ITEM 9 Progress Report on Agreed Actions
North Lanarkshire Council · 18 October 2023
Back to IJB Performance, Finance and Audit Committee — 18 October 2023 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: 9 1. PURPOSE OF REPORT 1.1 This paper is coming to the Performance, Finance and Audit (PFA) Committee: For approval For endorsement For noting 1.2 This report provides an outline of the actions agreed with the External Auditor, Internal Auditor, and the Senior Management Team to further develop the IJB governance framework. 2. ROUTE TO THE PERFORMANCE, FINANCE AND AUDIT COMMITTEE 2.1 This paper has been: Prepared By: Chief Finance Officer ☒ Reviewed By: Chief Officer ☒ Endorsed By: ☐ 3. RECOMMENDATIONS 3.1 It is recommended that the PFA Committee: (1) Acknowledge the contents of the report; and (2) Agree that further progress reports will be presented to future meetings of the PFA Committee in respect of the ongoing actions. 4. VARIATIONS TO DIRECTIONS 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 Recommendations to further strengthen the IJB governance framework were made by both external and internal audit. The Senior Management Team (SMT) have also identified improvement opportunities which will further contribute to the IJB’s annual assessment of their governance arrangements. 5.2 The original reports from external and internal audit and the SMT were previously reported in full to the IJB and PFA Committee as appropriate. This report summarises the agreed recommendations and provides an update on the progress made to date against each action. Further details are attached at appendices 1 to 3. 5.3 Any actions which are reported as complete will be removed from the next progress report to the PFA Committee. SUBJECT: Progress Report on Agreed Actions TO: IJB Performance, Finance and Audit Committee Lead Officer for Report: Ross McGuffie, Chief Officer North HSCP Author(s) of Report Amanda Kilburn, Chief Financial Officer DATE: 18 October 2023 Yes No N/A
Page 2
2 6. CONCLUSIONS 6.1 An update on the progress made to date was reported to the PFA Committee on 19 April 2023. A summary of the current position statement is shown in the table below: Source Total Actions Completed Actions Ongoing Actions External Audit 1 1 - Internal Audit 4 3 1 Senior Management 1 - 1 Total 6 4 2 67% 33% 6.2 The ongoing actions are measured against the revised timeline set out in appendices 1 to 3. 7. IMPLICATIONS 7.1 NATIONAL 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 reasonably 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 ☒ 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 ASSOCIATED MEASURE(S) The implementation of agreed actions will contribute to the ongoing development of the internal control framework and will also inform the Annual Governance Statement for 2023/24. 7.3 FINANCIAL This paper has been reviewed by Finance: Yes No N/A 7.4 RISK ASSESSMENT/RISK MANAGEMENT The strategic financial risks detailed in the IJB Risk Register has been updated where necessary and are included in a separate report to the IJB. Relevant Risk Register Details Current Risk Level Risk Owner Ineffective Governance Arrangements Low Ross McGuffie
Page 3
3 7.5 ENGAGEMENT & PARTICIPATION Please tick the engagement and participation objectives that link(s) with this piece of work and provide further details on the engagement and participation that was undertaken. Objectives Further details ☒ Involve stakeholders in the development work aimed at achieving the national outcomes This report includes all engagement and participation objectives as effective governance arrangements ensure the IJB can fulfil its statutory duties. Good governance enables the IJB to pursue its vision effectively as well as underpinning that vision with mechanisms for control and management of risk. ☒ 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 ☒ 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 7.6 INEQUALITIES & FAIRER SCOTLAND DUTY Equality and Diversity Impact Assessment Completed & Fairer Scotland Impact Assessment Form Completed and EQIA added to website: Yes No N/A 8. BACKGROUND PAPERS None. 9. APPENDICES Appendix 1 - External Audit Actions Appendix 2 - Internal Audit Actions Appendix 3 - Senior Management Actions Chief Finance Officer Members seeking further information about any aspect of this report, please contact Amanda Kilburn on telephone number 07816 126362.
