 2. Carry out regular audits to ensure robust and transparent quality assurance processes 3. To provide detailed guidance for staff, care plans need to be developed * Good communication and participation from service users * Good relationships and friendships maintained which supported positive outcomes and reduced social isolation * Well trained and knowledgable staff who were supportive of each other encouraging good teamwork Cumbernauld & Kilsyth 14/06/2019 VERY GOOD - 5 VERY GOOD - 5 VERY GOOD - 5 VERY GOOD - 5 VERY GOOD - 5 VERY GOOD - 5 N/A None None The setting is very good at promoting and enabling independence. Care and support is planned and recorded very well. Staff were organised and well trained and reviews and care plans were carried out within the timescales. Motherwell 16/11/2015 NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED VERY GOOD - 5 1. Quality of Care and Support (5) 2. Quality of Staff (5) 3. Quality of Environment (5) 4 Quality of Management & Leadership (5) Areas for improvement were not part of this inspection methodology as it was prior to the introduction of the new quality frameworks when recommendations were still in force. None * The performance of the service was excellent * Good engagement with service users, relatives and staff * The manager was supportive and approachable * Service Users were supported in a respectful way esuring privacy, dignity and respect Wishaw 24/03/2017 NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED GOOD - 4 1. Quality of Care and Support (4) 4 Quality of Management & Leadership (4) Areas for improvement were not part of this inspection methodology as it was prior to the introduction of the new quality frameworks when None Support Plans were person centred and individual to each person Staff provided good care and support resulting in good outcomes for people Page 278 of 288
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Appendix C – Community Alarm CI Status 78 community Alarm Service Date Inspection Took Place How well do we support people's wellbeing? How good is our leadership? How good is our staff team? How good is our setting? How well is care and support planned? Overall Grade Awarded Requirements Areas for Improvement Areas of Strength Covers All 6 Localities 26/03/2023 VERY GOOD - 5 GOOD - 4 VERY GOOD - 5 VERY GOOD - 5 None The service should introduce an improvement plan which includes its aims and objectives. The plan should detail challenges and goals in improving outcomes for people. The improvement plan should follow SMART principles and include timescales, progress towards goals and names staff responsible in each area. * Staff were well trained *Good hygiene levels and infection prevention and control * Staff were supported well with regular supervision and meetings Page 279 of 288
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Appendix D – Home Support CI Status 79 Home Support Service Date Inspection Took Place Date Draft Inspection Became Available Via Eforms Date Final Report became available via eforms How well do we support people's wellbeing? How good is our leadership? How good is our staff team? How good is our setting? How well is care and support planned? Overall Grade Awarded Requirements Areas for Improvement Areas of Strength Airdrie 09/08/2024 17/09/2024 01/10/2024 WEAK - 2 WEAK - 2 ADEQUATE - 3 WEAK - 2 WEAK - 2 (1) By 8 April 2024, the provider must ensure the support provided to people promotes and their health and wellbeing. To achieve this the provider must: Take action reduce the number of missed visits. This should include: a) Introduce systems that further develop existing ones to reduce the likelihood of missed visits. b) Further develop existing contingencies to respond quickly to actual missed visits to ensure people receive the care and support they require (2) By 8 April 2024, the provider must ensure the support provided to people promotes and their health and wellbeing. To achieve this the provider must: a) Ensure support visits are organised to provide sufficient time and staffing to provide the assessed support at each visit.b) Ensure support visits take place, as far as possible, at the times notified to people.c) Ensure sufficient time is allowed for all support needs to be met at each visit.d) Ensure schedules are accurate and received in advance of the start of the planned supports with details of times and named staff. To support positive outcomes for people experiencing care and support, the provider should inform people of significant changes. This should include, but is not limited to, changes made to their staff team and visiting times, including when changes occur at short notice if possible. (2) To support people's health and wellbeing, the provider should ensure that requests for specified times to meet medical appointments are kept. This should include, but is not limited to, agreeing how they will support people when reasonable notice has been given. Airdrie 13/11/2024 10/12/2024 06/01/2025 WEAK - 2 (1) By 8 April 2024, the provider must ensure the support provided to people promotes and their health and wellbeing. To achieve this the provider must: Take action reduce the number of missed visits. This should include: a) Introduce systems that further develop existing