Agenda Pack
North Lanarkshire Council · 21 June 2023
Back to IJB Performance, Finance and Audit Committee — 21 June 2023 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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A meeting of the Performance Finance & Audit Committee will be held on Wednesday 21st June 2023 at 9.30am-12pm via Microsoft Teams If anyone would like to join this meeting, please contact Stacey Connor on 01698 752594 or by email at Stacey.Connor@lanarkshire.scot.nhs.uk for the relevant information. AGENDA CHAIR: Brian Moore No Time Item Action Attachment Reporting 1. Welcome and Apologies B Moore 2. Declaration of Interests Members are invited to declare any interest in relation to any of the agenda items Board Members 3. Minutes Performance, Finance & Audit Committee (19th April 2023) For Approval Attachment B Moore 4. Matters Arising - Action Log For Approval Attachment R McGuffie GOVERNANCE 5. P,F & A Risk Register For Noting Attachment R McGuffie FINANCE & AUDIT 6. Unaudited Annual Accounts For Approval Attachment A Kilburn 7. Internal Audit For Noting Attachment A Kilburn 8. Financial Monitoring For Approval Attachment A Kilburn PERFORMANCE 9. Resilience Paper For Noting Attachment R McGuffie 10. Prisoner Healthcare For Noting Attachment M Thomson 11. Alcohol & Drug Partnership Annual Report For Approval Attachment R McGuffie 12. Equality Outcomes and Mainstreaming Report Update For Endorsement & Noting Attachment M Williamson
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13. Q4 Performance Report For Noting Attachment R McGuffie 14. Risk Consider whether, from the business discussed, any new, emerging risks need to be added to the Risk Register, or whether the discussion materially alters the assessed level of risk/risk tolerance and/or the mitigating controls B Moore 15. Date of Next Meeting: 18th October 2023 9.30am-12.30pm
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1 ITEM 3 Integration Joint Board Performance, Finance & Audit Committee Minutes from a meeting held on Microsoft Teams on Wednesday 19th April 2023 9.30am-12pm Present: Voting Members: Councillor Claire Barclay Proxy for Councillor Gerry Brennan North Lanarkshire Council Nominated Councillor Ally Boyle NHS Lanarkshire Nominated Non Exec Director Councillor Bob Burgess North Lanarkshire Council Nominated Councillor Phillip Couser (left 10.25am) NHS Lanarkshire Nominated Non Exec Director Councillor Paul Kelly (Left 10.15am) North Lanarkshire Council Nominated Councillor Councillor Ayeshah Khan North Lanarkshire Council Nominated Councillor Brian Moore (Chair) NHS Lanarkshire Nominated Non Exec Director James Muir NHS Lanarkshire Nominated Non Exec Director Non-Voting Members in Attendance Professional Advisors: Amanda Kilburn Section 95 Finance Officer Ross McGuffie Chief Officer, North Lanarkshire HSCP Stakeholders: Harry Robertson North Lanarkshire Carer Together John Watson Unison Rep In Attendance: Stacey Anderson Support Services, Project Manager Stacey Connor (Minutes) Minute Secretary Mark Dell Communications Manager Morag Dendy Head of Planning, Performance & Quality Maddy Halliday Chief Exec, VANL Third Sector Rep Dr Lucy Munro Medical Director North HSCP Elizabeth Seaton Partnership for Change User Rep Maggs Thomson Head of Health NHSCP Apologies: Paul Carey Audit Scotland Diane Fraser Head of Adult Social Work Services Cathy McGinty Unison Staff Side Rep (NHSL) Trudi Marshall Nurse Director North HSCP
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2 ACTION 1. Welcome and Apologies The chair welcomed everyone to the meeting and introductions were made; apologies were as noted above. 2. Declaration of Interests It was noted for Item 13 Brian Moore and other non-executive directors are part of the NHS Lanarkshire endowment committee which allocates funding for the social prescribing initiative. This was noted. 3. Minutes The previous minutes were approved as an accurate reflection of the discussion. 4. Matters Arising/ Action Log Under matters arising Brian Moore queried if a summary report for the annual report will be available. Ross McGuffie advised required reports will be published on the new HSCP website. Morag Dendy added the summary report is not finalised but it will be soon. Ross McGuffie advised Stacey Anderson is undertaking a review of action logs for both committees to streamline reports and update the action logs. The Liaison Sessions were first established to bring voting members together as an organisational development session but this has now moved towards more of a workshop session. Membership for liaison session will be extended to all members of the IJB. Item 18- IJB Self-Assessment Report- The work has identified a number of actions which are included as part of the progress report. Best value audits were previously stood down due to National Care Service work but are now expected to be reinstated. Item 22 MH Strategy- Will come back to liaison session and this is the final year of the current strategy so this will be reviewed in due course. Ross McGuffie also advised there is a new date for a liaison session in May, the main agenda item being human learning systems. Morag Dendy advised she have been able to secure a range of events through NES which commence this week to develop the process. Maddy Halliday advised that the community solutions programme has learning and improvement work across the programme which could feed through to HSCP going forward. This was noted.
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3 5. PF & A Risk Register The purpose of the report is to provide a summary to the Integration Joint Board on risk management activity, noting any amendments or additions to the current risk register. Following discussions at the last meeting of PFA on 14th February 2023, there has been a number of changes in the risk register: 3 risks closed: o IJB 03/21 – EU withdrawal o IJB 08/21 – Financial Implications of Covid o IJB 09/21 – Impact of pandemic on implementation of the strategic plan 1 risk increased: o IJB 06/21 – Prescribing – increased due to the projected increased costs facing the partnership in 2023/24 2 new risks identified: o IJB 19/23 – Service sustainability – a broader risk on sustainability challenges, replacing previous risks on EU withdrawal and Covid o IJB 20/23 – Workforce sustainability – a broader risk on sustainability challenges, replacing previous risks on EU withdrawal and Covid There are currently two risks rated as Very High on the IJB risk register. IJB 06/21 – Prescribing Activity and Costs IJB 17/22 – Unscheduled Care There are eight high rated risks on the IJB risk register. IJB 01/21 - Financial Challenges IJB 04/21 - Notional Set Aside Budget IJB 12/21 - Staff Health & wellbeing IJB 14/22 – CAMHS IJB 15/22 – Cost of Living IJB 16/22 – National Care Service IJB 19/23 – Service sustainability IJB 20/23 – Workforce sustainability. Ross McGuffie advised Stacey Anderson and Maggs Thomson have been working with Charlotte Hope (Corporate risk manager at NHS Lanarkshire ) to develop a new reporting template for risk reporting to the committee. This will also be looked at in more detail as part of the risk workshop at a future liaison session. Cllr Ayeshah Khan reminded the committee to be mindful of not using jargon within the risk reports; this was noted. Philip Couser referenced risk 20/23 (workforce sustainability) and queried what is the background to this risk to offer the committee assurance. Ross McGuffie acknowledged there are areas of pressure across a number of service areas due to recruitment challenges but this is a national issue.
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4 Trudi Marshall added that during covid the professional governance structure were redeployed to firstly support pandemic and then to support the firebreak and vaccination programme, which means there are gaps in the governance process due to this; have tried to mitigate the risk where possible. The IJB PFA agreed the following recommendations: Noted the contents of the report which includes the latest version of the IJB PFA risk register and a note of those operational risks highlighted by the Heath & Social Care North Lanarkshire partnership that impact upon delivery of IJB business. 6. Financial Monitoring Report The financial monitoring report provides a summary of the financial position of the North Lanarkshire Health and Social Care Partnership (HSCP) for the period from 1 April 2022 to 3 February 2023. The IJB year to date position is an underspend of £15.332m and the projected outturn for 2022/23 is an underspend of £17.264m, assuming the current trajectory of spend continues throughout this financial year. The key reasons why the IJB is currently projecting an underspend against its budget this year are as below: • Employee Costs net underspend of £12.323m: as previously highlighted there are ongoing challenges in terms of recruitment and retention issues across all service areas. For a wide range of posts recruitment has been unsuccessful due to the availability of the skills mix required or the competition being offered by other private and public sectors. These are issues that are being faced by IJBs across Scotland. • Home Support net overspend of £0.541m: within Home Support Services, employee costs have increased as the service continues to support delayed discharges and demand however, this additional cost is being funded from the current number of vacant posts throughout other parts of the partnership. • Payments to Other Bodies net underspend of £2.840m: the underspend is primarily due to the staff shortages and vacancies within the Care at Home sector who provide services to individuals via the self-directed support commissioning framework. There is also an underspend in package costs due to slippage in Self-Directed Support (SDS) start dates. It is anticipated these are in-year underspends only and the full budget will be required in future years. • Independent Care Homes net overspend of £0.788m: there are currently 1,461 care packages within this service however when the budget was set for this financial year, it was based on 1,361 care packages. This has resulted in the service experiencing a pressure on the current allocated budget.
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5 • Admin Costs net underspend of £1.884m: within the carers funding there is currently an unallocated budget of £1.8m. The anticipated underspend is reflective of the part-year implementation of contracts and additional funding from the Scottish Government for carers pressures in 2022/2023. As these pressures become evident within social care budgets, the funding will be moved to the relevant care package. • Prescribing net overspend of £0.500m: activity and cost per item within prescribing is 2.69% higher compared to the same period last year. Due to the uncertainty around costs and prescribing activity and the three-month time lag in receiving the data, the volatility experienced within prescribing is likely to continue for the foreseeable future. The current IJB reserves position for 2022/23 is a revised balance of £69.237m. James Muir asked is the vacancy trend rate increasing or decreasing, can more data be included to offer assurance. Amanda Kilburn replied the challenge is when recruiting when someone starts the likelihood is someone else will leave due to a number of reasons. More data will be included in the year-end report to offer some assurance. Ross McGuffie added trend rate is dependent on each services, although overall the 7% is reasonably static. When the organisation receives new funding sources staff move around the system to more attractive posts which creates vacancy issues in other services. Trudi Marshall acknowledged nursing is the largest workforce to add to the figure and advised that not all university places were filled last year which will impact on future recruitment. There is work being undertaken to look at new roles at band 4 level to sit under registrants, placements and careers fayres are also being planned. Ross McGuffie added that we produce an annual workforce plan which can be brought to the committee to offer a deeper dive; this was noted. Ally Boyle asked that for services with higher agency spend are there processes in place to manage and reduce this. Dr Lucy Munro noted agency spend in Mental Health is mainly on medical cover and all mitigations are considered before agency usage. Brian Moore noted the existing reserve under digital and IT strategy for home support scheduling tool and asked if we have a timeline or plan in relation to committing the funding. Ross McGuffie advised have now completed procurement process for SWISS programme which will take 12-18 months to fully implement. Brian Moore also queried, with regarding to in year allocations, if alcohol and drug funding is new . Ross McGuffie confirmed this is not new money and it is as expected.
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6 Brian Moored note if we haven’t committed money in reserves it will impact on future Scottish Government future funding allocations, he asked is this the case. Ross McGuffie advised looking at maximising funding already available where possible. The IJB PFA Committee agreed the following recommendations: (1) Note the contents of the report; and (2) Note the financial position is a year-to-date underspend of £15.332m. 7. Progress Report The progress report provides an outline of the actions agreed with the External Auditor, internal Audit, and the Senior Management Team to further develop the IJB governance framework. An update on the progress made to date was reported to the PFA Committee on16 November 2022. A summary of the current position statement is shown in the table below: Source Total Actions Completed Actions Ongoing Actions External Audit 5 4 1 Internal Audit 5 4 1 Senior Management 6 5 1 Total 16 13 3 81% 19% The results of the self-evaluation exercise were presented to the PFA Committee on 31st August 2022 with the main improvement actions being identified as follows: • Evidence how Health and Social Care spending contributes to prevention and early intervention; • Embed learning and new ways of working in the IJB from the response to the pandemic to ensure plans and governance are fit for purpose; and • Review how performance information is used by the IJB to ensure it is timely, relevant and provides a good measure of progress towards agreed outcomes. Ally Boyle suggested to include more narrative to advise the delays in actions is due to other factors; this was noted. Brian Moore referred internal audit actions relating to risk processes and requested further assurance regarding the actions.. Amanda Kilburn will review actions and provide more assurance where possible. The IJB PFA Committee note the following recommendations: (1) That the content of the report is noted; and
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7 (2) That further progress reports will be presented to future meetings of the PFA Committee in respect of any ongoing actions. 8. Resilience Update NHS Lanarkshire stood down its Live Covid Incident in January 2023, however, the operational pressures emanating from the pandemic recovery have been pronounced, with NHS Lanarkshire in Black status since 27th July 2022. Operation Flow was developed to create a ‘firebreak’ to rapidly reduce hospital inpatient capacity, then creating the staff capacity to work on service redesign to bring the system as a whole back into equilibrium. Following the 9-day firebreak, hospital inpatient capacity reduced by around 15% across Lanarkshire, supporting the system to move from black to red status on 6th March 2023. The North HSCP has held a feedback session based on the Firebreak activity and dedicated time at the Strategic Leadership Team to further review the learning so far. A number of key themes have emerged, including: Significant gains in whole system partnership working from the Firebreak The ever increasing role of Home Assessment Teams in supporting discharge and also controlling future demand into mainstream Home Support services The need to better steward referrals for equipment Hospital at Home’s extended hours (to 8pm) led to the safe management of a larger caseload of patients, with significant increases in referrals received Interim Care needs to continue as part of the Choices Protocol for Care Home admission and also to support any Localities struggling with Care at Home capacity The discharge process is complex, bureaucratic and time consuming and needs to be streamlined across the system We use multiple (largely paper based) systems to record the discharge journey, that means there is never one version of the truth and makes joined up working more challenging Trakcare isn’t updated frequently enough, with the example of 238 delayed discharge bed days being recorded on the system despite the patients already being discharged Further work required to consistently implement the Flow Bundle, including developments such as Planned Date of Discharge and Criteria Led Discharge
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8 One of the key aims of the Firebreak was to utilise multi-agency teams to review all inpatients on a daily basis, with the aim of improving the flow of the 95% of patients who don’t need supported discharge, but also supporting earlier identification of the 5% who will require support. However, despite the spike in demand, the recently improved performance in delayed discharge has been maintained. At the start of the firebreak, there were 84 delays in the system, with 40 of these on the acute sites, and at 31st March, this has reduced to 69 delays, with 26 on the acute sites. On 20th March, the HSCP had its lowest recorded number of delays since November 2021 at 59. There has been agreement to establish SLWG working groups in the first phase to look at learning. Before phase 2 commences to review the winter plan with a focus to take learning from operation flow and discharge events to develop the plan. Phase 3 will be the longer term work. Brian Moore asked how significant are the equipment delays to the discharge process. Ross McGuffie replied it is sometimes due to over ordering of equipment. Lanarkshire has more hospital beds in the community than across the acute sites. This comes down to education of staff to consider what they are ordering and requirements. There is a whole system review being undertaken of the equipment sources to identify any actions required. The IJB PFA: (1) Note that NHS Lanarkshire stood down its Covid Live Incident down in January 2023, though command structures have been adapted to continue to focus on ongoing wider resilience challenges, specifically, around service pressures (2) Note that NHS Lanarkshire was able to move from black to red status on 6th March 2023, following a successful ‘firebreak’ as part of Operation Flow 9. Q3 Performance Report 2022/2023 This report is to provide an update to the Committee on the areas for improvement which have been identified as part of the Quarterly Performance Review for the period 1 October to 31 December 2022 (Quarter 3). Report covers the following performance areas: Cervical Screening Immunisations Delayed discharges/home support and reablement Integrated equipment and adaption services CAMHS Psychological therapies
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9 Adult mental health Waiting times performance- medical children and young people Waiting times performance AHP and community services Stop smoking service Sickness absence Cllr Ayeshah Khan asked are we on target to clear CAMHS waiting lists backlog in summer time and is there any proposals to have mobile units for cervical screening appointments. Dr Lucy Munro advised by autumn time at the latest the waiting lists will be significantly reduced, need to consider who would use this capacity and also monitor if there is an increase in referrals to the services due to this additional capacity. Cllr Ayeshah Khan drew attention to 3rd sector involvement as an earlier engager with patients for prevention. Maddy Halliday agreed with this point and noted concerns with funding if not available in 3rd sector difficult to manage and asked where do strategic discussions take place. Dr Lucy Munro stated there are other supports available outside of CAMHS that patients can use. Morag Dendy advised that a new performance manager is in post and a key part of their role will be to align performance reporting work undertaken in a collective way. Maggs also noted that the programme board was established to bring RTT back into line and has a specific directive to achieve this. She also added CAMHS is also part of the MH strategy work so strategic discussion will occur as part of the MH workstreams. Ally Boyle asked are we starting to get intelligence on DNA reasons which is nearly 25% in CAMHS. Dr Lucy Munro advised some do not attend appointments as they no longer require the service. She advised that this is emerging data but needs to be looked at in more detail and that we require processes to follow up with those who DNA appointments. Maggs Thomson acknowledged that there is an issue around the data with Scottish Government which is being worked on. The IJB PFA Committee noted the contents of the report and its appendix. 10. Speech and Language Therapy Update Pre-Covid performance against the waiting times target of 90% of children seen within 12 weeks for specialist intervention was 67%. In March 2020 all routine SLT CYP services were paused and schools and nurseries closed. In June 2020 all routine clients/families were contacted, further risk assessment was carried out and families offered support. Waiting times performance in July 2020 was 4%. The service in clinics schools and nurseries recommenced from June to October 2020. Waiting times performance in February 2023 is 24%.
