ITEM 14 Q2 Performance Report
North Lanarkshire Council · 21 February 2024
Back to IJB Performance, Finance and Audit Committee — 21 February 2024 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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1 REPORT Item No: 14 SUBJECT: Performance Update – Quarter 2 (July – September 2023) TO: Performance, Finance & Audit Committee Lead Officer for Report: Morag Dendy, Head of Planning, Performance and Quality Assurance Author(s) of Report Stephen Forrest, Performance Manager DATE: 21 February 2024 1. PURPOSE OF REPORT This paper is coming to the IJB PFA for: For approval ☐ For endorsement ☐ To note ☒ 2. ROUTE TO THE BOARD This paper has been: Prepared By: ☒ Reviewed By: ☒ Endorsed By: ☐ Prepared by: Performance Manager Reviewed by: Senior Manager, Strategy & Performance
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2 3. RECOMMENDATIONS It is recommended that the IJB PFA Committee: (1) Note the contents of the report and the appendix. 4. VARIATIONS TO DIRECTIONS? 5. BACKGROUND/SUMMARY OF KEY ISSUES The Chief Officer has joint quarterly performance review meetings with the Chief Executives of NHS Lanarkshire and North Lanarkshire Council. These meetings are supported by a Chief Executives Performance Framework, comprising a range of performance measures taken from across both the health and social work systems, including relevant targets and trajectories for the measures presented. Each quarter there are areas for improvement identified within the performance framework; these are identified using a RAG rating and those measures that are flagged as Red or Amber are subject to improvement or corrective action. The performance review meetings are used as a means for jointly agreeing these actions. 6. CONCLUSIONS The areas for improvement and corrective action are attached as Appendix 1. The areas for improvement identified in Appendix 1 are being progressed as a matter of priority, and progress updates will be reported at future meetings of the Board and the Performance, Finance & Audit Committee. 7. IMPLICATIONS 7.1 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 ☒ Yes ☐ No ☐ N/A ☒
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3 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) None. 7.3 FINANCIAL This paper has been reviewed by Finance: 7.4 RISK ASSESSMENT/RISK MANAGEMENT Relevant Risk Register Details Current Risk Level Risk Owner IJB 11.21 - Oversight of Performance Activity Low Ross McGuffie NHSL 2014 - Recovery of Performance 2021/22 Very High NHSL Corporate NLC RIA0000460 – Performance & planning High NLC – Social Work/Social care 7.5 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 Yes ☐ No ☐ N/A ☒
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4 ☐ 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 The performance information, with the corresponding improvement and corrective actions will enable stakeholder representatives to participate in wider discussion about performance. ☐ 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 The performance information, with the corresponding improvement and corrective actions supports locality planning. 7.6 INEQUALITIES & FAIRER SCOTLAND DUTY EQIA Completed & Fairer Scotland Impact Assessment Form Completed and attached to report: EQIA added to website: Yes ☐ No ☐ N/A ☒ Yes / Date added ☐ No ☐ N/A ☒
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5 8. BACKGROUND PAPERS None. 9. APPENDICES Appendix One- Areas for Improvement (Quarter 2, July – September 2023) CHIEF ACCOUNTABLE OFFICER (or Depute) Head of Planning, Performance and Quality Assurance Members seeking further information about any aspect of this report, please contact the following; Stephen Forrest – Performance Manager Stephen.Forrest@lanarkshire.scot.nhs.uk
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6 Appendix One 1. Cervical Screening Target 2022/23 2023/24 Q1 2023/24 Q2 Performance Compared to Previous Quarter Performance Compared to Same Quarter Previous Year RAG Status Cervical Screening 80% 72.3% 72.3% Narrative & Corrective Action MiLan was used to analyse uptake for cervical screening across Lanarkshire. The graph below highlights that the cervical uptake rate for North Lanarkshire appears to be stable in the 6 localities, although none of the localities achieved the recommended target of 80%. Although there has been no significant change in uptake across localities, there has been a shift in uptake for 3 GP practices within Coatbridge. One practice has increased from 69.5% to 73.4%, with 2 practices declining from 76.0% to 67.2% and 73.8% to 67.9%. 69.1% 70.7% 71.5% 72.6% 75.8% 71.8% 69.4% 71.1% 71.4% 72.8% 75.9% 71.7% 62.0% 64.0% 66.0% 68.0% 70.0% 72.0% 74.0% 76.0% 78.0% 80.0% 82.0% Airdrie Bellshill Coatbridge Motherwell North Wishaw North 2023 Quarterly Uptake by locality 2023 Quarter 1 June 2023 Quarter 2 September 2023 Target