ones to reduce the likelihood of missed visits. b) Further develop existing contingencies to respond quickly to actual missed visits to ensure people receive the care and support they require. MET (2) To ensure people receive appropriate supports to maintain and enhance their well-being and achieve their outcomes, the provider must: a) Have system in place to ensure reviews of people's care and support take place not less than six-monthly. b) Ensure that care plans are reviewed more regularly when a person's needs change. c) Audit the quality of reviews to ensure consistency and quality. MET (3)The provider must ensure the support provided to people promotes and their health and wellbeing. To achieve this the provider must a) Ensure support visits are organised to provide sufficient time and staffing to provide the assessed support at each visit. b) Ensure support visits take place, as far as possible, at the times notified to people. c) Ensure sufficient time is allowed for all support needs to be met at each visit. (d) Ensure schedules are accurate and received in advance of the start of the planned supports with details of times and named staff NOT ASSSESSED AT THIS INSPECTION (4) The provider must ensure service users experience care and support which is consistent, safe, and meets their needs. To do this the provider must, at a minimum, ensure that service users' personal plans: a) are current, accurate, reflect good practice in being person-centred and outcome focussed. b) have sufficient detail in them to ensure people's individualised support needs and outcomes are met. c) are subject to regular evaluation and audit to monitor quality and effectiveness. In addition, the provider must, a) ensure each person supported is provided with a copy of their care plan b) ensure all care plans are available on request for the Care Inspectorate NOT ASSESSED AT THIS INSPECTION To support positive outcomes for people experiencing care and support, the provider should inform people of significant changes. This should include, but is not limited to, changes made to their staff team and visiting times, including when changes occur at short notice if possible. MET (2) To support people's health and wellbeing, the provider should ensure that requests for specified times to meet medical appointments are kept. This should include, but is not limited to, agreeing how they will support people when reasonable notice has been given. MET During this period service management have worked hard to reduce the number of missed visits. Daily checks were introduced to provide alerts. Positive work carried out to ensure no care reviews were overdue and that management had overview of the quality of the reviews. Airdrie 08/01/2025 28/01/2025 12/02/2025 ADEQUATE - 3 ADEQUATE - 3 ADEQUATE - 3 ADEQUATE - 3 Previous two (3) and (4) requirements were assessed at this visit and MET - OUTWITH THE TIMESCALES NONE The service continue to ensure staff are properly supported and trained. The quality of support plans had improved. Bellshill 18/04/2024 30/04/2024 14/05/2024 GOOD - 4 GOOD - 4 GOOD - 4 GOOD - 4 GOOD - 4 None To improve staff support the provider should ensure their policy regarding patch meetings is followed. Supervision and observation targets had improved, good quality assurance tools for observations, staff well trained Coatbridge 27/09/2024 04/11/2024 ADEQUATE - 3 ADEQUATE - 3 ADEQUATE - 3 ADEQUATE - 3 ADEQUATE - 3 By 30 November 2023, the provider must ensure that care plans are reviewed on a six-monthly basis as a minimum, in line with current legislation. To do this, the provider must, at a minimum, ensure: a) people are supported to understand and be included within their care review b) they collaborate with people and others involved with their care to gather their views on what is working well with their care and support. This includes but is not limited to reviewing health and safety risk assessments and needs assessments c) ensure that any agreed actions are completed and reviewed regularly to ensure they remain effective. Completed actions to be carried forward to the next agreed review date d) people and their representatives (where appropriate) have read over and are happy with the record of their review e) managers are involved in the monitoring and the audit of people's reviews. By 30 November 2023, the provider must ensure service users experience care and support which is consistent, safe, and meets their needs. To do this the provider must, at a minimum, ensure that service users' personal plans: a) are current, accurate, reflect good practice in being person-centred and outcome focussed b) have sufficient detail in them to ensure people's individualised support needs and outcomes are met c) are subject to regular evaluation and audit to monitor quality and effectiveness. Page 280 of 288
