ITEM 7 NL IJB IA progress report 25 February 2025 FINAL
North Lanarkshire Council · 25 February 2025
Back to IJB Performance, Finance and Audit Committee — 25 February 2025 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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Appendix 1 1 IJB Reporting Template REPORT ITEM NO: 7 SUBJECT: Internal Audit Progress Report TO: Integration Joint Board Performance, Finance & Audit Committee. Lead Officer for Report: Nicola Scott, Chief Finance Officer Author(s) of Report Francis Scott, Chief Officer (Audit and Risk), North Lanarkshire Council Jocelyn Lyall, Chief Internal Auditor, NHS Lanarkshire Contact details for Author(s) of Report Francis Scott – ScottFr@northlan.gov.uk Jocelyn Lyall – Jocelyn.lyall2@nhs.scot DATE: 25 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 PFA This paper has been: Prepared By: ☒ Reviewed By: ☒ Endorsed By: ☒
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Appendix 1 2 Chief Officer (Audit and Risk) (North Lanarkshire Council) and Chief Internal Auditor (NHS Lanarkshire) The Chief Finance Officer The Chief Officer 3. EXECUTIVE SUMMARY The progress in respect of the Internal Audit Plan 2024/2025 is summarised in Appendix 1. A workplan has been agreed to ensure the Internal Audit Plan 2024/2025 is delivered by 31 March 2025. 4. RECOMMENDATIONS 4.1 It is recommended that the IJB Performance, Finance & Audit Committee: 1) Consider the attached Progress Report at Appendix 1, the Summary of audits completed as part of the Internal Audit Plan 2023/24 at Appendix 2, the summary of relevant partner reports at Appendix 3 and note the final report on HSCP Governance Arrangements at Appendix 4. 5. VARIATIONS TO DIRECTIONS? This section outlines if the report requires a direction to be issued to the Local Authority, the Health Board, to both, or that no direction is required. 6. BACKGROUND As stated in the Integrated Resources Advisory Group guidance, it is the responsibility of the Integration Joint Board (IJB) to establish an adequate and proportionate internal audit of the arrangements for risk management, governance and control of the delegated resources. The internal audit arrangements for the IJB are provided jointly by the internal audit teams of North Lanarkshire Council and NHS Lanarkshire. The IJB approved the Internal Audit Plan 2024/2025 on 22 May 2024. A total of 60 days has been committed to undertake the IJB Internal Audit Plan, which has been designed to target the priority issues which have been aligned to Yes ☐ No ☒ N/A ☐
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Appendix 1 3 strategic risks and reflect the evolving and complex challenges to service delivery. The Public Sector Internal Audit Standards (PSIAS) require that activity and performance relative to the approved annual plan is periodically reported to the Performance, Finance & Audit Committee (PF&A Committee). The Internal Audit Plan 2024/2025 will provide sufficient evidence to form an Internal Audit Opinion on the overall adequacy and effectiveness of the IJB’s framework of governance, risk management and control arrangements. The Internal Audit Plan 2024/2025 also takes account of assurances which will be provided to the IJB based on the work performed under the Internal Audit Plans of both North Lanarkshire Council and NHS Lanarkshire for 2024/2025. The audit of operational activities is being undertaken under the auspices of the partner bodies. The IJB is asked to note that the outcomes of these operational audits are reported to the partner body Audit Committees and discussed with the IJB Chief Officer and IJB Chief Financial Officer. The assurances gained will be provided to the IJB as part of the overall assurances received from the partner body Audit Committees. We include a summary of relevant completed NHS Lanarkshire and North Lanarkshire Council reports at Appendix 3. 7. SUMMARY OF KEY ISSUES Progress on the Internal Audit Plan is 2024/25 at Appendix 1. Completed audits from the IJB Internal Audit Plan 2023/24 are summarised at Appendix 2. The Summary of relevant partner body reports is at Appendix 3 and a copy of the report on HSCP Governance Arrangements is included at Appendix 4. 8. CONCLUSIONS The Internal Audit Plan 2024/2025 is designed to target the priority issues and to provide sufficient evidence to form an Internal Audit Opinion on the overall adequacy and effectiveness of the IJB’s framework of governance, risk management and control arrangements. 9. IMPLICATIONS 9.1 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. ☐