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7 Of the 50 GP practices in North Lanarkshire, only 3 achieved the 80% target in quarter 2, this was consistent with quarter 1. The breakdown by locality is provided below. Airdrie (6 practices) – no practices achieved the 80% uptake target Bellshill (9 practices) – no practices achieved the 80% uptake target Coatbridge (6 practices) – no practices achieved 80% uptake target Motherwell (6 practices) – 1 practice achieved above 80% uptake target North (12 practices) – 2 practices achieved 80% or above Wishaw (11 practices) – no practices achieved the 80% uptake target Other Activity – Community Engagement. Two community engagement projects in Airdrie and Bellshill continue to work with local communities to raise awareness and identify barriers to engagement in cervical screening. More data will be available in Quarter 3. The “Culture Junction” project commenced delivery with workshops during October 2023. Following the in-person consultation with groups at the Lanarkshire Mosque, an online survey was developed by Jo's Trust to engage younger women, as this was identified as a gap in the previous consultations. This online survey was shared with relevant community contacts as well as on NHS HI social media at the beginning of August. Jo’s Trust are collating the results of both the online and in-person consultations and once analysed, the results will inform future communication and engagement plans. Work to address health inequalities, including the HPV vaccine and work with Jo’s trust to encourage screening for young people continues and is expected to impact positively in the longer-term. Quality Improvement Activity As described in the previous report, a small amount of capacity was released to provide support for GP practices to identify any areas for improvement in their uptake for cervical screening that could assist in achieving the national target of 80% uptake.
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8 Creating Conditions Establish relationships and link with health improvement colleagues and GP practices Link with individual GP practices and provide support and assistance with accessing and analysing data Access MiLan for breakdown of uptake by locality and GP practice Offer of support to GP practices in understanding systems Understanding Systems SCCRS is the national programme for recording and inviting individuals to participate in cervical screening. Results are recorded quarterly in the local system (MiLan). Reviewed SCCRS in order to identify areas for improvement and monitoring of uptake Analyse MiLan to identify uptake across Lanarkshire geographical areas. This provides a breakdown of uptake and number of patients eligible for cervical screening each quarter by locality and GP practice. Results for this quarter are shown in the above table and narrative. Developing Aims A questionnaire was developed to establish processes in place for cervical screening across Lanarkshire GP practices. This has been shared with some GP’s across the North locality who are keen to improve their screening uptake and help support ease of access to services. Evidence of uptake for GP practices was collated and presented at the GP cluster meeting. Other work ongoing is as follows:
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9 Meetings have taken place with Health Improvement Team (MH) & GP Cluster Lead (WH) for Bellshill in order to provide information specific to their practices. This has resulted in more in-depth engagement with cluster leads and increased intelligence on uptake and defaulters. A report on defaulters for Bellshill Practices used anonymised data and information and was shared with GP cluster lead. Meetings have taken place with GP cluster (JA cluster lead) for Bothwell, Uddingston and Viewpark. Intelligence on uptake and defaulters was shared, along with the questionnaire to identify processes within the GP practices for cervical screening. This identified that one practice had no practice nurse in place, however plans were identified to fill the post. However, as training was required for preferred candidate and it is not available locally, the service was able to provide access to that training in NHSGGC through their professional network. The service is now offering support in making best use of SCCRS to analyse data and also to assist with tailoring correspondence that reflects practice availability for patients due for screening (if required). 