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Appendix D – Home Support CI Status 80 Cumbernauld 27/01/2025 04/02/2025 27/02/2025 ADEQUATE - 3 ADEQUATE - 3 ADEQUATE - 3 ADEQUATE - 3ADEQUATE - 3 By 30 June 2023, the provider must ensure service users experience care and support which is consistent, safe, and meets their needs. To do this the provider must, at a minimum, ensure that service users' personal support plans are: a) Up-to-date, accurate, reflect good practice in being person-centred and outcome focussed b) Detailed enough to provide guidance to staff on how to support people, including risk assessments. c) Regularly audited to ensure consistency and quality. This has been extended to 30 April 2025 To ensure people are being supported by a competent workforce, the provider should ensure action plans generated from supervisions are completed and supervision records are regularly audited.This area for improvement has not been assessed and remains in place Cumbernauld 11/09/2024 02/10/2024 08/10/2024 ADEQUATE - 3 ADEQUATE - 3 ADEQUATE - 3 ADEQUATE - 3ADEQUATE - 3 By 30 June 2023, the provider must ensure service users experience care and support which is consistent, safe, and meets their needs. Support plans require to be: a) Up-to-date, accurate, reflect good practice in being person-centred and outcome focussed b) Detailed enough to provide guidance to staff on how to support people, including risk assessments. c) Regularly audited to ensure consistency and quality. . To ensure people are being supported by a competent workforce, the provider should ensure action plans generated from supervisions are completed and supervision records are regularly audited. 2 of the 3 requirements have been met. Improvements made with training, supervision and audits of reviews. Motherwell 15/08/2024 09/09/2024 02/10/2024 ADEQUATE - 3 WEAK - 2 WEAK - 2 WEAK - 2 WEAK - 2 By 31 December 2024, the provider must provide the service in a manner which promotes quality and safety and respects the independence of service users and affords them the choice in the way in which the service is provided to them. To do this the provider must, at a minimum: -implement a SMART short focused improvement plan which is updated regularly by service -record and monitor visits completed by family members as part of their contingency planning -ensure people receive their assessed time at each visit. 1. By 31 December 2024, to ensure that people’s care and support needs are met effectively, the provider must ensure staffing arrangements are safe. To do this, the provider must, at a minimum: regularly assess and review people’s care and support needs clear systems that identify the current support needs for people experiencing care relevant training is provided to all staff to ensure their competency in all aspects of their role which must include direct observations provide regular support for staff which includes supervision and appraisal develop a long term strategy for recruitment, retention and wellbeing of staff Adult Support and Protection incidents were generally well recorded and reported to the Care Inspectorate. We could see appropriate actions had been taken. However there were delays between the incidents and when they were notified to the Care Inspectorate, some by more than a couple of weeks. Notifications should be made in the timescales identified in the Care Inspectorate guidance for notification reporting. To ensure notifiable events are reported to the Care Inspectorate in a timely manner the service should comply with the Care Inspectorate guidance for notification reporting. Motherwell 26/03/2025 01/04/2025 16/04/2025 ADEQUATE - 3 ADEQUATE - 3 ADEQUATE - 3ADEQUATE - 3 All requirements were met All previous areas of improvement were met - 2 new areas for improvement was made: To ensure a confident well trained staff team the service should ensure schedulers have the training, mentoring and support they need. 2. To ensure there is clear evidence staff support is taking place the service should develop a robust monitoring system. Wishaw 15/10/2024 22/10/2024 28/10/2024 GOOD - 4 GOOD - 4 GOOD - 4 GOOD - 4 GOOD - 4 No requirements All 3 previous areas for improvement met. Further areas of improvements as below: To support a culture of continuous improvement, the provider should ensure that all action plans are fit for purpose and SMART (specific, measurable, achievable, realistic and time-bound) focused. To ensure that people are fully involved in developing and reviewing their care plan, the provider should ensure that review records are shared with them. The care and support that people experienced was right for them. Good communication across the staff team. Page 281 of 288
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Appendix D – Home Support CI Status 81 Childrens Residential Children's House Date Inspection Took Place How well do we support people's wellbeing? How good is our leadership? How good is our staff team? How good is our setting? How well is care and support planned? How well do we support children and young people's rights and wellbeing? Overall Grade Awarded Requirements Areas for Improvement Areas of Strength Buchanan Street 05/12/2024 NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED ADEQUATE - 3 ADEQUATE - 3 None 1. To ensure that all young people consistently experience trauma informed responses to their care and support needs, the provider should continue to develop staff practice which is based on the principles of relational practice. The expected impact of any natural consequences should be carefully considered prior to being implemented. 