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Appendix 1 4 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. ☐ 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. ☒ 9.2 ASSOCIATED MEASURE(S) 9.3 FINANCIAL There are no financial impacts arising directly from this report. This paper has been reviewed by Finance: Yes No X N/A 9.4 RISK ASSESSMENT/RISK MANAGEMENT The internal audit planning process which produced the Annual Internal Audit Plan considers the strategic risk profile of the organisation. Individual internal audit assignments identify the key risks at the planning stage and our work is designed to evaluate whether appropriate systems are in place and operating effectively to mitigate the risks identified. Legislative requirements are a core consideration in planning all internal audit reviews. Relevant Risk Register Details Current Risk Level Risk Owner Ineffective Governance Arrangements Low Chief Officer
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Appendix 1 5 9.5 ENGAGEMENT & PARTICIPATION The Chief Officer and the Chief Finance Officer have both been consulted in respect of the preparation of the Internal Audit progress report. 9.6 INEQUALITIES & FAIRER SCOTLAND DUTY An EQIA & Fairer Scotland Impact Assessment Form is not required as there are no EQIA implications arising directly from this report. All internal audit reviews which involve review of policies and procedures will examine the way in which equality and diversity is incorporated within documentation. EQIA Completed & Fairer Scotland Impact Assessment Form Completed and attached to report: Yes No X N/A EQIA added to website: Yes No X N/A 10. BACKGROUND PAPERS N/A 11. APPENDICES Appendix 1 – 2024/25 Internal Audit Progress Report Appendix 2 – Summary of 2023/24 IJB Internal Audit Reports Appendix 3 – Summary of Relevant NHS Lanarkshire and North Lanarkshire Council Reports issued Appendix 4 – Final Audit Report – HSCP Governance Arrangements
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Appendix 1 6 CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact the following: Chief Finance Officer
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Appendix 1 7 Ref Audit Indicative Scope Target Audit Committee Planning Stage Work in Progress Draft Issued Completed Grade Internal Audit Plan 2024/25 NL01- 25 Audit Planning Agreeing audit universe and preparation of internal audit annual plan. May 2024 N/A NL02- 25 Audit Management Liaison with management, liaison with Chief Finance Officer and attendance at Audit Committee. Ongoing N/A N/A N/A N/A N/A NL03- 25 1Audit Follow Up Review of progress made by management in implementing those actions committed to in response to previously agreed Internal Audit recommendations. December 2024 March 2025 NL04- 25 Annual Report Preparation for Annual Report including assistance with completion of IJB governance self-assessment checklist. August 2024 Reasonable
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Appendix 1 8 NL05- 25 2 Governance arrangements Review of governance arrangements with reference to the Blueprint for Good Governance in NHS Scotland. October 2024 March 2025 NL06- 25 Strategy Review of the content and implementation of the Strategic Commissioning Plan, including assessing the adequacy and effectiveness of arrangements for monitoring of delivery and performance reporting. March 2025 1The Audit Follow Up position will be reported to the March 2025 PF&A Committee. 2 As reported to the 21 August 2024 PF&A Committee, Internal Audit completed a review of the IJB Governance Checklist self- assessment in July / August 2024 and provided an adequate level of assurance (see Appendix 2). Therefore, this 2024/25 audit will now be completed for reporting to the March 2025 PF&A Committee. This should provide sufficient time for previous recommendations to be completed and will provide an opinion on the governance framework in place for 2024/25.