2. Childhood Immunisations Target 2022/23 2023/24 Q1 2023/24 Q2 Performance Compared to Previous Quarter Performance Compared to Same Quarter Previous Year RAG Status Immunisations – %s of 5 year olds 95% 91.4% 89.9% Narrative & Corrective Action It is of note that indicator for the percentage of 2 year olds, which was consistently below target is now RAG GREEN, however the measure 5 year olds remains in decline. A further deep-dive study of immunisation data and a pan-Lanarkshire SLWG to address performance in this area commenced in December 2023. The “Immunisation Inclusivity” programme has also now commenced, with a pan-Lanarkshire approach to addressing inequalities. As a result of recent analysis, the service is investigating a possible trend relating to recent migration and attitudes toward immunisation that may be impacting on performance in this area. With issues relating to cultural attitudes toward immunisation, it is believed that long-term engagement will be required to improve performance. There is significant work within locality teams to improve uptake of vaccinations, currently focusing on issues around consent, partial consent and withdrawn consent; this is resulting in focussed work and engagement with particular families. An SBAR has been produced explaining a recent analysis of the available data and found that 1149 pre-school children had incomplete immunisations. However, there was complexity within cases around the withdrawal of consent, multiple immunisations, etc., and on a more in-depth analysis, 322 cases were identified were the status was not clear due to incomplete data. This identified a very small number of exceptional cases that were not allocated to a HV but most issues seemed to involve recording errors, or omissions in the SIRS3 process, particularly for those moving into the authority area from elsewhere. The service has identified that the SIRS form and process is not effective in dealing with cases of partial, or complete withdrawal of consent; there is an overall increase in the numbers of those withdrawing consent, however the recording process and current practice is not best at managing such cases and there is a lack of understanding across the many stakeholders of how to record and manage this.
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10 The service has identified that there is inequity and inconsistency in delivery; depending on the alignment of HV to a GP or Locality and the custom and practice within that setting, the service delivery can be greatly affected including the provision of clinics and appointments, availability of home visits and travel expenses paid to HV. Immunisation Inclusivity” programme will work to address these inequalities. The service recommends that a SOP and standardised practice is required, however in the long-term, it will be essential to implement a digital solution. Communications, use of social media and staff training will be key to embedding improvements. The work in North localities, aligned to the direction of the pan-Lanarkshire SLWG are characterised in the Action Plan for North Lanarkshire Health Visiting Teams, which will be jointly managed by the Service Manager and Senior Nurse. The actions are organised around 5 key areas recommended for improvement: 3. 6 – 8 Week Reviews Target 2022/23 2023/24 Q1 2023/24 Q2 Performance Compared to Previous Quarter Performance Compared to Same Quarter Previous Year RAG Status Percentage of people who have completed 6-8 week review 90% 79.9% Quarterly/ 1 quarter behind Narrative & Corrective Action The management team have carried out “deep dives” of the historic data in order to better understand the decline in performance for this measure. This indicator reflects on the wider Home Visit/ Universal Home Visit Pathway and the deep-dive analysis identified that inconsistency in practice across GP practices and less effective communication between Health Visitors and GP practices may be playing some part in the decline in performance. Guiding Principles/Professional Practice • Home Immunisation position for all teams with guiding principles/SOP • Review Locality boundaries to realign with workforce utilising information from boundary paper and workload tool. • Agree guiding principles for immunisation scheduling and number of staff immunising. • Agree Interim latter for localities to use for non-attendance if Did Not Bring Policy not agreed. • Agree grade of staff to complete transfer in visit and completion of SIRS 3 form, • Consider any training needs in completion of the SIRS 3 form with guiding principles. IT • Review SIRS 3 form alignment with Morse • Agree platform for recording immunisations with consideration to Turas and new SIRS/CHI system implementation. • Review any potential options for text messaging system to remind patients of appointments Accomodation • SM to review and agree any locality requests for accommodation for additional clinics/pop up clinics • SM to review and agree any accommodation requests for evening and weekend clinics • SM to review and agree any financial costs associated with alternative clinics Locality processes for monitoring Q print • GP Practice and Health Visiting local processes to be considered to monitor Q print monthly and transfers in and out of locality. Public Health and Communications • Agree any media coverage to promote childhood vaccination programme.