2. To ensure that all young people's care and support needs are met by a staff team that works well together, the provider should maintain regular opportunities for collective discussion and decision making forums, to enable and promote agreed ways of working with young people. 3.To ensure the safety and wellbeing of all young people, the provider should provide closer monitoring of medication procedures to minimise the likelihood of errors occurring in practice. 4. To ensure that all young people receive high quality care and support, the provider should commit to regular, effective staff supervision for all members of staff, in line with their policy. 5. To ensure that all young people receive high quality care and support, the provider should undertake analysis, to determine the training and development needs of staff to promote professional growth. 6. To ensure that all young people receive high quality care and support from a service which is well led and managed, the provider should enable regular i d h i i Young people felt well cared for. There was good oversight of risk for young people. Personal plans were outcome focused. Cambusnethan 12/06/2024 NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED ADEQUATE - 3 ADEQUATE - 3 None 1. To ensure that young people's needs are met, the provider should source and implement staff training relating to the specific needs of all young people 2. To ensure that young people's needs and wishes inform their care and support, the provider should develop SMART personal plans which are informed by young people and are written in a child friendly style 3.To ensure young people's needs are met, the provider should keep staffing levels under review to ensure the correct number of staff are always available to meet the needs of children and young people. Cambusnethan worked well with partner agencies to support young people. There were some positive outcomes for young people and support for families was very good. Forest Street 08/08/2024 NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED GOOD - 4 GOOD - 4 None 1. To ensure that young people can assess their achievements, the provider should ensure that personal plans adequately document young people's progress toward good outcomes 2. To ensure the safety and wellbeing of all young people living at Forrest Street Residential Children's House, the provider should ensure that in each instance, admissions and matching assessments include assessment of the needs of young people already living in the house. The management team at Forrest Street Residential Children's House should inform decisions. 3. To ensure that young people help to inform improvement planning and continue to contribute to evaluations of progress toward identified outcomes, the provider should create a more streamlined approach to this process Risk was reduced for most young people and Leaders worked effectively with partners Fort Street 25/02/2025 NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED GOOD - 4 GOOD - 4 None 1. To ensure that young people achieve positive outcomes which are specific to them as individuals, personal plans should be SMART (specific, measurable, achievable, realistic and timebound.) Young people had meaningful relationships with staff. Partners felt that managers and staff worked proactively with them to support young people. Relationships with family and friends were actively promoted. The quality of the environment was very good. Young people were supported and enabled to make informed choices and decisions for themselves. The house provided a safe place for young people Main Street 31/01/2025 NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED GOOD - 4 GOOD - 4 None 1. To ensure effective oversight and governance of experiences and outcomes for young people, the provider should continue to improve quality assurance processes. 2. To ensure effective involvement of young people and their progress towards identified outcomes, personal plans should be SMART (specific, measurable, achievable, realistic and timebound) Most young people thrived, enjoying positive relationships with staff. The provider was responsive to risk impacting young people's safety and wellbeing. Education and employment was the norm for most young people. Some young people felt a strong sense of belonging. Interests and aspirations were fully supported. Personal plans should be SMART (specific, measurable, achievable, realistic and timebound). Leadership was positive and enabling. Page 282 of 288
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Appendix E – Children’s Houses CI Status 82 Childrens Residential Children's House Date Inspection Took Place How well do we support people's wellbeing? How good is our leadership? How good is our staff team? How good is our setting? How well is care and support planned? How well do we support children and young people's rights and wellbeing? Overall Grade Awarded Requirements Areas for Improvement Areas of Strength Buchanan Street 05/12/2024 NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED ADEQUATE - 3 ADEQUATE - 3 None 1. To ensure that all young people consistently experience trauma informed responses to their care and support needs, the provider should continue to develop staff practice which is based on the principles of relational practice. The expected impact of any natural consequences should be carefully considered prior to being implemented. 