12 - 2025-09-17 IJB - Quality Assurance Annual Report 2024-25 - Appendix 1
North Lanarkshire Council · 17 September 2025
Back to Health and Social Care Integration Joint Board — 17 September 2025 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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Quality Assurance Annual Report 2024/2025 APPENDIX 1
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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.
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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.
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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
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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
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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-
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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
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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.
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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
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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
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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
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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%
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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
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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.
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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)
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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
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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
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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.
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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
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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.
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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.
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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
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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)
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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.
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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
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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.
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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 %
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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
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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.
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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.
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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.
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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
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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.
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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.
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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
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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
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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
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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.
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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]
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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
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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.
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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
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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.
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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.
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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.
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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
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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.
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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.
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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.
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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.
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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:
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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.
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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.
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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.
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67 North Lanarkshire Registered Services Care Inspectorate Activity: Annual Report 2024/2025 Appendix 4
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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.
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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.
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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”
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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?”
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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)
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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.
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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.
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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.
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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.
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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
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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
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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.
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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.
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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.
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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.
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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.
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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.
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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
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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.