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10 The SLT CYP service have had temporary funding to March 2023 to recruit a further 12 posts in community SLT teams. Staff have been recruited to these posts, however due to staff turnover the SLT CYP service has at no time been over- establishment for the past 2 years. Maggs Thomson advised met with Strathclyde University to improve undergraduate programme to help attract some additional staff to the service. Cllr Bob Burgess noted concerns for maternity leavers do they eventually come back to the services or do we lose the skilled staff. Maggs Thomson noted this is a nationally funded programme, starting to see less applicants leading to posts going to clearing positions. She also confirmed that staff do come back to the service after maternity leave. Brian Moore noted it would useful in the next year to get another dedicated report; this was noted. He also noted issues around track care access. Ross McGuffie advised he has been discussing with IT the need to prioritise access for community services to track care. The IJB PFA agreed the following recommendations: 1. The IJB approves that mobilisation funding is extended to 2023-24 financial year to enable appointment of SLTs over-establishment of up to 6 WTE band 6 posts. 2. The IJB endorses the formation of a SLT Service Improvement Group with wider stakeholder engagement and support from Project Management and Service Improvement manager within the SCHSU. 11. OT Paediatrics Update Performance Background: The CYP OT Team have seen a 24% increase in demand post pandemic. Throughout the pandemic the team developed a wide variety of universal and targeted video resources and information packs to support children and families to access early therapy information and advice. This supported the service to absorb the increased demand and remain within the 12 week target until April 2022. National developments within CAMHS and Neurodevelopmental Services in 2022 resulted in a migration of experienced CYP OT staff to these new services. A total of 9 staff at B6 – B8a moved on from the service (7.0 wte to the NHSL Neurodevelopmental Assessment & Diagnostic Service; and 1.2 wte to NHSL CAMHS. There is currently a 28% vacancy factor within the CYP OT Team at Feb 2023. This picture is replicated across many Board areas, and there is currently a national
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11 challenge in the recruitment of experienced CYP OT. Locally, recruitment to Band 5 CYP OTs has been successful, but the staff require support to build their skills in this specialist area as OT practice based learning placement have been reduced across children’s services. All open cases have been transferred to the remaining CYP OT staff, reducing the ability to address new patient assessments, and impacting negatively on waiting times performance. It is predicted that the NHSL CYP OT Service will breach the locally agreed waiting times performance target over the next 6 months due to the national recruitment challenges of specialist and experienced CYP occupational therapy staff. However, the application of the performance recovery plan noted in the report, and progression of recruitment opportunities will be progressed to optimise performance and progress towards the 12 week waiting times target. Brian Moore noted it would be useful to get a yearly update on how the service is progressing; this was noted. The IJB PFA Committee: (1) Recognise the current demands on NHSL Children & Young People’s Occupational Therapy Services (2) Approve the enclosed mitigating actions to manage service demand and work towards the achievement of the agreed waiting times performance target 12. Digital Alarms This report informs Committee of the current position in relation to the Community Alarm Service, particularly describing the drivers for undertaking a review of the service and anticipated outcomes; and the Service’s transition from an Analogue to Digital infrastructure. In 2020, as part of the centralisation of Care at Home, the service was relocated to the Dalziel Building to sit alongside the centralised Home Support Service, strengthening links and connections. Because of the responsive nature of the support offered through Community Alarms, as well as providing core service it also provides resource to support the Home Support Service, particularly out of hours, as well as significant support to the Social Work Emergency Service. The reach and stretch of the service requires a review of the operating model. By 2025 all analogue telephone services in the UK will be switched off and replaced by digital systems using internet protocol (IP) technology. Telecommunication suppliers are well on the way to making this switch to IP networks. Scotland’s telecare service providers including health and social care partnerships, housing associations and many other organisations who use analogue connectivity to deliver their services, need to upgrade.
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12 North Lanarkshire Health and Social Care Partnership (NL H&SCP) and North Lanarkshire Council (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 being a crisis response service to being more proactive and preventative. The above circumstances summarise the importance of the Community Alarms Service, the changes to the digital infrastructure and need to review the operating model for the service. A review of the Community Alarms Service will develop options for the future service model that capitalise on new ways of working using digital technology, to establish community alarm and telecare services that are person-centred, and outcome focused, and support the achievement of the priorities and ambitions of the North Lanarkshire Health and Social Care Strategic Commissioning Plan 2023-26. Cllr Claire Barclay noted for 20% of alarm activations it results in someone requiring to attend a patient so for 80% they are activating for other reasons, is there some data on why they are being activated and if there are other routes which can be used. Morag Dendy acknowledged that the service is looking into this data in more detail currently. Cllr Bob Burgess asked will the new technology cost more money to patients, are there any issues with complexity of technology for the 7500 people listed and does this include partners. Morag Dendy advised previously had 10000 listed in reports as using the services previously but the figure is actually 7500, this is for the unit rather than the number of people supported. The expectation is the technology should be much easier and responsive for users. There will be an increased cost going forward but it is not decided who will cover these costs. Ally Boyle noted the new technology is not able to interface with smoke alarms which the old system previously did, so we need assurance going forward for those that require assistance they will receive this. It was noted that we need a solution as part of the transition process which is clearly communicated. Morag Dendy noted this has been flagged at a national level and we are considering if community alarms are the right response to assist those in this situation or if something else is required. Morag will ensure transition arrangements are communicated clearly and add update to action list to ensure work comes back when ready. Recommendations noted by the IJB PFA committee are as follows: (1) Acknowledge the contents of this Community Alarm Service Report. (2) Acknowledge the work being undertaken to ensure a seamless transition from analogue to digital and the work to date. (3) Acknowledge the progress to date and work ongoing regarding the Community Alarm Service review including the review of co-dependent
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13 services, particularly Home Support Out of Hours provision, Social Work Emergency Services and Registered Social Landlords. (4) Acknowledge that recommendations will come back to the committee for endorsement from the review. 13. Community Solutions Annual Report The Community Solutions Annual Report 2021-22 is presented to North IJB PFA for information and comment and, if appropriate, approval and/or referral to the IJB. The Report provides the following information: Background to the programme with reference to the new Community Solutions Strategy and Investment Plan 2022-25. A summary of performance and impact during 2021-22 with further detail provided in Appendices. The report provides high level summaries of: overall investment through the programme for 2021- 22 £3.6million key programme developments performance and impact of funded projects including: o reach in term of unique individuals o number of activities/services provided with examples o personal outcomes (with a few exceptions where it was not possible for funded projects to capture this information – e.g. Community Transport.) An overview of priorities for 2022-23 and progress as of March 2023, which are very positive and significant. Highlights include: development and agreement of the exciting, new Community Solutions “Improving Lives Initiative” successful recommissioning of the Community Solutions Locality Hosts development of a new Community Solutions Performance Management, Evaluation, Learning and Improvement Framework for implementation from April 2023, which will improve the quality of information captured and shared through the programme. Maddy Halliday will share summary document with the committee after the meeting. Cllr Ayeshah Khan noted figure missing in locally activity fund. Maddy Halliday noted this has not been fully agreed yet as part of an SLA but should be confirmed soon this is why it was not included. Brian Moore asked for some consideration to include financial information as an appendix in more detail in future. He asked where are we in relation to recruitment challenges. Maddy Halliday advised do report to governance group with more details around the budget which can be shared going forward. There are 2 critical posts which are on temporary contracts awaiting SLA to be able to fill permanently.
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14 The IJB PFA Committee comment and note on the Community Solutions Programme’s 2021-22 Annual Report. 14. Risk There was no new risk identified by the committee. 15. Date of Next Meeting 21st June 2023 10.30am-12pm
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1 ITEM 4 North Lanarkshire Integration Joint Board ROLLING ACTION LOG NO DATE ITEM NO DESCRIPTION ACTION BY ACTION & PROGRESS DUE DATE COMPLETION STATUS 4. 9.12.20 Item 6 & Item 11 Addictions services M Dendy 1. An update on accommodation issues affecting the delivery of the addiction services was requested. 21.9.21 – verbal update given – work ongoing to resolve accommodation issues. 2. Update requested on funding commitments. ADP strategy presented and approved at IJB on 21.9.21. Request for detail on commissioning of services, evidence of benefits and achievements and timelines for implementation of funding commitments to be brought back to IJB. 16.2.22 PF&A – update noted at meeting with commitment to report back on specifics and performance objectives June 2021 – deferred to September 2021 – deferred to PFA November 2021 – deferred to February 2022 September 2021 December 2021 August 2022 Complete Ongoing updates on progress scheduled into forward plan for PFA MAT standards update given to Feb IJB PFA
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2 6. 22.6.21 Item 6 Whistleblowing R McGuffie An agreement with NLC was to be developed to ensure a clear process for all H&SC NL staff. An annual report to be provided to the IJB March 2022 – draft guidance shared with NLC and awaiting comment December 2021 December 2022 Ongoing –update planned for sept 23 IJB Complete 11. 22.6.22 Item 8 Financial Plan - Provision of smoke alarms R McGuffie Agreed that H&SC NL funding towards provision of smoke alarms to meet new standards would be included within future Digital Strategy report. March 2023 Update to be provide after year- end figures 14. 22.6.22 Item 9 Equalities Mainstreaming Report M Dendy Progress updates on delivery of equality outcomes to be presented via Performance, Finance & Audit Committee May 2023 On agenda 18. 31.8.22 Item 6 IJB Self-Assessment Report R McGuffie Consider hosting a development session to further explore the self-evaluation work Ongoing – future Liaison session topic 19. 16.11.22 Item 5 Risk Management Strategy R McGuffie Reviewing risk management strategy which will be brought to the committee in due course. Reviewing a process to have shared risks between partnerships and acute and also review current risk register Update planned for March 2023 IJB Complete 20 16.11.22 Item 6 Analogue to digital R McGuffie Share progress report on the work On April 2023 agenda Complete 21. 14.2.23 Item 11 Performance Report R McGuffie Bring more information on OT paediatrics and speech and language On April 2023 agenda Complete 22. 14.2.23 Item 13 MH Strategy R McGuffie Consider dedicating liaison session for a more in-depth discussion
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3 Discuss wider thematic work with Brian Moore and Cllr Ayeshah Khan ACTION LOG – ITEMS DEFERRED DUE TO COVID NO DATE ITEM NO DESCRIPTION ACTION BY ACTION & PROGRESS DUE DATE COMPLETION STATUS
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5 CLOSED ACTIONS 1. NO DATE ITEM NO DESCRIPTION ACTION BY ACTION & PROGRESS DUE DATE COMPLETION STATUS 7. 21.9.21 Item 7 Primary Care Implementation Plan Dr L Munro 2. An update on planned engagement events with local people on the primary care implementation plan was requested. Update provided and noted at March 2022 IJB 21.6.22 – verbal update on progress noted 3. Memorandum of Understanding to be shared December 2021 Complete – update report to 16th Nov PFA Remove Complete 9. 21.9.21 Item 16 Best Value Audit M Dendy An update on the Self Evaluation exercise is to be presented to the PF&A committee. February 2022 – deferred to August 2022 as engagement event took place after PF&A meeting Complete Complete 10. 8.12.21 Item 14 Integration review - Chief Financial Officer R McGuffie Following approval to proceed from the IJB, reports were to be presented to NLC and NHSL Board to seek support for preferred option. 16.2.22 Update on progress provided at PF&A meeting. HR process being progressed 21.6.22 – Update on recruitment of CFO provided 23.3.22 – Update provided to IJB to note that HR process has commenced and recruitment to additional post is underway. March 2022 June 2022 Complete
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6 12. 22.6.22 Item 5 Unaudited Accounts R McG/NL Content of report to be amended to include more details around reason for significant underspend June 2022 Report updated accordingly. Complete 13. 22.6.22 Item 8 & Item 9 Equalities Mainstreaming Report & Risk Register R McG/CJ IJB members suggested additions to the IJB risk Register on following highlighted risks; Cost of Living Pressures Urgent/Unscheduled care Community Alarms (Analogue to digital) National Care Service September 2022 Complete 1. 30/10/18 Item 11 Reserves Strategy A Kilburn To develop a reserves strategy on receipt of national guidance on setting minimum levels of reserves. In the interim period a local reserves strategy will be progressed. Update September 2021: The IJB Reserves Strategy 2021/2022 was approved by the IJB on 22 June 2021. This report provided an update on the review of the existing IJB reserves and new reserves were established in line with planned commitments and Scottish Government guidance. Update on Exit strategies to be presented to PF& A in November 2021 8.12.22 Update provided within report Medium to Long Term Financial Planning. Further work being undertaken to confirm exit plans and ongoing areas of work. 23.3.22 – Update on Financial plan for 2022/23 presented that included update on reserves strategy June 2021 November 2021 – deferred to IJB December 2021 deferred to March 2023. Complete Reserve strategy presented to IJB PFA on 16th Nov. Final version to March IJB alongside updated SCP Added to March 23 agenda- complete
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7 but agreed at meeting to provide further more detailed update to include exit strategy for short term initiatives funded from reserves and conclusion of all other areas of reserve funding 2. 26.5.20 Item 10 Internal Audit Report – Due Diligence Review A Kilburn Further update on the disaggregation of the children, families and justice social work services budget to be presented to the IJB. Update September 2021: The progress in respect of this action is regularly reported to the IJB (Performance, Finance and Audit) Committee. The updated report to the IJB (Performance, Finance and Audit) Committee on 24 August 2021 advised that the budget disaggregation exercise has been concluded. The revised IJB direction to NLC issued on 23 March 2021 excludes the total budget transfer in respect of Children, Families and Justice Services. Work is continuing to progress in respect of the hosting arrangements for cross-cutting and support services. The original timeline of March 2021 has therefore been extended to the revised timeline of September 2021. The Service Level Agreement for the future hosting arrangements and associated budgets will be presented to the IJB following consultation and endorsement by the NLC Adult Health and Social Care Committee and Education and Families Committee. A further report will therefore be presented to the next meeting of the IJB (Performance, Finance and Audit) Committee on 9 November 2021. September/December 2020 Deferred to March 2021 – deferred to September 2021 – deferred to November 2021 Update March 2022 - Further work required to conclude agreements around hosting arrangements. Original Action complete with further update on hosting arrangements presented to PF&A in November 2021. Complete – presented to IJB PFA on 16th Nov
