12 - 2025-09-17 IJB - Quality Assurance Annual Report 2024-25
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.
Page 1
1 REPORT Item No: 12 SUBJECT: QUALITY ASSURANCE ANNUAL REPORT TO: JOINT INTEGRATION BOARD Lead Officer for Report: MORAG DENDY, CHIEF OFFICER, PLANNING, PERFORMANCE & QUALITY ASSURANCE Author(s) of Report MARIA BARRY, Senior Manager Quality Assurance DATE: 17 September 2025 1. PURPOSE OF REPORT This paper is coming to the IJB for: For approval ☐ For endorsement ☒ To note ☒ 2. ROUTE TO THE BOARD This paper has been: Prepared By: ☐ Reviewed By: ☐ Endorsed By: ☒ North Lanarkshire Council’s Adult Care and Social Work Committee. 3. RECOMMENDATIONS 3.1 It is recommended that the IJB: 1. Note and endorse the contents of the report
Page 2
2 4. EXECUTIVE SUMMARY / BACKGROUND 4.1 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. 4.2 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. 4.3 The health and social care environment in which we operate remains challenging and sharing of best practice and solution focused ideas are integral to ensure the people of North Lanarkshire receive good quality support to help meet their outcomes. 4.4 Our commitment is to provide an annual report on activity carried out in the preceding year. 4.5 The purpose of this report is to update Committee on our Quality Assurance activity over the annual period of 1 April 24 to 31 March 25. 4.6 This report highlights Quality Assurance activity over the period 1 April 2024 to 31 March 2025. It outlines how work has progressed in areas which includes Contracts & Contract Management Framework, Procurement, Back to Basics – Getting it Right for Everyone, Safe Staffing, Market Facilitation, Review of Registered Social Landlords, Duty of Candour, In House Monitoring, Social Work Risk Management, ASW Governance Subgroup for Registered Managers, Participation & Engagement and Carers. 4.7 Full detail of these activities is included in Appendix One. 5. Report Contracts 5.1 The Quality Assurance Team are responsible for coordinating and facilitating all procurement activity across social work. This is in partnership with our corporate procurement colleagues, who provide the framework and legal basis to ensuring that decisions taken are in line with legislation including the Procurement Reform (Scotland) Act 2014. 5.2 Over the past year, Quality Assurance have continued to ensure consistency across purchased services and that contractual arrangements have clearly defined terms and conditions. This has ensured that expectations are clearly outlined and there is a basis for contract monitoring to take place. This enables the quality of services being provided to people to be evaluated. Arrangements
Page 3
3 range from national frameworks to Individual Placement Agreements which balance quality against cost to achieve overall best value for services purchased to support people. Contract Management Framework 5.3 Adherence with the contract management framework is an integral component of the processes in place to demonstrate commissioned services are adhering to terms and conditions and that outcomes and best value are achieved. Contract monitoring is a means to identify unmet need and inform future strategic planning and commissioning. 5.4 The Contract Management Framework was also the focus of a recent internal audit of Quality Assurance. Findings were positive, with only minor recommendations for improvement. As a result of the audit, feedback from stakeholders and new legislation, further enhancements have been made: 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 5.4.1 We reported last year that we planned to produce a Quarterly Commissioned Services Performance Report. This was implemented as of 1st April 2024, to provide useful information to operational colleagues to assist in supporting people to make a choice of care provider based on the available intelligence. The report also enables the Quality Assurance Team to monitor performance, patterns, themes and trends in relation to areas such as notifications of concern, engagement & participation, Care Inspectorate Grades, Tier Ratings and compliance with annual/quarterly provider returns. 5.4.2 During the reporting period we started to provide information which assists Locality Teams in supporting people to identify their choice of care provider. All providers on the SDS Framework are included within the Performance Benchmark Tool, as are up to date contact details. Alongside each provider on the SDS Framework, we have included performance information which gives indicators to the quality of care being provided to people. We strive to ensure information is up to date. Benchmarks include Care Inspectorate grades, contract monitoring Tier indicating associated risk level and evaluation score at the time of entering the framework.
Page 4
4 Procurement 5.5 Quality Assurance continued to lead on procurement activity for all social work services in collaboration with colleagues within Corporate Procurement, Service Leads and Locality Social Work Teams, to ensure joined up planning, clear procurement processes and subsequent contract monitoring arrangements. This ensured that all commissioned contract work delivered best value, in accordance with Procurement Reform Scotland Act 2014 and the Procurement (Scotland) Regulations 2016. In House Monitoring Framework 5.6 Throughout 2024 a Test of Change for the newly developed In House Monitoring Framework continued within Home Support (Living Well at Home). The review and evaluation of the In-House Monitoring Framework commenced in December 2024 and those who had been involved in the development of this, and the participants of the Test of Change provided feedback on what worked well and what further developments could be embedded within the approach. Feedback consisted of individual meetings and group workshops. 5.7 The Senior Management Team have agreed the roll out of the revised In-House Monitoring Framework and a programme of activity will commence in April 2025. Market Facilitation 5.8 The health and social care sector continued to experience a variety of challenges. These challenges are expected to continue for some time. The Quality Assurance team continues to promote, stimulate and support market facilitation, and our approach is based on strategic intervention, relationship building, light touch intervention and supporting beneficial new relationships and activities that lead to resilient and sustainable approaches. In turn this leads to continuous improvement, improved ways of working and an active learning cycle, whereby planning impacts on delivery, review and learning. Engagement & Participation 5.9 In September 2024 the University Health and Social Care Engagement and Participation Strategy was launched alongside the Growth Pot Fund. Quality Assurance were involved in both the drafting of, and raising awareness of, the strategy and its ambitions. During the year work to collate examples of best practice to support staff across the service to further engage with those involved in services, was undertaken by Quality Assurance, in partnership with Planning and Performance colleagues. Back-to-basics to getting it right for everyone 5.10 Over the past year within Adult Health & Social Care Services, we have been working on the development of an enabling approach that supports the move from our work on back-to-basics to getting it right for everyone, as we recognise
Page 5
5 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. 5.11 Over the coming year we will further develop specific plans and service developments: as this is a whole system approach, we anticipate there will be a lot to focus on and much change across services, supports and responses that are needed to achieve and sustain change. Safe Staffing 5.12 The Health and Care (Staffing) (Scotland) Act 2019 (HCSA) came into effect on 1st April 2024. The purpose of this legislation is to establish a statutory framework to ensure appropriate staffing levels in health and care settings. North Lanarkshire Council have responsibilities as a provider of care and support and as a placing authority. 5.13 Quality Assurance supported both commissioned and in-house services with the implementation of the Act throughout the reporting period, by facilitating two dedicated working groups. 5.14 Quality Assurance have devised the Health and Care (Staffing) (Scotland) Act 2019 Annual Report for Social Work Services. Duty of Candour 5.15 All health and social care services in Scotland have an organisational duty of candour. This is a legal requirement which means that when certain types of incidents happen, the people affected understand what has happened, receive an apology, and the organisation learns how to improve for the future. 5.16 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. 5.17 The Duty of Candour notification procedure now includes two stages, which are: Part 1 Possible Duty of Candour incident (Initial Notification) Part 2 Managing the Duty of Candour Process 5.18 The intention underlying the introduction of the two-stage process is to enable internal monitoring and analysis of when Duty of Candour has been considered but not activated. It is envisaged that this data will contribute to organisational learning.