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Appendix 2 9 Summary of 2023/24 IJB Internal Audit Reports Report No. Report Description Audit Opinion Key findings 0500/2024/001 Review of NL HSCP Governance arrangements (copy of report at Appendix 4) Adequate The primary purpose of this audit review was to provide independent assurance on the adequacy and effectiveness of the processes in place to enable the North Lanarkshire Health and Social Care Partnership (HSCP) to review and assess its governance arrangements against expected good practice. The self-assessment was undertaken using a Governance Self-Assessment Checklist developed by the Chief Internal Auditor (NHS). This was based on professional judgement and relevant guidance, as well as the CIPFA Delivering Good Governance in Local Government Framework (2016). NLC Internal Audit thereafter undertook a high-level review of both the Governance Self- Assessment Checklist completed by the North Lanarkshire HSCP and the draft Annual Governance Statement for 2023-24, to identify areas where it is considered improvements could be made to strengthen the arrangements. We have concluded that the arrangements the North Lanarkshire HSCP has in place for reviewing and assessing its governance framework are largely satisfactory and that this framework is generally consistent with legislative requirements and expected good practice. The following areas for improvement were identified during the review: • A need to ensure that going forward the Annual Governance Statement (AGS) fully reflects any improvement actions arising from the annual self-assessment undertaken in respect of compliance with the principles outlined in the CIPFA Delivering Good Governance in Local Government Framework (2016), and that these actions are thereafter monitored, and their progress periodically reported to the Performance, Finance and Audit Committee; • Appropriate and timely action is required to progress previously agreed outstanding actions (service level agreement for those services ‘hosted’ by Education and Families and accessed by Adult Health and Social Work Services and vice versa, finalise the revised performance scorecard and determine a timeline for developing a sound understanding of the impacts for NL HSCP of the outputs of the National Care Service legislation); and • A need to review the North Lanarkshire Health and Social Care Partnership Audit Charter.
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Appendix 3 10 The following relevant reports have been issued by North Lanarkshire Council Report No. Report Description Audit Opinion Key findings 0510/2025/001 Social Work – Quality Assurance arrangements Reasonable The purpose of this audit was to provide independent assurance on the adequacy and effectiveness of the Council’s quality assurance arrangements in relation to the provision of social work and social care services. We are satisfied that the Services arrangements for monitoring external care providers is generally sound and broadly reflects good practice principles and reports have been produced for key stakeholders on the results of the Council’s quality assurance and continuous improvement activities. We are also satisfied that the key expectations set out in the contract management framework are generally being applied in practice. However, we identified several areas where we consider scope for improvement exists including: • A need for the Contract Management Framework to be reviewed and updated to fully reflect both best practice and actual current working practices; • A need to finalise, and thereafter implement, the monitoring framework for internally provided services • A need for greater consistency with, and for the Quality Assurance Team to better demonstrate compliance with, expected monitoring arrangements; and • Recently revised arrangements to record, monitor and track issues identified and actions arising from monitoring activity need to be reviewed to ensure they are adequate and effective.
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Appendix 3 11 The following relevant reports have been issued by NHS Lanarkshire Report No. Report Description Audit Opinion Key findings L05/25 Board & Operational Committees Reasonable An appropriate new governance structure has been approved for implementation it is still to be embedded. Therefore, we cannot yet comment on effectiveness of the revised governance structures, and we will report on this in our 2024/25 Internal Control Evaluation report. A programme of governance improvements, led by the Director of Human Resources, is ongoing to support the revised governance structures. A summary of areas for consideration as part of the further development of good governance was provided by internal audit and we will work with officers to support this ongoing work. Our review identified that the standard governance documentation for committees has not always been completed nor presented to the relevant committee at the stipulated time. We noted several developments, including that a standard cover paper template has been issued and the timeframe for issue of papers is included in all revised Terms of Reference. ‘Once for Scotland’ documentation was introduced in July 2024 and work on the Board Assurance Framework (BAF) will be taken forward with support from the Chief Internal Auditor, with review planned for the end of the financial year to ensure the BAF meets the requirements of the Board. L06/25 Risk Management Reasonable Assurance Our review identified that there are gaps and duplication in the extant NHS Lanarkshire Risk Management documentation. The Risk Management Strategy, Framework and Policy are currently under review and internal audit have made recommendations for inclusion in the revised documentation. Extant Risk Management documentation was not resubmitted to the Audit & Risk Committee for formal approval and therefore unapproved documents were posted on FirstPort. A Risk Appetite statement will be developed and implemented following Corporate Management Team and Board review, in November 2024. L08/25 Strategic Planning Substantial Assurance Internal Audit concluded that the process to develop Our Health Together followed robust project management methodologies, good governance was evident and there was an