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8 3. 22.9.20 Item 7 Recovery Process M Dendy IJB to receive an update on opportunities presented during recovery process. 21.9.21 – Report presented setting out proposed use of a Change Fund. Progress reports on each element of the proposed plan to be presented to the PF&A February 2022 – update on progress noted with further updates to be presented March 2021 Deferred to September 2021 February 2022 Ongoing – delegated to PF&A to complete action. Ongoing Complete 5. 9.12.20 Item 7 Category One Responders M Dendy An update on this issue was to be provided at the next meeting of the IJB following the completion of the consultation exercise and any further feedback from S Government. Update provided on 23.3.21 and a further update will be provided following completion of the engagement events with Chief Officers and IJB Chairs 21.9.21 – Update provided highlighting confirmation of named officers with lead responsibility. Further updates to be provided following anticipated national workshops. March 2021 September 2021 December 2021 Self assessment completed and feedback from West of Scotland Regional Resilience Partnership received. Update report to next IJB in March 23- Complete 8. 22.9.20 Item 5 Mental Health Continuing Care Contracted Beds R McGuffie Issue not progressed as planned during 2020 as engagement process postponed due to lockdown impact on visits to care homes. 21.9.21 Business Case to be developed and presented to IJB, South Lanarkshire IJB and NHSL Board. June 2022 Business case to be presented at IJB September 2022 Delayed following advice from HIS
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9 22.3.22 – Update provided on progress on engagement and development of business case September 2022 around engagement standards. Final business case to Dec IJB. Approved at NL IJB, SL IJB and NHS Board in December 2023. Complete. 15. 22.6.22 Item 12 Strategic Commissioning Plan M Dendy/T Marshall Detailed report on community nursing to be brought back to future meeting and included within SCP On March 23 IJb agenda –IJB approved plan 16. 22.6.22 Item 4 Community Alarms R McG Provide the committee with an update on community alarms switching from analogue to digital and risk to service users Complete Update provided at 16th Nov PFA 17. 22.6.22 Item 14 Audited Accounts R McG Bring audited accounts to Sept committee Complete
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REPORT Item No: 5 SUBJECT: Risk Management: IJB Risk Register TO: IJB Performance, Finance and Audit Committee Lead Officer for Report: Ross McGuffie, Chief Officer NHSCP Author(s) of Report Stacey Anderson, Support Services / Project Manager DATE: 21st June 2023 1. PURPOSE OF REPORT This paper is coming to the IJB Performance, Finance and Audit Sub- Committee: For approval For endorsement To note The purpose of this report is to provide a summary to the Integration Joint Board on risk management activity, noting any amendments or additions to the current risk register. 2. ROUTE TO THE IJB Performance, Finance and Audit Committee This paper has been: Prepared Reviewed Endorsed By: The Operational & Business Manager and Chief Officer for H& SC NL. 3. RECOMMENDATIONS 3.1 The IJB PFA is asked to note the contents of the report which includes the latest version of the IJB risk register and a note of those operational risks highlighted by the Heath & Social Care North Lanarkshire partnership that impact upon delivery of IJB business. 4. VARIATIONS TO DIRECTIONS? 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 From a good practice and sound governance perspective, all public bodies are required to identify and take account of the impact of any potential risks in delivering their business. Yes No N/A 1
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BACKGROUND/SUMMARY OF KEY ISSUES (CONT.) 5.2 The PFA Committee has delegated oversight and responsibility for financial and performance risks associated with the remit of the Integration Joint Board and the PFA committee considered the finance and performance risks at its last minute on 19th April 2023. The register was also reviewed at the IJB on 17th May 2023. 5.3 A full review of the risk management reporting within the IJB is currently in progress as part of the risk strategy review and in line with the dynamic developments and changes the new NHS Lanarkshire Risk Manager is implementing within the board. These developments will include review of how risk reporting is managed and presented at IJB and a further evaluation of the improvement methodology aligned with the risk actions. In order to provide a robust overview of these developments, a risk management session has been scheduled for the next IJB Liaison Session and a full report of changes/ developments will be provided to the IJB PFA and IJB at the next meeting. 5.4 Following discussions at the last meeting of PFA on 19th April 2023, the risk register has been updated and additional controls/actions added to: IJB 01/21 – Financial Challenges IJB 04/21 – Set Aside IJB 06/21 – Prescribing IJB 11/21 – Performance IJB 13/21 – Care Homes IJB 14/22 – CAMHS IJB 17/22 – Unscheduled Care 5.5 There are currently two risks rated as Very High on the IJB risk register. IJB 06/21 – Prescribing Activity and Costs IJB 17/22 – Unscheduled Care 5.6 There are eight high rated risks on the IJB risk register. IJB 01/21 - Financial Challenges IJB 04/21 - Notional Set Aside Budget IJB 12/21 - Staff Health & wellbeing IJB 14/22 – CAMHS IJB 15/22 – Cost of Living IJB 16/22 – National Care Service IJB 19/23 – Service sustainability IJB 20/23 – Workforce sustainability 5.7 There are a number of high/very high rated operational risks that have been identified as having or potentially having an impact on IJB objectives and/or delivery of services and these are highlighted below. No Risk Risk Rating Lead Organisation/Area 1882 Acute Sector Bed Capacity - availability of acute beds due to delays experienced for onwards Very High NHSL Corporate 2
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movement of patients 'fit for transfer' to care homes, those requiring care at home, exacerbated by rising cases of Covid and high demand 2085 Capacity within NHSL to respond to ongoing challenges due to Covid 19 and associated variants Very High NHSL Corporate 1379 Delayed Discharge Performance and Impact High NHSL Corporate 1984 Impact From Stepping Down Non-Urgent Services High NHSL Corporate 1832 Compliance with the Health & Care (Staffing) (Scotland) Bill: Clinical Workforce due to issues of availability, recruitment and retention. High NHSL Corporate 1710 Public Protection: There is a risk that NHSL could fail to identify harm to any vulnerable person, child or adult, or prevent harm to others resulting from the complexities of opportunity lost due to the current reprioritising of services in response to COVID- 19. High NHSL Corporate 659 Failure to deal effectively with major emergency Very High NHSL Corporate 2039 Staff Fatigue, Resilience, Wellbeing & Safety – Effects of prolonged Covid response is adversely impacting on staff, increasing staff absence and consequently reducing workforce capacity. Very High NHSL Corporate 1992 Continuous Covid Response & impact on routine PH Screening & surveillance programmes High NHSL Corporate 1587 Sustainability of the two-site model for the Out-of-Hours Service Very High NHSL Corporate 2004 Potential Impact on patients resulting from disruption of day to day clinical care in response to Covid pandemic Very High NHSL Corporate 1989 Ability to maintain a workforce commensurate with the need to suppress Covid, deliver Vaccination Programme, Recover & Remobilise Very High NHSL Corporate 2014 Recovery of Performance 2021/22 Very High NHSL Corporate 3
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2086 Sustaining GP Services Very High NHSL Corporate NLC RIA0000446 Unable to deliver services due to funding issues Very High NLC - Social Care/Social Work NLC RIA0000448 Availability of workforce to deliver services within legislative and regulatory compliance requirements. High NLC – Social Care/Social Work NLC RIA0000449 Information & Data Protection – non-compliance with information governance legislation, standards and processes and data security and inability to retrieve relevant data with deadlines High NLC – Social Care/Social Work NLC RIA0000450 Health & Safety of staff in SW & partnership companies – failure to ensure the health safety and welfare at work of the service, employees, partners and provider agencies High NLC – Social Care/Social Work NLC RIA0000453 Supplier failure or services not provided to required standard. Insufficient number of providers. High NLC – Social Care/Social Work NLC RIA0000457 Inadequate supervision, governance and monitoring across professional workforce High NLC – Social Work/Social care NLC RIA0000458 IT system not fit for purpose High NLC – Social Work/Social care NLC RIA0000459 Integration – there is a risk that services and not integrated effectively thus impacting on improving the outcomes for individuals receiving care and support High NLC – Social Work/Social care NLC RIA0000460 Performance & planning – increasing expectations and changing performance demands will result in a failure to provide performance information internal, external and including S Govt, High NLC – Social Work/Social care NLC RIS0000414 Community alarm and assistive technology – unable to continue to support people with a community alarm system and develop use of assistive technology Very High NLC – Social Work/Social care NLC RIS0000415 Mental Health Officers – Failure to comply with legal obligations High NLC – Social Work/Social care NLC RIS0000417 Communications strategies and engagement plans – Inadequate strategies not aligned with strategic objectives High NLC – Social Work/Social care 4
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NLC RIS000419 Non- compliance with Information Governance & Data Protection High NLC – Social Work/Social care NLC RIS000426 Analogue to digital transition & ability to provide a working community alarm service High NLC – Social Work/Social care 6. CONCLUSIONS 6.1 The IJB currently has 17 risks identified on its IJB risk register with 10 risks rated as high or very high. 6.2 Risks identified by H&SC NL as potentially impacting on IJB business are highlighted in the report. 7. IMPLICATIONS 7.1 NATIONAL OUTCOMES N/A 7.2 ASSOCIATED MEASURE(S) N/A 7.3 FINANCIAL This paper has been reviewed by Finance: Yes No N/A Financial risks are identified in the risk register. 7.4 RISK ASSESSMENT/RISK MANAGEMENT This report sets out the IJB risk register and risk assurance process for the IJB 7.5 PEOPLE N/A 7.6 STAKEHOLDER ENGAGEMENT Stakeholders are represented at the IJB and the IJB PFA Committee and can contribute to approval and amendments to the IJB risk register. 7.6 INEQUALITIES & FAIRER SCOTLAND DUTY EQIA Completed & Fairer Scotland Impact Assessment Form Completed: Yes No N/A 8. BACKGROUND PAPER None 5
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9. APPENDICES IJB Risk Register Appendix 1 IJB Risk Register Overview Appendix 2 CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact Stacey Anderson on telephone number 07976801913. 6
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Appendix 1 North Lanarkshire Integrated Joint Board Risk Register (Accurate as 22nd March 2023) IJB ID Category Opened Date Description of Risk Risk level (initial) Mitigating Controls Risk level (Current) Risk level (Target) Risk Owner Risk Register Lead Assurance Source Review Date Closed Date IJB02. 21 Financial Reputational 01/04/2021 Ineffective Governance Arrangements There is a risk that the IJB is unable to prevent and detect fraud and corruption within services because of inadequate governance arrangements and inadequate internal control systems which could lead to financial and reputational damage. LOW CONTROLS 1. Fraud awareness e‐learning. 2. National Fraud initiative. 3. Locality/SW Enablement Groups. 4. Segregation of duties in relation to authorising and processing direct payments. 5 Whistle blowing policies. 6. Procurement processes and standing orders. 7. Oversight via NLC Audit and Scrutiny Panel and NHSL Audit Committee. 8. Effective governance arrangements are in place and subject to internal and external audit review. 9. IJB and IJB PFA meetings established ensuring effective oversight of financial performance. 10. The IJB does not maintain its own policies relating to the prevention and detection of fraud and error but instead depends on those in place at its partner bodies. . The IJB has a Code of Conduct in place to which members subscribe and the Members’ Registers of Interests are publicly available on the IJB’s website. ACTIONS 1. Continue to raise fraud awareness through team briefings. 2. Annual planned Procurement and Standing Financial Instructions presentations. 3. Annual review of Code of Conduct 4. Review of how Members' Decleration of Interests are collated and reviewed. 5. IJB to request Fraud prevention and detection reports from both partners for oversight at the IJB PFA. LOW LOW Ross M cGuffie M arie M oy SLT, IJB PFA, IJB 31.03.24 Previously IJB6. Reviewed and updated on March 2023. IJB.01/ 21 Financial Strategic 01/04/2021 Financial Challenges There are a range of financial challenges which will impact on the IJB's ability to deliver the Strategic Commissioning Plan intentions within the financial envelope available. These include: 1. The absence of a unique IJB financial settlement from the Scottish Government. 2. The IJB is dependent on funding from both partners. 3. Late Scottish Government financial settlement. 4. Budget reductions due to insufficient Scottish Government financial settlements and/or partner contributions. 5. New Scottish Government policy commitments e.g. Carers (Scotland) Act 2016. 6. Demographic growth. 7. Competing service priorities. 8. Conflicting partner efficiency savings programmes which adversely impact on the HSCP's ability to deliver services. 9. In‐year cost pressures emerging due to the underachievement of planned savings, pandemics and other emerging risks which may lead to an overspend. 10. Each partner may be unable to maintain their financial contributions to the IJB in future years which would impact on frontline health and social care services. 11. The agreed transformational plans and service redesigns are not implemented in full and in line with the original implementation plan and/or do not secure the intended improvement outcomes in both performance standards and financial efficiency targets. 12. Future savings targets will continue to be challenging and are likely to impact on essential core services. 13. The IJB Financial Plan cannot be adhered to and budget recovery plans fail to achieve financial balance for both partners. 14. The impact of the pandemic on the financial sustainability of external providers in particular social care providers. 15. The financial implications of the impact of the pandemic on the workforce e.g. increase in sickness absence, early retirement requests and recruitment challenges. The above factors would lead to a failure to achieve the desired strategic aims and would also impact on service delivery. CONTROLS 1. IJB PFA Committee. 2. IJB Chief Officer is a member of each partner's key decision‐making forums. 3. Effective joint working between Chief Financial Officer and both Council and NHS Finance Departments. 4. Regular budget meetings with Chief Executives and Directors of Finance. 5. Regular HSCP budget monitoring meetings across Senior Leadership Team. 6. The IJB Financial Plan 2023/2024 has been agreed and is being reviewed regularly. 7. IJB medium term financial plan 2023‐25 and reserves strategy 2023‐24 approved at March 23 IJB 8. Capacity plans in place to maximise efficiency. 9. IJB Integration Scheme setting out the budget recovery processes. 10. IJB Financial Regulations and financial procedures. 11. Consultation and involvement with key stakeholders including service users and carers. 12. Prescribing Quality and Efficiency Programme, SWEG, ARG and Home Support monitoring groups are in place. 13. Joint Strategic Needs Assessment and ongoing move towards preventative and anticipatory approaches. 13. Strategic Planning Group, Locality engagement sessions and Partnership Boards. 14. Effective and ongoing service user engagement, staff consultation and Trade Union liaison at strategic and local levels. 15. Financial sustainability payment arrangements in place to 31 March 2023 to support external social care providers. 16. The Scottish Government announced on 5 October 2021 an additional £300m for winter health and social care pressures. 18. Work is ongoing with both partner organisations to confirm the final 2023/24 budget. Once complete, a new risk will be created to reflect the final 2023/24 financial plan. ACTIONS 1. Annual budget setting processes within each of the partners. 2. HSCP participating in NHSL Sustainability and Value process 3. Partnership will also be connected to new national whole system groups around budget Previously IJB2, IJB7, IJB10 and IJB12. Reviewed and Updated May 2023. HIGH M EDIUM M arie M oy M arie M oy SLT, IJB PFA, IJB 31.05.23 HIGH Report Prepared by Stacey Anderson on behalf of the Chief Officer 7