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11 The analysis identified issues with those reviews completed closer to the 8-week deadline where multiple and part records were being generated, resulting in recording errors. More generally, issues were identified where missing demographic information resulted in recording forms being rejected and then returned, leading to failures and errors in recording. The potential for multiple, parallel and incomplete records increases the risk of poor performance in this area. Many findings from the analysis related to administrative error that can be characterised by the lack of an applied standardised process for recording, returning and storing of records. Many of the problems are manifest at the point of recording and with the GP practice, where there are continual failures to complete or return forms. It was also noted that any delay in registration of children by their parents, for any reason, can result in failure to meet the target. The management team are using the analysis to provide more detailed presentation of the data showing the impact of various issues on overall performance, including the impact of “opting-out”. More work is required to understand how the uptake of reviews may be impacted by the nature of the opt-in, or opt-out approach to managing the UHVP reviews. The findings of the analysis and recommendations resulting from this work were documented in an SBAR that was presented to the CMT, who endorsed the recommendations. There is a national programme to move to an electronic recording solution, however this is not expected to be delivered until 2025. There is significant local work to investigate how Morse might facilitate an interim electronic solution. Following the submission of the SBAR to CMT, the Executive Team and their Digital colleagues are now reviewing the overall prioritisation of Morse implementation within the partnership to reflect areas the areas of greatest need and risk. The service continues to engage with the national work for a digital recording solution alongside the local work. It should be noted that although some improvement might be found through the adoption of Morse, this would not address the issue in entirety as GPs are not able to access the system. Changes in GP practice, changes in approach and the autonomy of GP practices mean that even embedded improvements can be subject to changes that are out with the control of the HSCP. The service believes that the lack of consistent process, or SOP is the critical factor in both performance, quality and safety. At a locality level the service continues to implement practical actions to address the immediate concerns around missed reviews, and incomplete or missing records. There is regular engagement with GP practices on the importance of communicating any non-attendance and specific engagement with GP and their Practice Managers to discuss the processes in place to ensuring CHSP forms are collected and delivered. There is a Test of Change in progress within Motherwell locality to trial an improved process; this is in the early stages but has already improved communication between the HV staff and GP practices and the early indication is that the change is positive. 4. Reablement and Rehabilitation Target 2022/23 2023/24 Q1 2023/24 Q2 Performance Compared to Previous Quarter Performance Compared to Same Quarter Previous Year RAG Status Reablement - % Of People With No or Reduced Home Support Service Required At End Of Process 70% 21.3% 22.6% Balance Of Care - % Of People (Age 65+) 45% 40.2% 36.7% IEAS - % Deliveries Achieved Within 7 Working Days Quarterly 80% 47.5% 49.9% Narrative & Corrective Action A working group has been formed to update the Standard Operating Procedures for Reablement. The group has MDT representation from the six localities, including locality Integrated Rehabilitation Teams and Home Support.
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12 Rehabilitation and Reablement have increased their levels of collaboration with the Technology Team to introduce more technology options, supporting improved outcomes for service users. A number of staff awareness sessions have taken place and where possible, co-location of Technology Team staff within the locality has enhanced the knowledge and understanding of tech options, built relationships and improved joint working. Wishaw locality has been involved in a test of change to take all functional and environmental assessments away from Access Social work and this has proved to be very successful in reducing waiting times for service users and provided quicker access to rehabilitation. This approach will be further tested in another locality to assess the effectiveness of this way of working. There are continued challenges faced by IEAS, however performance against the seven-day standard appears to have stabilised. There has been focused work on reducing the number of outstanding uplifts and higher priority deliveries. The ordering and delivery of equipment should be prioritised according the risk matrix, however most items ordered remain a Priority 1 and almost all equipment requested from hospitals is deemed essential for discharge, which increases strain on the service. IEAS staffing levels have significantly improved; the current position overall is a deficit of 5.89 WTE, however a refreshed induction and training programme for new staff members requires that the full capacity of these new staff is not wholly available to the service as yet. The procurement of the ELMS2 digital management system will improve processes, management information and communication. The system is currently in build and the training is being planned; the rollout is planned over six months with full integration expected in Autumn 2024. The Home Support Team continues support the wider Rehabilitation and Reablement services, with 1,253 referrals to HAT to 30th October 2023. Generally, a third of all referrals are Wishaw locality; Bellshill and Coatbridge have yet to fully start the HAT service. The number of referrals with no input services noted from HAT appears to be decreasing, suggesting that that people may be refusing services upon discharge. The largest input service is Home Support, followed by OT.