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Appendix 3 12 Report No. Report Description Audit Opinion Key findings extensive stakeholder engagement process. Therefore, we did not make any recommendations for improvement. L10&26/25 Review of Delayed Discharge & Data Reasonable Assurance Internal audit reviewed implementation of improvements to minimise Delayed Discharges monitoring and reporting of outcomes. The 'Sustaining Whole System Patient Flow' strategic risk was assessed as Very High with a target of Medium and has been adequately described and scored. There is appropriate assurance in place for the identified mitigating controls. Implementation of changes to pathways, development of models of care and redesign of services to improve delayed discharge performance commenced in Summer 2024. Therefore, sufficient information is not yet available to assess the impact of these changes on improved flow and sustained performance. We will report on this area in our 2024/25 Internal Control Evaluation and Annual Report. Internal audit concluded that all elements of national initiatives to improve Delayed Discharge performance are included in Operation Flow. The Chief Executive led a comprehensive diagnostic of the current delayed discharge performance in July 2024 and a route map to an improved position was developed with agreed actions to implement the optimal Discharge Planning Target Operating Model, establish a Once for Lanarkshire system Home First Assessment approach and complete Demand, Capacity, and Queue analysis of community and social care resources. A Delayed Discharge Improvement Plan has been developed and is monitored through the Operation Flow governance and performance reporting structures. We concluded that these reporting and monitoring structures are robust. Recording of a Planned Date of Discharge (PDD) within 48 hours of admission is a key control to improve the route map through the patient journey but was not recorded for all patients in our sample. The ‘Firebreak 24’ in September 2024 focused on accelerating transformation efforts to reduce hospital occupancy, streamline admissions, and manage unscheduled care demand, as well as planning for increased demand over winter. A ‘24/72’ discharge rule setting out the notice
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Appendix 3 13 Report No. Report Description Audit Opinion Key findings period for requesting support on discharge was implemented and remains in place. We would expect to see future reporting of the impact of the 24/72 discharge rule on delayed discharges. To support the full implementation of the Optimal Discharge Target Operating Model, and further embedding of the flow foundation bundle, a training, education, communication, and engagement plan will be supported by the establishment of an Unscheduled Care Improvement Team. The team will work with Management to deliver the improvement actions and activity required to ensure that PDD setting and recording is fully implemented across the system. Work is ongoing with Health Improvement Scotland colleagues to develop a PDD decision making tool to further support frontline operational and clinical teams. L27/25 Waiting Times Limited Assurance Internal audit L31/24 Review of Waiting Times methodology was issued in June 2024 and provided Limited Assurance. While there has been some progress, implementation of actions has been delayed. This follow up report described the progress made to date. As in 2022/23 and 2023/24, Internal Audit provided a Limited Assurance opinion on this system. Two of the three recommendations made in internal audit L31/24 have not progressed and one recommendation relating to communication has been partially implemented. We do however acknowledge that progression of actions is partially dependent on development of national processes. Original recommendation Due date Revised due date RAG status, updated position, and Agreed Action Implementation of four “Next Steps” detailed within the Patient Rights (Treatment Time Guarantee) (Scotland) Directions 2022: Communication with staff and patients and August 2024 April 2025 Work is progressing to align all communications with Scottish Government Communication trigger points. Netcall reminder service is in place. Content of letters, including single point of contact being updated. TTG Letters acknowledgement and apology revised and tested.
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Appendix 3 14 Report No. Report Description Audit Opinion Key findings automation of clinical letters. Not currently possible to align all clinical letters with TrakCare due to specialty specific information - working to migrate when / where possible. Production of automated TTG letters August 2024 April 2025 A national approach to production of automated TTG letters has been agreed, to be phased across Boards from February 2025. This will require consideration of: • A Communication plan • Amendment and alignment of letters with regard to patient response time • Testing to determine any unexpected impact on other processes • Agreement of a Go live date. Completion of Waiting Times audits August 2024 April 2025 Automated Waiting List letters are not being produced to inform patients of progress on their TTG pathway and the reasons for not meeting the dates. As a result monthly TTG audits are not being completed. The original ‘NHS Waiting Times Guidance’ Short Life Working Group is progressing to become a Reference Group to support audit requirements and ensure they are aligned to both what can be done locally and the National requirement. The audits will be recommenced once the letters are ready to be sent out to patients.