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Appendix 1 North Lanarkshire Integrated Joint Board Risk Register (Accurate as 22nd March 2023) IJB ID Category Opened Date Description of Risk Risk level (initial) Mitigating Controls Risk level (Current) Risk level (Target) Risk Owner Risk Register Lead Assurance Source Review Date Closed Date IJB04. 21 Financial Strategic 01/04/2021 Notional Set‐Aside Budget There is a risk that resources will not be transferred from Acute Services to the HSCP in line with the shift in the balance of care from residential and acute settings to community based alternatives as expected in terms of the notional set‐aside concept. This includes the ongoing development of locality pathways to support maintaining people at home e.g. transitional care models. VERY HIGH CONTROLS 1.There is complete transparency and ongoing dialogue between the IJB and the Health Board on the challenges associated with the implementation of the notional set‐aside concept. 2. Bed modelling and capacity planning arrangements are in place. 3. Effective working relationships between both partners and the IJB have been established. 4. Since the inception of the IJB, an agreement is in place whereby the NHSL Health Board will manage the overspend or underspend across the notional set‐aside budget. This arrangement continues to be in place for 2022/23 ACTIONS 1.The Chief Officer and the Chief Financial Officer continue to raise this concern at a national level. 2. Discussions ongoing with NHSL Director of Finance around unscheduled care spend in 2023/24 and potential carry forward from 22/23 budget HIGH M EDIUM Ross M cGuffie M arie M oy SLT, IJB PFA, IJB 31.05.23 Reviewed and Updated May 2023. IJB05. 21 Financial Strategic 01/04/2021 Hosted Services There is a risk of dispute between the North Lanarkshire IJB and the South Lanarkshire IJB in respect of the financial allocations underpinning the Hosted Services particularly as a result of the budget changes linked to the implementation of devolved locality models. This could impact on the ability of each IJB to achieve its commissioning intentions and may also have an adverse impact on service users across Lanarkshire. VERY HIGH CONTROLS 1. North and South IJBs aim to co‐operate to ensure a pan‐Lanarkshire approach is achieved across all hosted services. 2. Financial and budgetary controls. 3. Performance reports on service delivery. 4. The Hosted Services principles in respect of the management of the overspends and underspends are agreed for each financial year. M EDIUM M EDIUM Ross M cGuffie M arie M oy SLT, IJB PFA, IJB 30.06.23 IJB06. 21 Financial Operational 01/04/2021 Prescribing Activity and Costs The cost of prescribing is growing due to issues in supply chains driving increased wholesaler cost of medicines, advance treatment developments resulting in the need for more expensive medications, aging population and increase in patients requiring regular medication. Medication availability has been impacted following the EU withdrawal the UK 's membership of the common regulatory bodies and EU agencies, such as the European Medicines Agency, (EMA), European Centre for Disease Prevention and Control and the European Atomic Energy Community. The risk is that this could impact on the availability of medicines, healthcare techniques and technology and in respect of the supply of medicines and medical devices, additional checks are now required at ports in the UK and the EEA before goods, including medical products, can cross the border. New customs checks are required when moving medicines between the EEA and the UK. M edium CONTROLS 1.. Prescribing Quality and Efficiency Programme. 2. Prescribing Management Board functions and membership. 3. Deputy Lead Pharmacist supporting HSCP Senior Leadership Team. 4. Locality Pharmacist input. 5. Earmarked reserve established to address prescribing costs. 6. Regular HSCP monitoring. In respect of the regulation of medicines and medical devices, the Medicines and Healthcare products Regulatory Agency (MHRA) became the UK’s sovereign regulator. 7. The new trade deal contains specific clauses that mean both the UK and EEA states formally recognise each other’s good practice in medicine manufacturing. 8. To reduce the risk of divergence from the EU rules, there are three interrelated factors; the technical annexes of the new trade deal, the Northern Ireland protocol and the UK Internal Market Act. 9. The effectiveness of the Border Operating Model to import and export goods to and from the EEA, which was being implemented in stages from 2020 to minimise any risk of disruption, is still being assessed. The risk of border delays is still evident. Other measures were also implemented specifically to mitigate the risk of supplies of medicines and medical devices being disrupted. In August 2020 the UK government instructed medicine suppliers to maintain a stockpile equivalent to six weeks’ supply though the first three months of 2021. In addition, the Department of Transport has secured additional freight capacity to bring medicines into the country via other routes. ACTIONS 1. Review of Locality Prescribing Action Groups. 2. Prescribing part of NHSL Sustainability and Value structures 3. Continuation of Scriptswitch. VERY HIGH LOW Ross M cGuffie M arie M oy SLT, IJB PFA, IJB 31.06.23 Previously IJB11. IJB07. 21 Financial Strategic 01/04/2021 Third and Voluntary Sector There is a risk that Third Sector organisations in North Lanarkshire are vulnerable because of the lack of certainty in respect of long‐term funding security. This uncertainty has the potential to lead to service instability, recruitment and retention challenges and an increasing reliance on statutory services. HIGH CONTROLS 1. Third Sector Interface represented on key strategic groups. 2. Community capacity building and carer support infrastructure embedded across North Lanarkshire. 3. Community capacity building is regularly reviewed. 4. Maximising funding opportunities for the third and voluntary sector will continue to be progressed. ACTIONS 1.The annual HSCP funding which is directed to the third sector is recurring funding. Funding will be confirmed each year in line with the agreement of the IJB Financial Plan and subject to the Scottish Government financial settlements for future years. LOW LOW Ross M cGuffie M arie M oy SLT, IJB PFA, IJB 31.12.23 Previously IJB16. Report Prepared by Stacey Anderson on behalf of the Chief Officer 8
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Appendix 1 North Lanarkshire Integrated Joint Board Risk Register (Accurate as 22nd March 2023) IJB ID Category Opened Date Description of Risk Risk level (initial) Mitigating Controls Risk level (Current) Risk level (Target) Risk Owner Risk Register Lead Assurance Source Review Date Closed Date IJB.10. 21 Financial Strategic 01/04/2021 Ineffective Governance Arrangements Due To the Covid‐19 Pandemic 1. There is a risk that the intensity of the required response to Covid‐19 could result in a failure of governance impacting on the effectiveness of the IJB decision‐making, IJB directions to partners and IJB oversight of operational service delivery. Routine governance processes could be overwhelmed. 2. New or amended Covid‐19 legislation and Scottish and UK Government guidance may not be adopted effectively and timeously. 3. There is no / limited public access to IJB and PFA meetings during the period of the pandemic, in line with Public Health advice. 4. Ineffective information governance controls could lead to data breaches and an impact on the General Data Protection Regulations. 5. Communications with employees, patients and service users may be ineffective. 6. There will require to be changes to the working environment including remote working and working from home. 7. There is a reduced ability to protect the wellbeing of employees, patients and service users. 8. There may be adverse media coverage locally, a loss of public confidence and reputational damage. M EDIUM CONTROLS 1. National Networks are established which are providing the framework to support a national approach where appropriate. 2. Public Health advice and support is in place. 3. Increased numbers of agile workers and increased number of laptops/tablets. 4. Continued working from home arrangements supported by the roll out of MS Teams / Zooms. Regular updates on the guidance for the use of MS Teams / Zoom Meetings is circulated. A blended approach to home/work‐based working is being developed going forward. 5. Risk registers are in place for the IJB and each partner. Each partner has a specific HSCP Covid‐19 Risk Register in place. 6. The IJB and both partners aim to comply with the European Working Time Directive (WTD) and minimise the risk of all staff working beyond 48 hours per week, in particular front‐line service delivery. As a result of the withdrawal from the European Union, the WTD ceased to apply to the United Kingdom at the end of the transition period (31 December 2020). However, the UK's Working Time Regulations which implement the EU Working Time Directive will continue to apply unless and until amended by UK law. ACTIONS 1. Staff health and well being is a key priority for both partners and all key stakeholders. The commitment to staff health and well being is being actively promoted through all available forums. M EDIUM LOW Ross M cGuffie M arie M oy SLT, IJB PFA, IJB 30.06.23 IJB.11 21 Performance 30/07/2021 Oversight of Performance Activity There is a risk that the IJB is not provided with adequate or sufficient performance information to enable it to discharge its scrutiny and oversight role; make informed decisions and recommend remedial actions to address any performance concerns. LOW CONTROLS 1. Regular (quarterly) reports on the IJB performance framework, providing updates on areas for improvement, remedial actions (and timescales) and updates on performance issues previously reported. 2. Chief Executive Performance Review arrangements. 3. Hosted Services Performance Review arrangements. 4. Sector/Locality Performance Review arrangements. ACTIONS 1. Request detailed topic based performance reports on specific areas of concern e.g. CAMHS & Psychological Therapies. 2. Face to face Q3 performance reviews taking place throughout May 23 with sectors/units low LOW Ross M cGuffie M orag Dendy SLT, IJB PFA, IJB 31.12.23 IJB.12. 21 Performance 30/08/2021 Staff Health & Wellbeing There is a risk to the delivery of the Strategic Commissioning Plan as a result of sustained pressures on staff availability due to additional pressures associated with Covid 19, current sickness abscence levels and potential for further staff redeployment due to winter planning contingency arrangements. medium Controls 1. Strategic Staff Health & Wellbeing Committee established reporting to NLC & NHSL corporate management teams. 2. Range of support services available both nationally and locally e.g Occupational Health, Spiritual care, Psychological Services, national wellbeing hub (www.PRoMIS.scot.uk). 3. Rest & Recuperation areas identified. 4. Peer Support Networks established 5. Well established Occupational Health supports available to support staff sickness. Actions 1. Short Life Working Group for wellbeing with targeted approach for immediate actions including Staff Health & Wellbeing Champions, access to online supports, access to Occupational Health Services, helpline established and dedicated resource identified for wellbeing officers to be recruited. 2. Funding recieved by Scottish Government specificaly targeting staff well being programmes and supports. Local plans for use of funding being developed. 3. Managers supporting & encouraging staff to take planned leave/use full leave allocation 4. Audits of adherence to sickness absence policy being undertaken HIGH low Ross M cGuffie Ross M cGuffie SLT, IJB PFA, IJB, SC&CG, AH&SC 31.05.23 Reviewed and Updated May 2023 IJB.13. 2021 Performance 30.08.21 Care Homes Inability of care homes to sustain service due to staffing or Covid outbreaks resulting in closure to new placements. This may increase delayed discharge numbers putting additional pressure on acute site capacity and impacting on recovery. The financial support for social care providers during the Covid‐19 pandemic is being reviewed. Payments in respect of under‐occupancy in care homes were extended to 31 October 2021. High Controls 1. Establishment of Care Home Assurance Team. 2. Escalation Process in place. 3. National protocol to support discharge of Covid 19 patients in place. Actions 1. Public Health teams providing guidance on infection control. 2. Care Home assurance team undertaking support visits to all care homes & action plans in place for each care home. 3. Staff and visitor testing in place. 4. All care homes advised to use PPE in line with national addendum. 5. Development day on 12th May 23 to agree structures and approach for year ahead medium medium Ross M cGuffie Trudi M arshall IJB, PF&A, SLT, SC&SC, A H &SC 31.12.23 Report Prepared by Stacey Anderson on behalf of the Chief Officer 9
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Appendix 1 North Lanarkshire Integrated Joint Board Risk Register (Accurate as 22nd March 2023) IJB ID Category Opened Date Description of Risk Risk level (initial) Mitigating Controls Risk level (Current) Risk level (Target) Risk Owner Risk Register Lead Assurance Source Review Date Closed Date IJB.14. 2022 Strategic & Performance 30.04.22 CAMHS ‐ There is a risk that the CAMHS service cannot meet the increasing clinical demands due to a significantly high number of cumulative staff vacancies for both clinical and non‐clinical posts and challenges recruiting to new posts identified through the national recovery and renewal fund. This is impacting on community, in‐ patient and out‐ patient care with the potential to adversely affect response time to referrals; longer waiting times; poorer outcomes; delays in redesign and reputation of the IJB. Very High Controls ‐ 1. Prioritisation of referrals; all referrals 1vetted daily with urgent referrals prioritised 2. Commenced programme of work and implementation of a more structured partnership approach through Choices & Partnership Approach (CAPA) service model, with tier 1 & 2 referred through 3rd sector and interfacing with North & South Education Departments 3. Secured significant national investment to fully implement new service model 4. Active review of skill mix to utilise medical staff only when required for highly complex patients 5. Vacancy gap analysis with active recruitment commenced. Expected to have recruited 75% of gap by end of May 2023 6. Continuous review and validation of the waiting list Action 1. Incremental implementation of the new service model 2. CAPA appointments begin on 1st May 2023 3. Refurbishment of North Lanarkshire facilities commences early summer 2023 High medium Ross M cGuffie M orag Dendy IJB,PF&A, SLT 31.05.23 Reviewed and Updated May 2023. IJB.15. 2022 Strategic & Performance 05.09.22 Cost of Living There is a risk that the IJB's Strategic Commissioning Plan will be unable to be delivered or not have the desired impact due to the cost of living rises being faced by residents across North Lanarkshire, leading to a further widening of the inequality gap, reduced quality of life and increased health and social care demand due to individuals and families having insufficient funds to support basic requirements such as food and heating. High CONTROLS 1. NLC Silver command group stood up focused on cost of living 2. NHSL commenced review through CMT 3. Population Health Committee to review activity around cost of living ACTIONS 1. Survey of NLC hybrid workers to see if home working remains financially viable 2. Business case being developed to expand 'support for people' arrangements used in pandemic to support resident access to welfare rights and other supports 3. 3% increase in individual budgets to support service users to maintain current levels of supports at higher cost 4. Recommendation from adult social work, care and wellbeing committee to review all charges to service users and wider cost of living supports that could be offered 5. SW Committee approval sought for cost of living contract increases in May 2023 High M edium Ross M cGuffie Ross M cGuffie SLT, IJB 31.05.23 Reviewed and Updated May 2023. IJB.16. 2022 Strategic 05.09.22 National Care Service There is a risk that the ongoing work around a National Care Service could destabilise current service delivery due to significant change activity, time demands around the co‐design process, staff uncertainty and partner organisations having to focus inwardly due to the impact of change leading to an impact on the ability to deliver the significant ongoing change programmes already approved by the IJB and the Strategic Commissioning Plan for 2023‐26. High CONTROLS 1. NLC establishing NCS working groups 2. Key HSCP leads involved in national developments 3. Ongoing progress updates to IJB and IJB PFA ACTIONS 1. IJB response submitted on proposed Bill 2. Strong partnership links into working groups at Chief Officers, Chief Finance Officers and Social Work Scotland groups High Low Diane Fraser Ross M cGuffie SLT, IJB PFA, IJB, ASW C&W B 31.05.23 Reviewed and Updated May 2023. IJB.17. 2022 Strategic & Performance 05.09.22 Unscheduled Care There is a risk that we cannot sustain whole system patient flow through peak winter pressures due to increased front door demand; hospital workforce capacity; delays in onward movement of patients due to care home capacity/outbreaks and care at home capacity; and community health and social care workforce capacity leading to reduced ability to meet 'routine' and increasing bed demand for more unwell patients, deteriorating delayed discharge performance and an inability to recover services. Very High CONTROLS 1. Care Home Assurance Group and associated supports for care homes through liaison service, IPC advice and support, risk assessment for onward movement of patients etc 2. Care at Home Assurance group and associated activity to try to support and sustain independent sector provision 3. NHS CMT and Covid response group oversight of performance 4. Daily PDD meetings to review every planned supported discharge and delayed discharge 5. Operation Flow now underway to ensure whole system approach to unscheduled care/delayed discharge challenges ACTIONS 1. Expansion of Home Support service 2. Roll out of Home Assessment Teams across all 6 Localities by Feb 3. New CSW roles in District Nursing teams to proactively support Care Managed patients 4. Additional Nursing capacity in District Nursing Teams 5. Expansion of Equpiment and Adaptation Service to support rapid access in community 6. Expansion of H@H service (hours of provision as well as moving to support discharges as well as admission prevention) 7. Expansion of Integrated Rehabilitation Teams in all six Localities to support rehab in the community and reduce long‐term service demand 8. 5 Task and Finish groups now established to roll out the key actions agreed through the Operation Flow programme (Phase 2 to be completed by Sept 23) Very High M edium Ross M cGuffie Ross M cGuffie SLT, IJB PFA, IJB 28.06.23 Report Prepared by Stacey Anderson on behalf of the Chief Officer 10