2. To ensure that all young people's care and support needs are met by a staff team that works well together, the provider should maintain regular opportunities for collective discussion and decision making forums, to enable and promote agreed ways of working with young people. 3.To ensure the safety and wellbeing of all young people, the provider should provide closer monitoring of medication procedures to minimise the likelihood of errors occurring in practice. 4. To ensure that all young people receive high quality care and support, the provider should commit to regular, effective staff supervision for all members of staff, in line with their policy. 5. To ensure that all young people receive high quality care and support, the provider should undertake analysis, to determine the training and development needs of staff to promote professional growth. 6. To ensure that all young people receive high quality care and support from a service which is well led and managed, the provider should enable regular management meetings and other opportunities to develop the service. Young people felt well cared for. There was good oversight of risk for young people. Personal plans were outcome focused. Cambusnethan 12/06/2024 NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSEDADEQUATE - ADEQUATE - 3 None 1. To ensure that young people's needs are met, the provider should source and implement staff training relating to the specific needs of all young people 2. To ensure that young people's needs and wishes inform their care and support, the provider should develop SMART personal plans which are informed by young people and are written in a child friendly style 3.To ensure young people's needs are met, the provider should keep staffing levels under review to ensure the correct number of staff are always available to meet the needs of children and young people. Cambusnethan worked well with partner agencies to support young people. There were some positive outcomes for young people and support for families was very good. Forest Street 08/08/2024 NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSEDGOOD - 4 GOOD - 4 None 1. To ensure that young people can assess their achievements, the provider should ensure that personal plans adequately document young people's progress toward good outcomes 2. To ensure the safety and wellbeing of all young people living at Forrest Street Residential Children's House, the provider should ensure that in each instance, admissions and matching assessments include assessment of the needs of young people already living in the house. The management team at Forrest Street Residential Children's House should inform decisions. 3. To ensure that young people help to inform improvement planning and continue to contribute to evaluations of progress toward identified outcomes, the provider should create a more streamlined approach to this process Risk was reduced for most young people and Leaders worked effectively with partners Fort Street 25/02/2025 NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSEDGOOD - 4 GOOD - 4 None 1. To ensure that young people achieve positive outcomes which are specific to them as individuals, personal plans should be SMART (specific, measurable, achievable, realistic and timebound.) Young people had meaningful relationships with staff. Partners felt that managers and staff worked proactively with them to support young people. Relationships with family and friends were actively promoted. The quality of the environment was very good. Young people were supported and enabled to make informed choices and decisions for themselves. The house provided a safe place for young people Main Street 31/01/2025 NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSEDGOOD - 4 GOOD - 4 None 1. To ensure effective oversight and governance of experiences and outcomes for young people, the provider should continue to improve quality assurance processes. 2. To ensure effective involvement of young people and their progress towards identified outcomes, personal plans should be SMART (specific, measurable, achievable, realistic and timebound) Most young people thrived, enjoying positive relationships with staff. The provider was responsive to risk impacting young people's safety and wellbeing. Education and employment was the norm for most young people. Some young people felt a strong sense of belonging. Interests and aspirations were fully supported. Personal plans should be SMART (specific, measurable, achievable, realistic and timebound). Leadership was positive and enabling.Page 283 of 288