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13 The number of people being re-admitted to hospital at the end of the HAT process is decreasing, the number of those requiring no further service is increasing, as is the percentage of people completing the HAT process. The approach is well embedded in Wishaw and Cumbernauld, with increasing activity in Airdrie and Motherwell localities. The next steps for the project are to complete recruitment and the locality roll-out, ultimately leading to adopting the HAT approach for all people being discharged from hospital, allowing for a seamless flow to Reablement and greater capacity within Home Support. Further service improvements are expected through the review of Home Support, which has necessary interdependencies with HAT, Reablement and IRT teams. The Home Support Programme Board governs and provides strategic direction for this work. Input SW 4% OT 51% Physio 17% AHP Support Staff 11% Home Support 70% CAS 22% Technology 4% Pharmacy 3% Com. Nursing Team 10% Med. Realignment 2%
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14 5. CAMHS Target 2022/23 2023/24 Q1 2023/24 Q2 Performance Compared to Previous Quarter Performance Compared to Same Quarter Previous Year RAG Status 18 Week RTT Performance – CAMHS NHSL (NORTH HOSTED) 90% 28.1% 47.1% Narrative & Corrective Action The Waiting List Initiative continues to evidence a steady downward trajectory in children and young people who are waiting to be seen. Combined with the impact of CAPA, there is evident reductions in the waiting list and the longest waits. Although embedded as standard practice, the service continues to monitor the impact of CAPA and the WLI to ensure that it is addressing ongoing challenges around the RTT target and that appointment capacity is maximised across the whole system. Modelling suggests that increased activity through waiting list initiative will not fully deliver RTT improvement in RTT in the short-term, however the expected consistent positive trajectory appears to be manifest in the data. 6. Adult Mental Health Target 2022/23 2023/24 Q1 2023/24 Q2 Performance Compared to Previous Quarter Performance Compared to Same Quarter Previous Year RAG Status Consultant Outpatient WT - Adult Mental Health - 12wks (NHSL) (NORTH HOSTED) 90%* 57.4% 48.9% Narrative & Corrective Action The Scottish Government published their Core Mental Health Quality Standards in September 2023. The standards are available at Core Mental Health Quality Standards (www.gov.scot). These set out the vision for Scotland to achieve the best mental health and wellbeing possible, built around a clear national framework with themes informed by people with lived experience of using mental health and psychological services and the workforce. The themes are: Access Assessment, Care Planning, Treatment and Support Moving between and out of Services Workforce
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15 Governance and Accountability The long-standing shortage of psychiatrists and the wider staffing emergency in mental health services across Scotland presents a significant challenge for Lanarkshire to adhere to these standards. Currently, staff are working in an environment with reduced staff availability but with increased levels demand. It is believed that in Lanarkshire, ADHD cases are the most significant area of increased demand. The following actions are ongoing to address operational planning and business continuity for the services: Escalation to senior medical management and the NHSL executive; the issue is being managed on the risk register and the position noted as deteriorating. SLWG to implement actions to mitigate the low staffing levels whilst still allowing for the cover of core work. Bespoke recruitment process and documenting of a recruitment and retention strategy. 7. Medical Paediatrics Target 2022/23 2023/24 Q1 2023/24 Q2 Performance Compared to Previous Quarter Performance Compared to Same Quarter Previous Year RAG Status Medical Paediatrics WT - 12 wks (NHSL) (NORTH HOSTED) 90%* 49.5% 56.1% Narrative & Corrective Action In-reach capacity is limited and capacity is being balanced across the system to ensure cover. Vacancy gaps in the Tier 3 rota have been partially filled with two locum positions and have stabilised staffing arrangements. The service is investigating potential OD and CPD opportunities for staff that may contribute to recruitment and retention of core staff. It should be noted that whilst the RTT target was not being met, significant improvement had been made in the length of wait, from 11.5 to 4.5-months had been realised. The complicated system pressures between Neuro and Paediatrics are currently being analysed as patients can be subject of multiple referrals and waits. This is in parallel with modernisation work within the service and work to identify the data, information and metrics similar to that in CAMHS is being considered as part of the approach. 