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Appendix 1 North Lanarkshire Integrated Joint Board Risk Register (Accurate as 22nd March 2023) IJB ID Category Opened Date Description of Risk Risk level (initial) Mitigating Controls Risk level (Current) Risk level (Target) Risk Owner Risk Register Lead Assurance Source Review Date Closed Date IJB.18. 2022 Strategic and Performance 05.09.22 Community Alarms There is a risk that the community alarm system will be destabilised due to the national change from analogue to digital telephony by 2025, leading to community alarm users not getting a response when required. High CONTROLS 1. Working group established to coordinate all activity 2. Oversight through Home Support Programme Board 3. Reporting to Adult Social Work, Care and Wellbeing Committee 4. Reporting to IJB ACTIONS 1. NLC Committee approval to purchase 1000 digital alarms so the service can support any imminent changes over to digital in individual areas 2. NLC part of SG once for Scotland procurement process for a new digital alarm receiving centre 3. Communication out to all community alarm service users 4. Instructions issued to all community alarm service users on how to do test calls to ensure alarms are operational 5. Engagement with telecommunication suppliers to ensure sight of roll out plans across NL M edium Low Diane Fraser Ross M cGuffie SLT, IJB PFA, IJB, ASW C&W B 30.06.23 IJB.19. 2023 Performance 27/02/2023 Service Sustanability Due to competing service priorties and workforce/ operational and finacial challenges there is a risk that the IJB will be unable to implement the strategic plan/commision plan . Failure to achieve the desired strategic aims of the IJB poses a risk on operational service delivery and the achievement of financial balance and patient safety High Controls 1. IJB PFA Committee. 2. IJB Chief Officer is a member of each partner's key decision‐making forums. 3. Effective joint working between Chief Financial Officer and both Council and NHS Finance Departments. 4. Regular budget meetings with Chief Executives and Directors of Finance. 5. Regular HSCP budget monitoring meetings across Senior Leadership Team. 6. The IJB Financial Plan is regulary reviewed and agreed. 7. Capacity plans in place to maximise efficiency. 8. Consultation and involvement with key stakeholders including service users and carers. 9. Joint Strategic Needs Assessment and ongoing move towards preventative and anticipatory approaches. 10. Strategic Planning Group, Locality engagement sessions and Partnership Boards. 11. Effective and ongoing service user engagement, staff consultation and Trade Union liaison at strategic and local levels. Actions 1. Sustainability plans to be reviewed regulalry 2. Re‐introduction of scruity panels 3. Improve linkage across all risk registers (tiers 1 to 3, council and NHS) to help ensure areas of concern are identified and reviewed regularly. 4 Review of reporting process into IJB to ensure contionus review of services/ service developments High Low Ross McGuffie Ross McGuffie SLT, IJB PFA, IJB 31.05.23 Reviewed and Updated May 2023 IJB.20. 2023 Workforce Sustanability It is becoming increasingly difficult to recruit to particular roles across Health and Social Care. Gaps in the workforce can result in reduction of service provsion, increase in staff workload and inability to deliver the strategic plan. Following EU withdrawl there is no longer the free movement of labour between the UK and EEA countries. All workers arriving from the EEA and non‐EEA countries are subject to the same immigration rules. The new points‐based immigration system makes exceptions for the majority of health care professionals with an NHS job offer and for qualified social workers via a new fast‐track visa route, known as the Health and Care Worker Visa. There are however no exceptions made for other social care roles, such as care workers. The Mutual Recognition of Professional Qualifications Directive is an EU‐wide directive that allows professional regulators in all member states to automatically recognise professional qualifications. The UK government has decided to continue recognising qualifications gained in the EEA for at least two years after the transition period ends. This however is not a reciprocal and there is no guarantee that qualifications gained in the UK will be accepted by professional regulators in EEA nations. High CONTROLS 1. All successful Health and Care Worker Visa applicants are exempt from the Immigration Health Surcharge, a one‐off charge levied against arriving migrant workers as part of the visa application process. The system has been designed to make international recruitment into health and social care roles more straightforward for employers and employees alike. These changes to immigration rules are in law as part of the Immigration and Social Security Co‐ordination (EU Withdrawal) Act 2020. As such, from 1 January 2021, they apply to all workers arriving to work in the NHS or adult social care. All workers from EEA nations who are already resident in the UK had until 30 June 2021 to apply for the EU Settlement Scheme which will guarantee their right to work in the UK indefinitely. 2. In respect of the mutual recognition of professional qualifications, professional regulatory bodies are working with the UK government to review future registration requirements for those with qualifications gained in the EEA and decide what they will be from January 2023. 3. Development of the Care Academy 4. Dedicated HR support identified in NHSL and NLC to support key priority areas of recruitment such as Mental Health and Home Support ACTIONS 1. Annual workforce plan being prepared 2. NHSL programme underway to support international recruitment 3. On the day recruitment events being trialled in Home Support 4. Use of university status being explored following positive gains in Podiatry and Psychological Therapies recruitment High Medium Ross McGuffie Ross McGuffie SLT, IJB PFA, IJB 31.05.23 Reviewed and Updated May 2023 Report Prepared by Stacey Anderson on behalf of the Chief Officer 11
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NORTH LANARKSHIRE IJB RISK REGISTER OVERVIEW May/June 2023 Appendix 2 12
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North Lanarkshire IJB Risks – Dashboard Executive Summary Following an agreement of the IJB Risk Strategy at the IJB held in May 2023, a full review of the IJB risk register was undertaken Any emerging or new risks are discussed at the IJB PFA and presented for information at IJB All risks on the IJB Risk Register are consistently reported to relevant assurance committees to provide oversight and assurance Highest Scoring Risks IJB Risk Score Trend IJB 06/21 – Prescribing Activity and Costs Very High Started as Medium Risk (April 2021) IJB 17/22 – Unscheduled Care Very High IJB 01/21 ‐ Financial Challenges High IJB 04/21 ‐ Notional Set Aside Budget High Started as Very High Risk (April 2021) IJB 12/21 ‐ Staff Health & wellbeing High IJB Risk movement since last report No Change Risk Level Increase Risk Level Decrease New Risks Closed Risks Risks with Action Updates 10 0 0 0 0 7 Risk Registers Number of Risks IJB 17 NL Council NHS Lanarkshire 18 13
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Started as Medium Risk (Aug 2021) IJB 14/22 – CAMHS High Started as Very High Risk (April 2022) IJB 15/22 – Cost of Living High IJB 20/23 – Workforce sustainability High IJB 19/23‐ Service Sustainability High IJB 16/22‐ National Care Service High NL Council Risk Score Trend NLC RIA0000446‐ Unable to deliver services due to funding issues Very High NLC RIA0000448 ‐Availability of workforce to deliver services within legislative and regulatory compliance requirements. High NLC RIA0000449‐ Information & Data Protection – non‐compliance with information governance legislation, standards and processes and data security and inability to retrieve relevant data with deadlines High NLC RIA0000450‐ Health & Safety of staff in SW & partnership companies – failure to ensure the health safety and welfare at work of the service, High 14
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employees, partners and provider agencies NLC RIA0000453‐ Supplier failure or services not provided to required standard. Insufficient number of providers. High NLC RIA0000457‐ Inadequate supervision, governance and monitoring across professional workforce High NLC RIA0000458 ‐ IT system not fit for purpose High NLC RIA0000459‐ Integration – there is a risk that services and not integrated effectively thus impacting on improving the outcomes for individuals receiving care and support High NLC RIA0000460‐ Performance & planning – increasing expectations and changing performance demands will result in a failure to provide performance information internal, external and including S Govt, High NLC RIS0000414‐ Community alarm and assistive technology – unable to continue to support people with a community alarm system and develop use of assistive technology Very High NLC RIS0000415‐ Mental Health Officers – Failure to comply with legal obligations High 15
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NLC RIS0000417 ‐ Communications strategies and engagement plans – Inadequate strategies not aligned with strategic objectives High NLC RIS000419‐ Non‐ compliance with Information Governance & Data Protection High NLC RIS000426‐ Analogue to digital transition & ability to provide a working community alarm service High NHS Lanarkshire Risk Score Trend 1882‐ Acute Sector Bed Capacity ‐ availability of acute beds due to delays experienced for onwards movement of patients 'fit for transfer' to care homes, those requiring care at home, exacerbated by rising cases of Covid and high demand Very High 2085 ‐ Capacity within NHSL to respond to ongoing challenges due to Covid 19 and associated variants Very High 1379‐ Delayed Discharge Performance and Impact High 1984‐ Impact From Stepping Down Non‐Urgent Services High 1710 ‐ Public Protection: There is a risk that NHSL could fail to identify harm to any vulnerable person, child or adult, or prevent harm to others resulting from the complexities of opportunity lost due to the current High 16
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reprioritising of services in response to COVID‐19. 659‐ Failure to deal effectively with major emergency Very High 2039 ‐ Staff Fatigue, Resilience, Wellbeing & Safety – Effects of prolonged Covid response is adversely impacting on staff, increasing staff absence and consequently reducing workforce capacity. Very High 1992 ‐ Continuous Covid Response & impact on routine PH Screening & surveillance programmes High 1587 ‐ Sustainability of the two‐site model for the Out‐of‐Hours Service Very High 2004 ‐ Potential Impact on patients resulting from disruption of day to day clinical care in response to Covid pandemic Very High 1989 ‐ Ability to maintain a workforce commensurate with the need to suppress Covid, deliver Vaccination Programme, Recover & Remobilise Very High 2014 ‐ Recovery of Performance 2021/22 Very High 2086‐ Sustaining GP Services Very High 17
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Details of IJB Risk Movement/ Update of Actions Risk (Reference and Title) Date Risk Added to Register Review Date Current Score Trend Target Score Commentary Actions for the risk IJB.01/21 Financial Strategic Financial Challenges 01/04/2021 31.05.23 High Medium 'CONTROLS 1. IJB PFA Committee. 2. IJB Chief Officer is a member of each partner's key decision‐making forums. 3. Effective joint working between Chief Financial Officer and both Council and NHS Finance Departments. 4. Regular budget meetings with Chief Executives and Directors of Finance. 5. Regular HSCP budget monitoring meetings across Senior Leadership Team. 6. The IJB Financial Plan 2023/2024 has been agreed and is being reviewed regularly. 7. IJB medium term financial plan 2023‐25 and reserves strategy 2023‐24 approved at March 23 IJB 8. Capacity plans in place to maximise efficiency. 9. IJB Integration Scheme setting out the budget recovery processes. 10. IJB Financial Regulations and financial procedures. 11. Consultation and involvement with key stakeholders including service users and carers. ACTIONS 1. Annual budget setting processes within each of the partners takes place before the start of each financial year. 2. HSCP participating in NHSL Sustainability and Value process 3. Partnership will also be connected to new national whole system groups around budget 18
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12. Prescribing Quality and Efficiency Programme, SWEG, ARG and Home Support monitoring groups are in place. 13. Joint Strategic Needs Assessment and ongoing move towards preventative and anticipatory approaches. 13. Strategic Planning Group, Locality engagement sessions and Partnership Boards. 14. Effective and ongoing service user engagement, staff consultation and Trade Union liaison at strategic and local levels. 15. Financial sustainability payment arrangements in place to 31 March 2023 to support external social care providers. 16. The Scottish Government announced on 5 October 2021 an additional £300m for winter health and social care pressures. 18. Work is ongoing with both partner organisations to confirm the final 2023/24 budget. Once complete, a new risk will be created to reflect the final 2023/24 financial plan. IJB04.21Financial Strategic Notional Set‐ Aside Budget 01/04/2021 31.05.23 High Medium CONTROLS 1.There is complete transparency and ongoing dialogue between the IJB and the Health Board on the challenges associated with the implementation of the notional set‐ aside concept. ACTIONS 1.The Chief Officer and the Chief Financial Officer continue to raise this concern at a national level. 19
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2. Bed modelling and capacity planning arrangements are in place. 3. Effective working relationships between both partners and the IJB have been established. 4. Since the inception of the IJB, an agreement is in place whereby the NHSL Health Board will manage the overspend or underspend across the notional set‐aside budget. This arrangement continues to be in place for 2022/23 2. Discussions ongoing with NHSL Director of Finance around unscheduled care spend in 2023/24 and potential carry forward from 22/23 budget IJB05.21 Financial Strategic Prescribing Activity and Costs 01/04/2021 31/06/23 Very High Low CONTROLS 1.. Prescribing Quality and Efficiency Programme. 2. Prescribing Management Board functions and membership. 3. Deputy Lead Pharmacist supporting HSCP Senior Leadership Team. 4. Locality Pharmacist input. 5. Earmarked reserve established to address prescribing costs. 6. Regular HSCP monitoring. In respect of the regulation of medicines and medical devices, the Medicines and Healthcare products Regulatory Agency (MHRA) became the UK’s sovereign regulator. 7. The new trade deal contains specific clauses that mean both the UK and EEA states formally recognise each other’s good practice in medicine manufacturing. 8. To reduce the risk of divergence from the EU rules, there are three interrelated ACTIONS 1. Review of Locality Prescribing Action Groups. 2. Prescribing part of NHSL Sustainability and Value structures 3.Continuation of Scriptswitch. 20
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factors; the technical annexes of the new trade deal, the Northern Ireland protocol and the UK Internal Market Act. 9. The effectiveness of the Border Operating Model to import and export goods to and from the EEA, which was being implemented in stages from 2020 to minimise any risk of disruption, is still being assessed. The risk of border delays is still evident. Other measures were also implemented specifically to mitigate the risk of supplies of medicines and medical devices being disrupted. In August 2020 the UK government instructed medicine suppliers to maintain a stockpile equivalent to six weeks’ supply though the first three months of 2021. In addition, the Department of Transport has secured additional freight capacity to bring medicines into the country via other routes. IJB.1121 Performance Staff Health & Wellbeing 30/08/2021 31.05.23 High Low Controls 1. Strategic Staff Health & Wellbeing Committee established reporting to NLC & NHSL corporate management teams. 2. Range of support services available both nationally and locally e.g. Occupational Health, Spiritual care, Psychological Services, national wellbeing hub (www.PRoMIS.scot.uk). 3. Rest & Recuperation areas identified. 4. Peer Support Networks established Actions 1. Short Life Working Group for wellbeing with targeted approach for immediate actions including Staff Health & Wellbeing Champions, access to online supports, 21