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Appendix E – Children’s Houses CI Status 83 Childrens Residential Children's House Date Inspection Took Place How well do we support people's wellbeing ? How good is our leadership ? How good is our staff team? How good is our setting? How well is care and support planned? How well do we support children and young people's rights and wellbeing? Overall Grade Awarded Requireme nts Areas for Improvement Areas of Strength Buchanan Street 05/12/2024 NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED ADEQUATE - 3 ADEQUATE - 3 None 1. To ensure that all young people consistently experience trauma informed responses to their care and support needs, the provider should continue to develop staff practice which is based on the principles of relational practice. The expected impact of any natural consequences should be carefully considered prior to being implemented. 2. To ensure that all young people's care and support needs are met by a staff team that works well together, the provider should maintain regular opportunities for collective discussion and decision making forums, to enable and promote agreed ways of working with young people. 3.To ensure the safety and wellbeing of all young people, the provider should provide closer monitoring of medication procedures to minimise the likelihood of errors occurring in practice. 4. To ensure that all young people receive high quality care and support, the provider should commit to regular, effective staff supervision for all members of staff, in line with their policy. 5. To ensure that all young people receive high quality care and support, the provider should Young people felt well cared for. There was good oversight of risk for young people. Personal plans were outcome focused. Page 284 of 288
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Appendix E – Children’s Houses CI Status 84 undertake analysis, to determine the training and development needs of staff to promote professional growth. 6. To ensure that all young people receive high quality care and support from a service which is well led and managed, the provider should enable regular management meetings and other opportunities to develop the service. Cambusneth an 12/06/2024 NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED ADEQUATE - 3 ADEQUATE - 3 None 1. To ensure that young people's needs are met, the provider should source and implement staff training relating to the specific needs of all young people 2. To ensure that young people's needs and wishes inform their care and support, the provider should develop SMART personal plans which are informed by young people and are written in a child friendly style 3.To ensure young people's needs are met, the provider should keep staffing levels under review to ensure the correct number of staff are always available to meet the needs of children and young people. Cambusnethan worked well with partner agencies to support young people. There were some positive outcomes for young people and support for families was very good. Page 285 of 288
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Appendix E – Children’s Houses CI Status 85 Forrest Street 08/08/2024 NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED GOOD - 4 GOOD - 4 None 1. To ensure that young people can assess their achievements, the provider should ensure that personal plans adequately document young people's progress toward good outcomes2. To ensure the safety and wellbeing of all young people living at Forrest Street Residential Children's House, the provider should ensure that in each instance, admissions and matching assessments include assessment of the needs of young people already living in the house. The management team at Forrest Street Residential Children's House should inform decisions.3. To ensure that young people help to inform improvement planning and continue to contribute to evaluations of progress toward identified outcomes, the provider should create a more streamlined approach to this process Risk was reduced for most young people and Leaders worked effectively with partners Fort Street 25/02/2025 NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED GOOD - 4 GOOD - 4 None 1. To ensure that young people achieve positive outcomes which are specific to them as individuals, personal plans should be SMART (specific, measurable, achievable, realistic and timebound.) Young people had meaningful relationships with staff. Partners felt that managers and staff worked proactively with them to support young people. Relationships with family and friends were actively promoted. The quality of the environment was very good. Young people were supported and enabled to make informed choices and decisions for themselves. The house provided a safe place for young people Page 286 of 288
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Appendix E – Children’s Houses CI Status 86 Main Street 31/01/2025 NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED NOT ASSESSED GOOD - 4 GOOD - 4 None 1. To ensure effective oversight and governance of experiences and outcomes for young people, the provider should continue to improve quality assurance processes. 2. To ensure effective involvement of young people and their progress towards identified outcomes, personal plans should be SMART (specific, measurable, achievable, realistic and timebound) Most young people thrived, enjoying positive relationships with staff. The provider was responsive to risk impacting young people's safety and wellbeing. Education and employment was the norm for most young people. Some young people felt a strong sense of belonging. Interests and aspirations were fully supported. Personal plans should be SMART (specific, measurable, achievable, realistic and timebound). Leadership was positive and enabling. Page 287 of 288
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