Page 4
4 Update on External Audit Actions Appendix 1 Ref Finding Recommendation Management Response Current Position 1 Accounts inspection advert The notice of inspection should state the objection end date and the advert should be posted on the IJB website in addition to the North Lanarkshire Council website. Original The IJB should ensure it has procedures in place to ensure the accounts inspection advert is published in line with criteria set out in the Local Authority Accounts (Scotland) Regulations 2014. Agreed The IJB will ensure future adverts are posted on the IJB website in addition to the North Lanarkshire Council website. IJB Chief Financial Officer Original Timeline: June 2023 COMPLETE – advert placed on IJB website 05 June 2023: https://hscnl.org.uk/2023/06/north-lanarkshire-integration-joint-board-annual-accounts-2022-2023/
Page 5
5 Update on Internal Audit Actions Appendix 2 Ref Performance Management (August 2019) Current Position Per Management Update Internal Audit Comment 2 Risk: The IJB may not provide adequate performance information to key stakeholders to enable them to make informed decisions and recommend remedial actions to address concerns arising. The Performance, Finance and Audit Committee may not be in a position to fulfil its remit which includes the requirement to ‘review quarterly performance and recommend remedial action to address concerns’ and to ‘ensure effective arrangements are in place to register all performance and operational risks’. Recommendation: Management should undertake a formal review of the current arrangements for monitoring and reporting performance to reflect on whether reports are fit for purpose and contain relevant comprehensive information useful to stakeholders. This could include comparison with other IJB published reports. Particular consideration should be given to the areas identified in the finding: An overview of all indicators on the performance scorecard including a mechanism to provide an update on indicators previously reported but now considered satisfactory; Areas for improvement listed should include proposed actions with timescales, progress with these and how effective they are; Greater use of benchmarking with other IJBs and trend information and Incorporating reporting by locality. Category: Amber Original Timeline: October 2019 Revised Timeline: March 2022 September 2023 Original Responsible Officer: Performance Manager The Performance Framework for the HSCP is well defines, although not always referenced in those terms. A clear link exists between the National Health and Wellbeing Outcomes, nationally agreed performance indicators and frameworks, and local indicators, including those presented at HSCP level, Chief Executive/Organisational level, and service/directorate level. A session was held in June 2023 to discuss the framework and to review the scorecard. As a result, it was agreed: A refreshed CE Scorecard would be produced including new indicators. A similar workshop would be held with locality managers to improve quarterly performance reviews. This was held in August 2023. The development of the Strategic Commissioning Plan and the associated Programme of Work provides another core element of the performance framework. The relevant performance indicators, data and information will be developed and reported on as the work progresses. This will inform improvement planning and provide rich content for performance reviews carried out within the performance framework. The IJB will be provided with both quarterly and annual performance reporting within this framework. The draft 22/23 Annual Performance Report will be presented to the September IJB which follows a similar format to prior years as due to the timescale for publication there is little flexibility to deviate from the agreed North Lanarkshire format. A quarterly performance report is also provided to the IJB which is based around the Chief Executive’s Scorecard and quarterly performance reviews. Internal Audit are pleased to note that significant action has been taken in this area or is planned for the coming months to fully implement the recommendations made. Internal Audit acknowledge that delays in implementation were initially due to the pandemic but were further impacted by the Performance Manager post being vacant for approximately 18 months. This post has now been filled, with the post holder taking up their position mid-April 2023 and work is progressing to meet the revised timescales. Given that the action is required to further improve the control environment, Internal Audit assess the residual risk as ‘Medium’ and consider it important that the agreed revised timescale of September 2023 is achieved. COMPLETE - Email received from internal audit to confirm the actions taken appears to be sufficient to enable the recommendation to be closed. As part of internal audit follow-up and in line with audit process, internal audit will undertake testing to ensure that the expected actions are being complied with. Ref Performance Management (August 2019) Current Position Per Management Update Internal Audit Comment 3 Risk: There is no formal documented record or clear rationale for the targets and trajectories set. Recommendation: Management should ensure that a formal record is retained detailing the rationale for, and approval of, the targets and trajectories set for the indicators on the performance scorecard and this information should be shared with the Performance, Finance and Audit Committee. Category: Amber Original Timeline: October 2019 Revised Timeline: March 2022 September 2023 Original Responsible Officer: Performance Manager The rationale for all indictors appearing in the scorecard will be agreed and documented in the scorecard and reporting. The narrative explanation for the rationale may not be displayed next to the visualisation of the data but will be held within a version-controlled document. Internal Audit are pleased to note that there has been some action taken in this area and acknowledge that implementation of the recommendation was delayed as a result of the pandemic in the first instance and thereafter due to the Performance Manager post being vacant for approximately 18 months. This post has now been filled, with the post holder taking up their position mid-April 2023 and work is progressing to meet the revised timescales. Given that action is required to further improve the control environment, Internal Audit assess the residual risk as ‘Medium’ and consider it important that the agreed revised timescale of September 2023 is achieved. COMPLETE - Email received from internal audit to confirm the actions taken appears to be sufficient to enable the recommendation to be closed. As part of internal audit follow-up and in line with audit process, internal audit will undertake
Page 6