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5. Well established Occupational Health supports available to support staff sickness. access to Occupational Health Services, helpline established and dedicated resource identified for wellbeing officers to be recruited. 2. Funding received by Scottish Government specifically targeting staff wellbeing programmes and supports. Local plans for use of funding being developed. 3. Managers supporting & encouraging staff to take planned leave/use full leave allocation 4. Audits of adherence to sickness absence policy being undertaken 22
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5. Findings of the audit to be shared with IJB. IJB.13.2021 Performance Care Homes 30.08.21 31.12.23 Medium Medium Controls 1. Establishment of Care Home Assurance Team. 2. Escalation Process in place. 3. National protocol to support discharge of Covid 19 patients in place. Actions 1. Public Health teams providing guidance on infection control. 2. Care Home assurance team undertaking support visits to all care homes & action plans in place for each care home. 3. Staff and visitor testing in place. 4. All care homes advised to use PPE in line with national addendum. 5. Development day on 12th May 23 to agree structures and approach for year ahead 23
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IJB.14.2022 Strategic & Performance CAMHS 30.04.22 31.05.23 High Medium Controls ‐ 1. Prioritisation of referrals; all referrals 1vetted daily with urgent referrals prioritised 2. Commenced programme of work and implementation of a more structured partnership approach through Choices & Partnership Approach (CAPA) service model, with tier 1 & 2 referred through 3rd sector and interfacing with North & South Education Departments 3. Secured significant national investment to fully implement new service model 4. Active review of skill mix to utilise medical staff only when required for highly complex patients 5. Vacancy gap analysis with active recruitment commenced. Expected to have recruited 75% of gap by end of May 2023 6. Continuous review and validation of the waiting list Action 1. Incremental implementation of the new service model 2. CAPA appointments begin on 1st May 2023 3. Refurbishment of North Lanarkshire facilities commences early summer 2023 4. Progress report will be submitted to IJB approx. Nov 23. IJB.17.2022 Strategic & Performance Unscheduled Care 05.09.22 28.06.23 Very High Medium CONTROLS 1. Care Home Assurance Group and associated supports for care homes through liaison service, IPC advice and support, risk assessment for onward movement of patients etc. 2. Care at Home Assurance group and associated activity to try to support and sustain independent sector provision 3. NHS CMT and Covid response group oversight of performance ACTIONS 1. Expansion of Home Support service 2. Roll out of Home Assessment Teams across all 6 Localities by Feb 3. New CSW roles in District Nursing teams to proactively 24
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4. Daily PDD meetings to review every planned supported discharge and delayed discharge 5. Operation Flow now underway to ensure whole system approach to unscheduled care/delayed discharge challenges support Care Managed patients 4. Additional Nursing capacity in District Nursing Teams 5. Expansion of Equipment and Adaptation Service to support rapid access in community 6. Expansion of H@H service (hours of provision as well as moving to support discharges as well as admission prevention) 7. Expansion of Integrated Rehabilitation Teams in all six Localities to support rehab in the community and reduce long‐ term service demand 8. 5 Task and Finish groups now established to roll 25
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out the key actions agreed through the Operation Flow programme (Phase 2 to be completed by Sept 23) 26
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REPORT Item No: 6 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 overview of the unaudited North Lanarkshire IJB Annual Accounts for the financial year 2022/2023, in line with the legislative requirements. 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) Approve the Annual Governance Statement and associated reports for inclusion in the statutory accounts; (2) Approve the unaudited North Lanarkshire IJB Annual Accounts 2022/2023 at Appendix 1; (3) Approve the submission of the unaudited annual accounts to Audit Scotland; and (4) Acknowledge the arrangements for publications of the North Lanarkshire IJB Annual Accounts 2022/2023 in line with the legislative requirements. 4. VARIATIONS TO DIRECTIONS 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 The Public Bodies (Joint Working) (Scotland) Act 2014 was passed by the Scottish Parliament on 25 February 2014 and received Royal Assent in April 2014. This established the framework for the integration of health and social care in Scotland, to be governed by Integration Joint Boards with responsibility for the strategic planning of the functions delegated to it and for ensuring the delivery of its functions through the locally agreed operational arrangements. SUBJECT: North Lanarkshire IJB Unaudited Annual Accounts 2022/2023 TO: Performance, Finance and Audit Committee Lead Officer for Report: Ross McGuffie, Chief Officer Author(s) of Report Amanda Kilburn, Chief Financial Officer DATE: 21 June 2023 Yes No N/A
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5.2 The IJB is specified in legislation as a ‘Section 106’ body under the terms of the Local Government Scotland Act 1973 and as such is expected to prepare annual accounts in compliance with the CIPFA/LASAAC Code of Practice on Local Authority Accounting in the United Kingdom and International Financial Reporting Standard (IFRS). 5.3 LASAAC (The Local Authority (Scotland) Accounts Advisory Committee) and CIPFA have produced additional guidance on accounting for the integration of health and social care. 6. CONCLUSIONS 6.1 This report provides the unaudited North Lanarkshire IJB Annual Accounts for the financial year 2022/2023 in line with the legislative requirements. 7. NORTH LANARKSHIRE IJB ANNUAL ACCOUNTS 2022/2023 7.1 The unaudited annual accounts are attached at Appendix 1 and have been prepared in line with proper accounting practice but remain subject to audit by Audit Scotland. 7.2 As prescribed by the Local Authority Accounts (Scotland) Regulations 2014 and in line with previous years, the unaudited annual accounts will be available for public inspection in the Council Offices for a three-week period from Monday 3 July 2023 until Friday 21 July 2023 inclusive. The Regulations also require publication of the annual accounts on the North Lanarkshire IJB website. The unaudited annual accounts are therefore available online from Friday 30 June 2023 until the date the audited Annual Accounts are published. 7.3 The proposed sequence of events to approve the North Lanarkshire IJB Annual Accounts 2022/2023 is summarised in the following table: Key Dates Items to be Approved PFA Committee: 21 June 2023 Approve Annual Governance Statement and associated reports for inclusion in the statutory accounts. Approve the unaudited annual accounts at Appendix 1 Approve the submission of the unaudited annual accounts to Audit Scotland. Audit Scotland: 12 September 2023 Issue of draft letter of Representation and proposed Independent Auditor’s Report Agreement of audited and unsigned annual report and accounts IJB: 27 September 2023 Approve the audited annual accounts.
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8. IMPLICATIONS 8.1 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 ☒ 8.2 ASSOCIATED MEASURE(S) None. 8.3 FINANCIAL This paper has been reviewed by Finance: Yes No N/A 8.4 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 Financial Challenges High Amanda Kilburn Ineffective Governance Arrangements Low Ross McGuffie Notional Set-Aside Budget High Ross McGuffie Hosted Services Medium Ross McGuffie Prescribing Activity and Costs Very High Ross McGuffie 8.5 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 The Director of Finance of NHSL and the Head of Financial Solutions of NLC both continue to be consulted on the financial position of the NL IJB.
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☐ 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 Financial information is shared with stakeholders on a regular basis and is provided to the PFA and IJB on a quarterly basis. ☒ 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 IJB Financial Plan and Reserves Strategy aligns and supports the IJB Strategic Commissioning Plan to ensure robust financial monitoring and scrutiny. 8.6 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 9. BACKGROUND PAPERS None. 10. APPENDICES Appendix 1 - North Lanarkshire IJB Unaudited Annual Accounts 2022/2023 Chief Finance Officer Members seeking further information about any aspect of this report, please contact Amanda Kilburn on telephone number 07816 126362.
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NORTH LANARKSHIRE INTEGRATION JOINT BOARD ANNUAL ACCOUNTS UNAUDITED 2022/2023
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Page | 2 CONTENTS Page Management Commentary Purpose 3 The Role and Remit of North Lanarkshire Integration Joint Board 3 A Profile of North Lanarkshire 4 North Lanarkshire IJB Outcomes for the Year 5 o Achievements 5 o Challenges 6 Our Priorities and Ambitions for 2023/2026 7 Medium Term Financial Plan 8 Financial Performance 9 Resources Available to the IJB 9 Summary of Financial Position 2022/2023 10 Reserves Strategy 11 Risk Management 12 Acknowledgements 13 Statement of Responsibilities 14 Remuneration Report 16 Annual Governance Statement 19 Comprehensive Income and Expenditure Statement 25 Movement in Reserves Statement 26 Balance Sheet 27 Notes to the Financial Statements Note 1: Significant Accounting Policies 28 Note 2: Critical Judgements and Estimation Uncertainty 30 Note 3: Events after Balance Sheet Date 30 Note 4: Expenditure and Income Analysis by Nature 31 Note 5: Taxation and Non‐Specific Grant Income 31 Note 6: IJB Operating Costs 32 Note 7: Short Term Debtors and Creditors 32 Note 8: Usable Reserves 32 Note 9: Related Party Transactions 33 Note 10: Covid‐19 Costs and Funding 34 Note 11: Hosted Services 35 Note 12: Additional Council Services Delegated to the IJB 36 Note 13: VAT 36 Note 14: External Audit Costs 36 Note 15: New Standards Issued but not yet Adopted 36
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Page | 3 MANAGEMENT COMMENTARY Purpose This publication contains the financial statements of North Lanarkshire Integration Joint Board (IJB) for the year ending 31 March 2023. The management commentary provides an overview of the key outcomes relating to the objectives and strategy of the IJB. It considers our financial performance for the year 2022/23 and looks forward, outlining our future financial plans and the challenges and risks that we will face as we strive to meet the needs of the people of North Lanarkshire. Faced with the unprecedented challenges of Covid‐19, followed by the continued cost of living crisis, the IJB entered into a phase of recovery and remobilisation. By working with our partners, staff and communities, our services have responded effectively to this ongoing crisis by protecting lives and keeping people safe but also recognising that the future will require new and innovative solutions to support continued recovery and increased levels of demand created by the pandemic. The IJB and Health and Social Care Partnership (HSCP) Senior Management Team would like to extend our gratitude for the magnificent work our staff continue to undertake despite the challenges they face on a daily basis, ensuring that services to those in need continue to be delivered safely and effectively. The Role and Remit of North Lanarkshire Integration Joint Board North Lanarkshire IJB, formally established on 1 April 2016, has responsibility for the strategic planning and commissioning of a wide range of health and social care services within North Lanarkshire. These functions delegated to the IJB, under the Public Bodies (Joint Working) (Scotland) Act 2014, are detailed in the formal partnership agreement between the two partner organisations, North Lanarkshire Council (NLC) and NHS Lanarkshire (NHSL) referred to as the Integration Scheme1. The IJBs primary purpose is to set the strategic direction for the delegated functions through its Strategic Commissioning Plan and includes: accident and emergency services provided in a hospital; inpatient services related to general, geriatric, rehabilitation, and respiratory medicine; palliative care services; community health services; and social care services. The IJB comprises of eight voting members, made up of four Elected Members appointed by NLC and four Non‐Executive Directors appointed by NHSL. Non‐voting members include the Chief Officer, Chief Finance Officer, service professionals, third sector, service users, carers, and staff representatives. 1 HSCP North Lanarkshire Integration Scheme Our Purpose People of North Lanarkshire will achieve their full potential through: living safe, healthy, and independent lives in their communities; and receiving the information, support and care they need, efficiently and effectively, at the right time and in the right way.
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Page | 4 A Profile of North Lanarkshire A full profile of North Lanarkshire IJB is set out in the Strategic Commissioning Plan 2023/2026. Some of the key population characteristics include the following: By mid‐2043, the 0 to 15 age group is projected to see the largest decrease (‐11%). 75 and over age group is projected to see the largest percentage increase (+53.5%). In 2021/22, 13.5% of Lanarkshire residents were living with three or more long term health conditions. North Lanarkshire has a higher rate per 1,000 population compared to Scotland for several health indicators including A&E attendances, acute emergency hospital admissions, readmissions, NHS24 calls and alcohol and drug related hospital admissions. 10% of North Lanarkshire population is identified as being in a caring role with early indication that this number is set to rise. In North Lanarkshire, life expectancy at birth was higher for females (79.2 years) then for males (74.5 years) in 2018‐2020, however both male and female remains below that of the Scottish average. North Lanarkshire Population is 341,400. There are 24,796 working‐age people in North Lanarkshire experiencing employment deprivation. This is 11% of the working‐age population. Across North Lanarkshire 15% of people are income deprived. The Scottish average is 12%.
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Page | 5 North Lanarkshire IJB Outcomes for the Year The achievements and challenges highlighted below represent some of the common themes which emerged in our engagement activities with staff and our stakeholders. Achievements Resilience Within the System – staff, carers, and service users A common thread through all our engagement activity was the recognition of the efforts and resilience of members of staff from across the health and social care sector, volunteers, carers, service users and family members in dealing with the many challenges of the pandemic. Focus on Staff Health, Wellbeing, and Connectedness Training, practical, and psychological supports have been developed for staff wellbeing across the Health and Social Care Partnership (HSCP) over the past two to three years. These initiatives are now aligned and incorporated within the major strategic workplans of both the partnership, NLC and NHSL which will inform and shape the way we work going forward by engaging with staff, embedding good practise in our ways of working and improving our methods of supporting staff in the longer term. Care Academy The Health and Social Care Academy provides curriculum opportunities linked to the health and social care sector. These are targeted at young people in the senior phase of learning from the nine secondary schools in North Lanarkshire. It is focused on assisting pupils to gain qualifications as well as work related learning experiences which will help them in gaining employment and assist in meeting the workforce requirements of the sector. The main areas are health and social care, general nursing, and allied health professions. Community Solutions – community capacity building Community Solutions is the community led, health and social care investment programme operating across North Lanarkshire, focused on building communities where people can have full, independent lives. The programme, which has been in place since 2013, is a partnership between HSCP, Voluntary Action North Lanarkshire (VANL), the community and the voluntary sector of North Lanarkshire. Its latest Strategy and Investment Plan 2022/2025 was agreed in March 2022, setting out investment plans within the programme to strengthen community capacity and resilience and deliver person‐centred, community‐ based support and services to priority groups. Enhanced Capacity and Resilience In February 2022, the IJB approved a £20m business case utilising both recurring and non‐recurring funding to transform the whole health and social care system by building capacity and resilience within it. Building on the wider approach to recovery and renewal across the sector, investment has started to be made in supports and approaches which: maximise capacity through new staffing, resources, and services; ensure staff wellbeing; ensure system flow by improving planned discharge from hospital and increasing access to care in a range of community settings; and improve outcomes through collective investment in people, systems, services and supports which deliver the right care in the right setting.