8. SLT Target 2022/23 2023/24 Q1 2023/24 Q2 Performance Compared to Previous Quarter Performance Compared to Same Quarter Previous Year RAG Status SLT - Paediatrics - 12wks (NORTH HOSTED) 90%* 25.1% 18.3% Narrative & Corrective Action A service improvement plan is in progress and the management team have been provided with additional support to implement the improvements. There are six discreet areas of improvement work: -
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16 1. Communication and Engagement – Communications are being disseminated via the dedicated website and YouTube. This is led by the NHS Communications Team and supported by the SCHSU Engagement Officer. 2. Waiting List – Improvement work is ongoing to address the waiting list and waiting times, with a focus on consistency of approach and use of Trakcare. 3. Accommodation - A review is yet to be undertaken of currently allocated space and capacity of clinical rooms to meet clinical demand. 4. HR and Workforce - Scoping of workforce demography and the development of a new workforce and service delivery model is yet to be undertaken. 5. Administration - A scoping of tasks against current capacity and demand is planned. 6. eHealth - Testing of the current Trakcare build and expanding this to all parts of service is to be led by colleagues from eHealth. 9. Dietetics Target 2022/23 2023/24 Q1 2023/24 Q2 Performance Compared to Previous Quarter Performance Compared to Same Quarter Previous Year RAG Status Dietetics - 12wks (NORTH HOSTED) 90%* 75.4% 69.1% Narrative & Corrective Action The improvement in performance seen in Q1 has not been sustained, although the overall trend in the longer-term is still for improving performance. Recovery continues to be restricted by the (approximately) 20% reduction in available workforce, which is due to both long term sickness and sustained vacancies in the workforce. Although recruitment activity continues, as with many services Dietetics has difficulty in attracting suitably skilled and experienced staff due to lack of available workforce nationwide. 10. Adult Social Work Target 2022/23 2023/24 Q1 2023/24 Q2 Performance Compared to Previous Quarter Performance Compared to Same Quarter Previous Year RAG Status Percentage of Notifications Received by LAC Team Within 3 days of LAC Date 95% 13% 41% % Of Adult Protection Referrals Passed To Care Team For Investigation 20% 12.4% 14.8% % Of Adult Protection Investigations Going To Initial Case Conference 20% 20.3% 10.4% Narrative & Corrective Action The number of APS referrals received by localities continues to rise. Care Homes continue to be the primary source of referrals for ASP, which has been a consistent trend over the last 12 months. It is important to recognise that number of referrals does not automatically equate to the number of adults at risk of harm. Work continues to be undertaken with Care Homes and relevant stakeholders to promote high-quality ASP referrals and defensible decision-making based on a good understanding of risk, harm and the impact (or lack-of) this has on the adult being referred, and ultimately whether ASP is the correct referral route to take. In addition, community based referrals are more likely to progress to ASP investigation when compared to referrals from Care Homes. Referrals generated by Social Work and partners often relate to
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17 multiple types of harm but our analysis has identified that self-neglect and hoarding continue to rise; these cases are often complex and require a long-term, inter-agency response. Police “Adult Concern” reports continue to rise; combined with ASP referrals, these generate a significant body of protection work that is undertaken by localities to keep adults in the community safe.
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18 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