Page 6
6 Review of Registered Social Landlords 5.19 Since the summer of 2023, Quality Assurance has been leading on the review of five Registered Social Landlords who provided thirteen sheltered & very sheltered developments across North Lanarkshire. These services were funded to provide housing support, using Supporting People funding. This funding stream was discontinued around 2016/17, leading to mainstream social work funding being accessed pending review. This review has now concluded, and North Lanarkshire Council no longer commission or fund these Registered Social Landlords. Adult Social Work Subgroup – Registered Managers 5.20 An Adult Social Work Subgroup for Registered Managers was established in 2025. This group meet eight weekly, and the chair is the Quality Assurance Service Manager or delegated person. This group reports through the ASW Governance Group and its purpose is to ensure robust governance and oversight across Registered Services. Social Work Risk Management 5.21 Quality Assurance have oversight of the social work risk register and are responsible for quarterly & annual reporting, compliance audits and for the facilitation and coordination of the Social Work Risk Forums. Quality Assurance participate in Corporate Risk Management Team meetings, and cascade appropriate information through the correct forums. 5.22 Risk Champions and Facilitators act as points of contact for risk management matters within social work and promote risk awareness across the service. 6. IMPLICATIONS 6.1 NATIONAL OUTCOMES Link(s) to National Health and Wellbeing Outcomes People are able to look after and improve their own health and wellbeing and live in good health for longer ☐ People, including those with disabilities or long-term conditions, or who are frail, are able to live, as far as reasonable practicable, independently and at home or in a homely setting in their community ☐ People who use Health and Social Care Services have positive experiences of those services, and have dignity respected ☐ Health and Social Care Services are centred on helping to maintain or improve the quality of life of people who use those services ☐ Health and Social Care Services contribute to reducing health inequalities ☐ People who use Health and Social Care Services are safe from harm ☐
Page 7
7 People who work in Health and Social Care Services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide ☐ Resources are used effectively and efficiently in the provision of Health and Social Care Services ☐ 7.2 FINANCIAL This paper has been reviewed by Finance: 7.3 RISK ASSESSMENT/RISK MANAGEMENT Relevant Risk Register Details Current Risk Level Risk Owner Choose an item. 7.4 ENGAGEMENT & PARTICPATION Please tick the engagement and participation objectives that link(s) with this piece of work and provide further details regarding the engagement and participation that was undertaken. Objectives Further Details ☐ Involve stakeholders in the development work aimed at achieving the national outcomes ☐ Provide stakeholders with information on how to get involved ☐ Ensure a diverse range of engagement and participation and opportunities are in place to suit different needs ☐ Measure how well we involve community stakeholders in the planning, design and delivery of our services ☐ Provide regular feedback on how stakeholder engagement and participation is shaping and influencing service development and delivery Yes ☒ No ☐ N/A ☐
Page 8
8 ☐ Provide support to enable stakeholder representatives to participate meaningfully and confidently at meetings ☐ Develop participation guidelines to ensure a common understanding and set of expectations for both stakeholders and partnership staff ☐ Support engagement planning and participation in localities, taking account of other engagement activity and local plans across the Community Planning Partnership 7.5 INEQUALITIES & FAIRER SCOTLAND DUTY EQIA Completed & Fairer Scotland Impact Assessment Form Completed and attached to report: EQIA added to website: 8. APPENDICES Appendix 1: Quality Assurance Annual Report 2024/25 Members seeking further information about any aspect of this report, please contact the following; Morag Dendy Chief Officer (Planning, Performance, and Quality Assurance) Yes ☐ No ☐ N/A ☐ Yes / Date added ☐ No ☐ N/A ☐
Page 9
9 Direction from North Lanarkshire Integration Joint Board (IJB) 1 Reference Number 2 Report Title 3 Date direction issued by IJB 4 Date from which direction takes effect 5 Direction to: 6 Does this direction supersede, revise or revoke a previous direction – if yes, include reference number(s) 7 Functions covered by direction 8 Full text of direction 9 Budget allocated by Integration Joint Board to carry out direction 10 Performance Management / Governance arrangements 11 Date direction will be reviewed