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Page | 6 Use of Technology – within a variety of settings The use of technology has expanded considerably over the past three years, and the experience of the Covid‐19 restrictions resulted in the acceleration of our plans to use technology more in relation to online appointments and consultations, technology enabled care and also as a key element of our communication and day‐to‐day management. Mental Health Renewal and Recovery The recovery and renewal of our mental health services continues to progress and the importance of linking these efforts with our new priorities was reflected in engagement discussions and feedback. Challenges Demographic Growth and Demand Health and social care services are experiencing increasing demand due to demographic growth, an ageing population, complexity of care needs, and deprivation. It remains to be seen how detrimental the lasting impacts of Covid‐19 will have on our communities, but we project this will result in negative impacts on the health of our residents in the future and subsequently as a direct result, an increase in pressures on our services. Cost of Living Crisis and Widening Inequalities Given the current challenges in relation to the cost‐of‐living crisis, the wider issues of poverty and income deprivation were highly prevalent in discussions which emerged in our engagement activities. There are significant and persistent inequalities in outcomes across the North Lanarkshire population that have a significant impact on people’s life opportunities and life chances. There is strong evidence to suggest the experience of the pandemic has widened inequalities with some sectors of society disproportionately affected by the disruption and restrictions. The current cost of living crisis will also disproportionately affect those with lower incomes. Staff Recruitment and Retention The wider health and social care sector have experienced challenges related to the recruitment and retention of staff for some time, with the recent experiences of the pandemic and the withdrawal from the European Union placing further pressure on an already challenging situation. There is a need to invest in the workforce through training and development with clear career pathways, to ensure we make employment within the sector as attractive as possible. Through a values‐based approach we need to offer flexible and positive working environments with an embedded culture of staff wellbeing. National Care Service The independent review of Adult Social Care recommended the creation of a National Care Service (NCS) and a system of care which took a human right based approach with a focus on incorporating the views of those with lived experience about what needs to change to make real and lasting improvements. The aspirations of the NCS represent a progression from the Scottish Government’s Health and Social Care Delivery Plan and supports their long‐standing desire to shift the balance of care and support from hospital to a community care setting. The outcome of this review is currently subject to ongoing consultation and will be used to shape and develop the new legislation, with the intention that the NCS will be fully functioning by the end of the Parliamentary term in 2026. This will impact on the delivery of services and over the next 2 – 3 years, proposed changes will have a direct impact on colleagues working in health and social care resulting in uncertainty and increased work challenges as we prepare for the implementation of the NCS.
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Page | 7 Our Priorities and Ambitions for 2023/2026 The long‐term vision for North Lanarkshire HSCP which was set out in the original Strategic Plan 2016/20262 remains relevant and will continue as our over‐arching vision. Our Strategic Commissioning Plan 2023/20263 sets out our commitment to achieve our long‐term ambitions. Only by working together, can we bring about real change to improve the overall health and wellbeing for the people of North Lanarkshire. We continue to experience the long‐term and lasting impact of the Covid‐19 pandemic, whilst working with people to ensure they can access the support and treatment they require following a sustained period of disruption and restriction. This new plan will help to inform financial planning and how we allocate our resources to the programme of work 2023/2026. To enable us to measure how well we are doing, our achievements will be measured and reported against a range of national and local performance measures including the nine national health and wellbeing outcomes below. NATIONAL HEALTH & 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 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 their dignity respected. 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. People who provide unpaid care are supported to look after their own health and wellbeing, including to reduce any negative impact of their caring role on their own health and wellbeing. Health and social care services are centred on helping to maintain or improve the quality of life of people who use those services. Resources are used effectively and efficiently in the provision of health and social care services. Health and social care services contribute to reducing health inequalities. People using health and social care services are safe from harm. Following our engagement with stakeholders, taking into account the experience of the past three years and the current and future challenges facing the partnership, we have revised our ambitions to the following: 2 Strategic Plan 2016/2026 3 Strategic Commissioning Plan 2023/2026 Strategic Commissioning Plan 2023/2026 Do the right thing first time Increased focus on prevention, early intervention and tackling inequalities Improve mental health and wellbeing Develop and support a workforce for the future Support people through a whole family approach
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Page | 8 Clearly, these priorities are interlinked, and we expect them to influence and shape each other as we progress our implementation. Under each priority area we will develop an agreed set of medium‐term goals that we plan to address between 2023 and 2026. The Programme of Work will set out in detail the programmes that will be progressed over the next three years and will be annually updated to ensure that we stay on track, and at the same time, be able to respond to any new or emerging issues that we need to address. We will closely monitor our progress and continue to seek feedback from service users, carers, and families on the impact we are making. Medium Term Financial Plan 2023/2026 The North Lanarkshire IJB Medium to Long Term Financial Plan 2020/2030, outlined the anticipated financial challenges and opportunities that the partnership expected over the ten‐year period and provided a framework which would support the partnership to remain financially sustainable. The impact of Covid‐19 on health and social care services and the economy created considerable unanticipated pressures, and therefore the partnerships governance arrangements were reviewed and adapted to support the response, and redesign of services. Whilst many of the elements in the previous financial plan remain, the pandemic and ensuing cost of living crisis has accelerated the delivery of some of our objectives, made others increasingly important and lowered the priority of some of our previously agreed actions. Alongside the development of the new Strategic Commissioning Plan 2023/2026, it is consequently necessary to update our supporting plan to a Medium‐Term Financial Plan (MTFP). The new MTFP 2023/20264 reflects the impact of recovering from Covid‐19 and other challenging factors facing the IJB. It has been condensed to a three‐year plan rather than the original ten‐year plan due to the pending formation of the National Care Service and the continuing uncertainty around future funding. By linking the MTFP to the plans and actions below, we ensure that consideration is given to all areas of our business, rather than concentrating on standalone objectives: 4 Medium‐Term Financial Plan 2023/2026 Medium Term Financial Plan Reserves Strategy Engaging with Partner Bodies Supporting Transformation Workforce Planning Strategic Commissioning Plan Financial Management and Planning Budget Setting Process
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Page | 9 As was the case prior to the pandemic, the IJB’s financial planning arrangements remain subject to active review, to enable us to continue to plan for a range of potential outcomes and scenarios. This helps us to manage emerging financial risks and challenges and the likely impact these could have on the financial position of the IJB. The financial position for public services continues to be challenging and it is therefore important that the IJB’s ambitions are set within the content of the funding available. The aspiration to prepare a balanced budget covering a longer term will support the development of strategic savings plans and ensure the available resources are allocated effectively across competing priorities. This aspiration however is dependent on the certainty of the financial settlement from the Scottish Government. Both partners have a proven track record of managing budgets effectively over many years. A clear strategy is required to ensure the IJB continue to remain financially sustainable over the medium term. The limited financial and workforce resources will require to be focussed on services which are sustainable and are targeted to those with the greatest need. In preparing the financial plan, a co‐ordinated and strategic approach across the partnership has been adopted with both partners including the cost pressures in relation to their delegated functions. A range of outcomes will continue to be analysed and the financial planning assumptions updated as the most likely scenarios emerge for future years. The Scottish Government aspiration to move to multi‐year settlements in the future is welcome and would reduce the uncertainty which is currently impacting on strategic commissioning activity across the health and social care partnership. Financial Performance The financial year 2022/2023 has brought a fresh set of challenges including continued recovery from the pandemic, the current cost of living crisis, a changing demographic profile, staffing shortages and increased demand for services. Through regular updates to the IJB from the Chief Finance Officer (CFO) and by ensuring decisions made throughout 2022/2023 were taken to support financial sustainability, the HSCP has successfully managed to deliver year on year financial balance. This has been achieved through a combination of: Flexible use of recurring and non‐recurring resources. Creation and use of reserves for specific commitments. Delivery of approved savings through service redesign and removing duplication. Workforce planning and focusing on services that are sustainable in line with our Strategic Commissioning Plan. Implementing a co‐ordinated and strategic approach across the partnership. Effective governance and audit controls. Resources Available to the IJB North Lanarkshire IJB delivers and commissions a range of health and social care services to our local population. This is funded through budgets delegated from both NHS Lanarkshire and North Lanarkshire Council. The level of funding available to the IJB is therefore heavily influenced by these organisations grant settlement from Scottish Government.
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Page | 10 The combined recurring and non‐recurring budgets available to the IJB in 2022/2023 to take forward the commissioning intention in line with the Strategic Commissioning Plan, is circa £764m. Included within the resources available is a ‘Large Hospital Services’ (Set Aside) budget totalling £69.120m. This budget is in respect of the functions delegated by the Health Board which are carried out in a hospital setting. The Set Aside budget for delegated services provided in acute hospitals is determined by apportioning the hospital expenditure to individual patient episodes, separating out episodes for services delegated to the IJB from those that are not, and assigning these to the relevant IJB based on postcode. Summary of Financial Position 2022/2023 Throughout 2022/2023 the CFO financial monitoring report to the IJB projected an underspend, prior to the transfer of year end balances to reserves. The year end underspend totalled £35.495m. Adjustments incurred against reserves in 2022/2023 totalled £57.001m leaving a deficit on the provision of services of £21.506m as shown in the Comprehensive Income and Expenditure Statement on page 25 and Movement in Reserves on page 26. North Lanarkshire HSCP Final Outturn 2022/2023 £m HSCP Underspend as at 31 March 2023 (35.495) Adjustments to Reserves: Drawdown of Reserves for IJB Use COVID‐19 Funding Returned to Scottish Government In Year Adjustment 31.193 25.916 (0.108) Deficit on Provision of Services (Page 25) Movement in Reserves (Page 26) 21.506 The following provides a high‐level summary of the key pressures and the main reasons why the IJB’s final outturn resulted in an underspend against its budget in 2022/2023: Employee Costs net underspend of £17.377m is in relation to ongoing challenges in terms of recruitment and retention of staff across all service areas. This underspend also includes Scottish Government funding of £8.270m allocated to help address the current staffing pressures. This funding will be carried forward into 2023/2024 within specific ring‐fenced reserves to be used in 2023/2024.
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Page | 11 The cost of services incurred in 2022/2023 is compared to the previous two years in the table below: Reserves Strategy The IJB has the same legal status as a local authority and is therefore able to hold reserves under section 106 of the Local Government (Scotland) Act 1973. A reserve strategy was developed to provide security against unexpected cost pressures and to aid financial stability. The IJB Reserves Strategy 2022/2023 allows for flexibility in terms of potential fluctuations. This allows for the IJB to increase contingency reserve balances significantly where resources permit providing future financial resilience for those years where the level of resources available to the IJB may be significantly constrained and will require a draw down from these reserves in order to deliver financial balance. To protect the financial resilience of the IJB in the context of an increased financial risk profile, the IJB transferred £7.885m from the 2022/2023 in year underspend to contingency reserves. This provides a total contingency reserve of 3% of our financial envelope and aligns to the recommendation in our IJB Reserve Strategy of holding a 3% contingency reserve where possible. 2020/2021 2021/2022 2022/2023 £m £m £m Social Care Services 189.048 202.610 236.972 Health Care Services 65.557 74.073 74.527 Family Health Services 105.773 109.652 115.625 Delegated Services 1.281 2.207 2.437 Hosted Services 141.034 149.126 159.642 IJB Operating Costs 0.212 0.214 0.247 Prescribing Costs 69.088 68.739 71.332 Covid‐19 Costs 21.342 13.412 7.072 Set Aside 63.066 65.164 69.120 Income (2.507) (3.800) (4.717) COST OF SERVICES 653.894 681.397 732.256 North Lanarkshire HSCP Services Payments to Other Bodies net underspend of £1.511m is primarily due to the staff shortages and vacancies within the Care at Home sector who provide services to individuals via the self‐directed support commissioning framework. Admin Costs net underspend of £1.431m. This is ring‐fenced carers funding that will be transferred to a dedicated earmarked reserve to fund carers pressures in 2023/2024. Mental Health, Alcohol and Drug Partnership and HSCP Planning combined net underspend in non‐pays totalling £13.330m. This is due to additional funding received from Scottish Government (£13.141m) which will be carried forward into 23/24 and allocated against new spending plans. Prescribing net overspend of £1.750m is due to activity and cost per item being 3.19% higher compared to 2021/2022. Due to the uncertainty around costs and prescribing activity, the volatility experienced within prescribing is likely to continue for the foreseeable future. Supplies and Services net overspend of £2.531m is due to additional purchases of PPE and staff uniform due to the increase in home support staff and costs associated with winter planning. There has also been additional expenditure in relation to aids and adaptations to meet current demand. £1.550m additional income was drawn down from earmarked reserves to offset some of this overspend and is showing in the over recovery of income. Income over‐recovery of £6.031m for Social Care is due to the drawdown of earmarked reserves to offset expenditure relating to winter planning, adaptations, digital and IT and staffing costs.