6 testing to ensure that the expected actions are being complied with. Ref Financial Due Diligence Audit Report (May 2020) Current Position Per Management Update Internal Audit Comment 4 Risk: A lack of formally documented arrangements may increase the risk that the resources transferred from the IJB to the Council do not reflect the cost of the relevant services in terms of delegated and non-delegated functions. Recommendation: Each of the reports listed contained similar recommendations in respect of the disaggregation of Children, Families and Justice Social Work Services and need for hosting arrangements to be finalised for cross-cutting services. Reports: Internal Audit – Financial due diligence (May 2020) – 2 actions External Audit – Annual Audit Report 2019/20 – 1 action Annual Governance Statement – Continuous improvement 2019/20 – 1 action Original Timeline: March 2021 Revised Timeline: September 2021 June 2022 Revised timescale to be determined once further clarity obtained regarding National Care Service proposals. Original Responsible Officer: Chief Officer Revised Responsible Officer: Head of Adult Social Work and Head of Planning, Performance and Quality Assurance The budget disaggregation exercise has been concluded and the revised IJB direction to NLC issued on 23 March 2021 excludes the total budget transfer in respect of Children, Families and Justice Services. Management recognises that the finalisation of the Service Level Agreement (SLA) for future hosting arrangements and associated budgets is overdue. Once finalised, the SLA will be presented to a future meeting of the IJB and NLC Education and Families Committee for approval. The SLA between Children, Families and Justice Services will be revised once further clarity has been obtained around what services will be part of the new National Care Service. Updated Timeline for NCS: STAGE 1 – General Principles Bill introduced on 20 June 2022 Financial Memorandum posted 20 June 2022 Statement of Legislative Competence posted 20 June 2022 Delegated Powers Memorandum posted 27 June 2022 Public submit view on Stage 1 – closed 02 September 2022 and posted 03 November 2022 National Care Service Forum held 03 October 2022 7 June 2023 Parliament agreed a motion to further extend the deadline for the completion of Stage 1 of the National Care Service (Scotland) Bill to 31 January 2024. The deadline for MSPs to debate the Bill and agree its general principles has now been delayed almost a year later than originally planned. Internal Audit are pleased to note the budget disaggregation exercise has been concluded and acknowledge that Covid has had a significant impact on the HSCP which has in turn impacted on the prioritisation of resources. In addition, it is acknowledged that further clarity around the services which will be part of the National Care Service is required before the SLA between Children, Families and Justice Services can sensibly be finalised. Given the delays in implementation of the remaining actions, Internal Audit assess the residual risk as ‘High’. Ref Risk Maturity Assessment (August 2019) Current Position Per Management Update Internal Audit Comment 5 Risk: Decisions may not fully reflect risk management considerations. The Risk Register may not reflect issues highlighted within performance management and other assurance reports. Recommendation: IJB and PFA Committee papers should contain a section on risk which considers whether issues raised should be included within the risk register and overtly reflect the impact on any existing strategic risks. Performance reports should reference relevant strategic risks and assess whether scores are accurate and whether actions intended to reduce risk to target level are on track. Category: Amber Original Timeline: March 2020 Revised Timeline: June 2021 June 2022 September 2023 Revised Responsible Officer: Service Support Project Manager A new IJB reporting template has been developed as part of the IJB Governance Documents update and this template has a greater focus on EQIAs, Risk, Participation and Engagement, National Outcomes and Directions. IJB reporting template guidance has also been developed to support authors when completing the reporting template. Additional work associated with internal audit comment includes: New IJB reporting template which includes the risk level of the report, which risks is held on the risk register and the mitigation in place. As per the new guidance, reports will be returned to authors if they are not completed on the new template. Risks are reviewed at each IJB and PFA board. New risk reporting structure in place which includes a risk dashboard, level of risk, risk movement and SMART actions aligned to each risk. Risk sharing document in place. Internal Audit are pleased to note that there is now a higher percentage of reports presented to the IJB and PFA Committee which contain a section of risk. Internal Audit acknowledge that further steps are planned to increase compliance and fully address this recommendation. Internal Audit consider the revised timescale to be reasonable and have assessed the residual risk for this recommendation as ‘Low’. COMPLETE - Email received from internal audit to confirm the actions taken appears to be sufficient to enable the recommendation to be closed. As part of internal audit follow-up and in line with audit process, internal audit will undertake testing to ensure that the expected actions are being complied with.
Page 7
7 Update on Senior Management Actions Appendix 3 Ref Annual Governance Statement Continuous Improvement Actions (2021/2022) Current Position Per Management Update Internal Audit Comment 4 Risk: N/A Recommendation: To develop a sound understanding of the impact for the North Lanarkshire Health & Social Care Partnership of the outputs of the National Care Service legislation. Original Timeline: March 2023 Revised Timeline: To be determined once further clarity obtained regarding National Care Service proposals. Due to the uncertainty and lack of detail currently available, this will be revisited once further clarity has been obtained. The Scottish Government has delayed further discussion and consultation in respect of the National Care Service legislation until after the summer recess. Updated Timeline: STAGE 1 – General Principles Bill introduced on 20 June 2022 Financial Memorandum posted 20 June 2022 Statement of Legislative Competence posted 20 June 2022 Delegated Powers Memorandum posted 27 June 2022 Public submit view on Stage 1 – closed 02 September 2022 and posted 03 November 2022 National Care Service Forum held 03 October 2022 7 June 2023 Parliament agreed a motion to further extend the deadline for the completion of Stage 1 of the National Care Service (Scotland) Bill to 31 January 2024. The deadline for MSPs to debate the Bill and agree its general principles has now been delayed almost a year later than originally planned. Internal Audit acknowledge that implementation of the recommendation has been delayed as a result of the uncertainty and lack of detail available in respect of the new National Care Service. Given the delay in implementation and that action is required to further improve the control environment, Internal Audit have assessed the residual risk as ‘Medium’ and consider it important that, once further clarity has been obtained, management consider and agree an appropriate revised timescale.