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Page | 12 The IJB also has committed actions attached to the Strategic Commissioning Plan and funding is therefore earmarked to specific projects to allow spend to be managed in a way that represents best value for the IJB to achieve its national outcomes. It is also important that in year funding available for government priorities are able to be ring‐fenced and carried forward into the following financial year. As these funding allocations are to meet specific commitments, they must be carried forward to meet the conditions attached to their receipt. The table below shows the breakdown of the underspend transferred to reserves at year end: Risk Management The IJB Risk Management Strategy, which was updated and approved by the IJB in March 2023, complements the existing risk management processes within each partner by ensuring risk reports form a substantial item of business at all IJB meetings. There are three main risk registers across the partnership: IJB risk register outlining the strategic risks to the IJB; Health operational risk register, hosted within the NHS Lanarkshire system; and Social Work operational risk register, hosted within North Lanarkshire Council system. Strong ties have been maintained with the corporate risk managers in both partner organisations and the IJB Risk Management Strategy, has been developed in conjunction with these leads, linking closely to both the North Lanarkshire Council and NHS Lanarkshire Risk Management Strategies. At time of writing, there are currently seventeen open risks identified within our North Lanarkshire IJB Risk Register with two of these risks rated as very high and eight rated as high. The table below shows a summary of these: Category Description of Risk Summary Current Risk Level Financial Financial Challenges: There are a range of financial challenges which will impact on the IJB’s ability to deliver the Strategic Commissioning Plan with the financial envelope available. High Financial Ineffective Governance Arrangements: There is a risk that the IJB is unable to prevent and detect fraud and corruptions within services due to inadequate governance arrangements and internal controls. Low Financial Set‐Aside Budget: There is a risk that the resources will not be transferred from Acute Services to the HSCP in line with the shift in the balance of care. High Financial Hosted Services: There is a risk of dispute between the North and South Lanarkshire IJB in respect of the financial allocations underpinning the Hosted Services budget. Medium Financial Prescribing: Prescribing costs may escalate due to the increases in activity and price volatility, new drugs becoming available, the response to Covid‐19 and the impact of the EU withdrawal. Very High Financial Third and Voluntary Sector: There is a risk our third sector organisations are vulnerable because of lack of certainty in respect of long‐term funding, leading to instability and recruitment and retention challenges. Low Financial Ineffective Governance Arrangements Due to Covid‐19 Pandemic: There is a risk that the intensity of the required response to Covid‐19 could result in a failure of governance. Medium Analysis of Transfer to IJB Reserves £m Ring‐Fenced Reserves 21.411 Earmarked Reserves 6.199 Contingency Reserves 7.885 Total 35.495
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Page | 13 Category Description of Risk Summary (Continued) Current Risk Level Performance Oversight of Performance Activity: There is a risk the IJB is not provided with adequate or sufficient performance information to enable it to discharge its scrutiny and oversight role. Low Performance Staff Health & Wellbeing: There is a risk to the delivery of the Strategic Commissioning Plan as a result of sustained pressures on staff availability due to pressures, sickness, and redeployment. High Performance Care Homes: Inability of care homes to sustain service due to staffing or Covid outbreaks resulting in closure to new placements. Medium Performance Service Sustainability: There is a risk that the IJB will be unable to implement the strategic plan. Failure to achieve the desired IJB strategic aims poses a risk on operational service delivery. High Performance Workforce Sustainability: It is becoming increasing difficult to recruit to particular roles across Health and Social Care. Gaps in the workforce can result in reduction of service provision, increase in staff workload and inability to deliver the strategic plan. High Strategic & Performance Children and Adolescent Mental Health Services: There is a risk that the CAMHS service cannot meet the increasing clinical demands due to a significantly high number of staff vacancies and recruitment challenges. High Strategic & Performance Cost of Living: There is a risk that the Strategic Commissioning Plan will be unable to be delivered or not have the desired impact due to the cost‐of‐living increases being faced by residents. High Strategic & Performance Unscheduled Care: There is a risk that we cannot sustain whole system patient flow through peak winter pressures due to increased front door demand, hospital workforce capacity, delays in onward movement of patients and HSCP workforce capacity. Very High Strategic & Performance Community Alarms: There is a risk the community alarm system will be destabilised due to the national change from analogue to digital telephony by 2025. Medium Strategic National Care Service: The ongoing work around the NCS could destabilise current service delivery due to significant change activity, time demands and staff uncertainty. High Acknowledgements We would like to acknowledge the significant effort required to both produce the annual accounts and successfully manage the finances of the IJB and to record our thanks to the Finance teams in both North Lanarkshire Council and NHS Lanarkshire and colleagues in other services within the Partnership for their continued hard work and support. Councillor Ayeshah Khan Chair, North Lanarkshire Integration Joint Board Date: Ross McGuffie Chief Officer Date: Amanda Kilburn FCCA Chief Finance Officer Date:
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Page | 14 STATEMENT OF RESPONSIBILITIES Responsibilities of the North Lanarkshire Integration Joint Board The North Lanarkshire Integration Joint Board is required to: Make arrangements for the proper administration of its financial affairs and to ensure that the proper officer of the board has responsibility for the administration of those affairs (section 95 of the Local Government (Scotland) Act 1973). In this IJB, that officer is the Chief Finance Officer. Manage its affairs to secure economic, efficient, and effective use of resources and safeguard its assets. Ensure the Annual Accounts are prepared in accordance with legislation (The Local Authority Accounts (Scotland) Regulations 2014), and so far, as is compatible with that legislation, in accordance with proper accounting practices (section 12 of the Local Government in Scotland Act 2003). Approve the Annual Accounts. I confirm that these Annual Accounts were approved for signature at a meeting of the North Lanarkshire Integration Joint Board on xx. Signed on behalf of the North Lanarkshire Integration Joint Board Councillor Ayeshah Khan Date: Chair, North Lanarkshire Integration Joint Board
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Page | 15 Responsibilities of the Chief Finance Officer The Chief Finance Officer is responsible for the preparation of the Integration Joint Board’s Annual Accounts in accordance with proper practices as required by legislation and as set out in the CIPFA/LASAAC Code of Practice on Local Authority Accounting in the United Kingdom (Accounting Code). In preparing the Annual Accounts, the Chief Finance Officer has: Selected suitable accounting policies and then applied them consistently. Made judgements and estimates that were reasonable and prudent. Complied with legislation. Complied with the Local Authority Code (in so far as it is compatible with legislation). The Chief Finance Officer has also: Kept proper accounting records which were up‐to date. Taken reasonable steps for the prevention and detection of fraud and other irregularities. I certify that these Annual Accounts present a true and fair view of the financial position of the North Lanarkshire Integration Joint Board as at 31 March 2023 and the transactions for the year then ended. Amanda Kilburn FCCA Date: 21 June 2023 Chief Finance Officer
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Page | 16 REMUNERATION REPORT The Local Authority Accounts (Scotland) Regulations 2014 (SSI No. 201/200) require local authorities and IJBs in Scotland to prepare a Remuneration Report as part of the annual statutory accounts. The information in the tables below is subject to external audit. The explanatory text in the Remuneration Report is reviewed by Audit Scotland to ensure it is consistent with the financial statements. Voting Board Members Voting IJB members constitute councillors nominated as board members by constituent authorities and NHS representatives nominated by the NHS Board. The voting members of North Lanarkshire IJB were appointed through nomination by North Lanarkshire Council and NHS Lanarkshire. The regulations require disclosure of remuneration information for ‘relevant’ persons. A ‘relevant’ person in relation to the Remuneration Report includes a senior officer holding office with associated authority, whether on a permanent or temporary basis, in the financial year to which that Remuneration Report relates. The Board Members do not receive remuneration or expenses directly from the IJB. Any remuneration or reimbursement of expenses for voting board members is governed by the relevant IJB partner organisation. The IJB does not provide any additional remuneration to the Chair, Vice Chair or any other board members relating to their role on the IJB. The IJB does not reimburse the relevant partner organisations for any voting member costs by the partner. Vice Chair vacant from 1 April 2022 to 21 June 2022. The IJB does not have responsibilities, either in the current year or in future years, for funding any pension entitlements of voting IJB members. Therefore, no pension rights disclosures are provided for the Chair or the Vice Chair. There were no exit packages payable during the financial year. Taxable Expenses 2021/2022 £ Name Post Held* Nominated by Taxable Expenses 2022/2023 £ IJB Chair (1 April 2022 to 21 June 2022) IJB Chair (22 June 2022 to 24 August 2022) IJB Chair (25 August 2022 to 31 March 2023) IJB Vice Chair (22 June 2022 to 31 March 2023) ‐ ‐ ‐ ‐ ‐ ‐ ‐ ‐ Cllr Ayeshah Khan North Lanarkshire Council Brian Moore NHS Lanarkshire Cllr Tracy Carragher North Lanarkshire Council Cllr Paul Kelly North Lanarkshire Council
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Page | 17 Officers of the IJB The IJB does not directly employ any staff in its own right however specific post‐holding officers are non‐ voting members of the Board. The Chief Officer and the Chief Finance Officer are appointed by the North Lanarkshire IJB and employed by North Lanarkshire Council. Both posts are seconded to the IJB in line with the local arrangements. The senior officers received the following remuneration in the period: M Moy, Chief Finance Officer was also appointed to the South Lanarkshire IJB from 1 April 2021 to 6 May 2022. Therefore, the remuneration disclosed above for this post, is the proportion of remuneration received solely in relation to the activity of the North Lanarkshire IJB. FYE: Full Year Estimate includes an estimate of the full year salary from 1 April 2022 for Amanda Kilburn who started as Chief Finance Officer on 22 August 2022 and a proportion of full year salary to 31 March 2023 for Marie Moy who left as Chief Finance Officer on 6 May 2022. Pay band information is not separately provided as all staff pay information has been disclosed in the information above. Pension Benefits In respect of officers’ pension benefits the statutory liability for any future contributions to be made rests with the relevant employing partner organisation. On this basis, there is no pension liability reflected on the IJB balance sheet for the Chief Officer or the Chief Finance Officer. The IJB however, has responsibility for funding the employee contributions for the current year in respect of the officer time spent fulfilling the responsibilities of their role on the IJB. The following table shows the IJB’s funding during the year to support officers’ pension benefits. The table also shows the total value of the accrued pension benefits which may include benefits earned in other employment positions and from each officer’s own contributions. Total Earnings Total Earnings * 2021/2022 2022/2023 £ £ Ross McGuffie Chief Officer 1 April 2022 to 31 March 2023 Marie Moy Chief Finance Officer 1 April 2022 to 6 May 2022 Amanda Kilburn Chief Finance Officer 22 August 2022 to 31 March 2023 ‐ 45,844 (FYE 74,370) Name and Post Title* 102,352 112,098 36,631 3,645 (FYE 38,004)
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Page | 18 The pension contribution and benefits for M Moy, Chief Finance Officer relate to the proportion attributable to the activity of the North Lanarkshire IJB based on a pro‐rata approach. Councillor Ayeshah Khan Chair, North Lanarkshire Integration Joint Board Date: Ross McGuffie Chief Officer Date: For Year to 31/03/2022 For Year to 31/03/2023 As at 31/03/2022 As at 31/03/2023 £ £ £000 £000 Pension 10 12 Lump Sum ‐ ‐ Pension 16 ‐ Lump Sum 22 ‐ Pension ‐ 15 Lump Sum ‐ ‐ Amanda Kilburn Chief Finance Officer ‐ 8,848 Name and Post Title In Year Pension Contribution* Accrued Pension Benefits* Marie Moy Chief Finance Officer Ross McGuffie Chief Officer 21,291 21,635 7,058 365 Description
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Page | 19 ANNUAL GOVERNANCE STATEMENT The Annual Governance Statement reports on the effectiveness of the IJB’s governance arrangements and system of internal control and explains how the IJB complies with the Code of Corporate Governance and meets the requirements of the ‘Delivering Good Governance in Local Government’ framework developed by CIPFA and SOLACE in 2016. Scope of Responsibility The IJB is responsible for ensuring that its business is conducted in accordance with the law and appropriate standards, that public money is safeguarded, properly accounted for, and used economically, efficiently, and effectively. The IJB also aims to foster a culture of continuous improvement in the performance of the IJB’s functions and to make arrangements to secure best value. To meet this responsibility, the IJB has established arrangements for governance which includes a system of internal controls. The system is intended to manage risk to support the achievement of the IJB’s policies, aims and objectives. Reliance is also placed on the North Lanarkshire Council and NHS Lanarkshire systems of internal control which support compliance with both organisations’ policies and promotes achievement of each organisations aims and objectives, as well as those of the IJB. This system can only provide reasonable and not absolute assurance of effectiveness. Purpose of the Governance Framework The governance framework comprises the systems and processes, and culture and values, by which the IJB is directed and controlled. It enables the IJB to monitor the achievement of the objectives set out in the IJB’s Strategic Commissioning Plan. The governance framework is continually updated to reflect best practises, new legislative requirements, and the expectations of stakeholders. The system of internal control is based on an ongoing process designed to identify and prioritise the risks in the achievement of the IJB’s objectives, to evaluate the likelihood of those risks being realised, the impact should they be realised, and to manage them effectively. Governance Framework and Internal Control System The IJB comprises of eight voting members, with one from each partner organisation assuming the role of Chair and Vice Chair. Four are Council Members nominated by North Lanarkshire Council and four are Non‐Executive Members appointed by NHS Lanarkshire. The term of office is for a period of three years. There are also a number of non‐voting professional and stakeholder members on the IJB board. Stakeholder members currently include third sector, carers, staff representatives, service users and professional members including the Chief Officer and Chief Finance Officer. The IJB, via a process of delegation from NHS Lanarkshire and North Lanarkshire Council, has responsibility for the planning, resourcing and operational delivery of all delegated health and social care within its geographical area. The main features of the governance framework are: Principles The IJB follows the principles set out in the Convention of Scottish Local Authorities (COSLA) and the Accounts Commission in 1996 Code of Guidance on Funding External Bodies and Following the Public Pound for both resources delegated to the IJB, and resources paid to its Local Authority and Health Service partners.
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Page | 20 Formal Frameworks The IJB is formally constituted through the Integration Scheme agreed by North Lanarkshire Council and NHS Lanarkshire and approved by Scottish Ministers. The IJB operates within an established procedural framework. The roles and responsibilities of board members and officers are defined within standing orders, scheme of delegation and financial governance arrangements which are subject to regular review. The IJB Code of Corporate Governance5 was approved by the IJB on 18 July 2017 which is subject to ongoing updates as required. Board members adhere to an established Code of Conduct and are supported by induction and ongoing training and development. Staff ‘Personal Development Plan’ (PDP) schemes are also in place, the aim of which is to focus on performance and development that contributes towards achieving service objectives. The HSCP has robust structures which are based on service delivery, care and interventions that are person centred, timely, outcome focused, equitable, safe, efficient, and effective. Reports are presented to the IJB throughout the year which provides evidence to demonstrate the delivery of our core components within our frameworks and the Clinical and Care Governance principles specified by Scottish Government. Strategic Planning The overarching strategic vision and objectives of the IJB are detailed in the IJB Strategic Commissioning Plan which sets out the key outcomes the IJB is committed to delivering with its partners. The Strategic Planning Group sets out the IJB’s approach to engage with stakeholders. Consultation on the future vision and activities of the IJB is undertaken with its Health Services and Local Authority partners. The IJB regularly publishes information regarding its performance. The Medium‐Term Financial Plan 2023/2026 outlines the financial challenges and opportunities the HSCP faces over the next three years and provides a framework which will support the HSCP to remain financially sustainable. It complements the IJB Strategic Commissioning Plan 2023/2026, highlighting how the financial plan will support the delivery of the IJB’s strategic objectives and priorities. Oversight Effective scrutiny and service improvement activities are supported by the formal submission of reports, findings and recommendations by Inspectorates and the appointed Internal Audit Service to the IJB’s Senior Management Team, the main IJB board and the Performance, Finance and Audit Committee, as appropriate. Performance management, monitoring of service delivery and financial governance is provided by the HSCP to the IJB, who are accountable to both the Health Board and Local Authority. It reviews reports on the effectiveness of the integrated arrangements including the financial management of the integrated budget. This ensures there is a regular scrutiny at senior management, committee, and board level. Information on performance can be found in the Annual Performance Report published on our North Lanarkshire HSCP website6. Risk Management In line with the continued and ongoing review of the IJB Risk Register, new and emerging risks or changes in risk level are agreed at each Senior Management Team, IJB and PFA meeting as appropriate. The current risks at time of writing are summarised in the Management Commentary on pages 12‐13. 5 IJB Code of Corporate Governance 6 Health & Social Care North Lanarkshire Website
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Page | 21 Financial Control Responsibility for maintaining and operating an effective system of internal financial control rests with the Chief Finance Officer. The system of internal financial control is based on a framework of regular management information, Financial Regulations and Standing Financial Instructions, administrative procedures, including segregation of duties, and management and supervision including delegation and accountability. Development and maintenance of these systems is undertaken by managers within the HSCP supported by North Lanarkshire Council and NHS Lanarkshire in relation to the operational delivery of health and social care services. Transformational Change The Medium‐Term Financial Plan and the Strategic Commissioning Plan recognises the need to transform the way in which the HSCP delivers services to ensure the sustainability of health and social care services going forward. Together with the IJB Reserves Strategy, both plans are regularly reviewed over their lifespan, and amended as necessary to reflect the current challenges and pressures the partnership face. Review of Adequacy and Effectiveness Due to the nature of the IJB membership, a conflict of interest can arise between individual board and committee members and the responsibilities they have to the IJB. It is the responsibility of board and committee members to declare any potential conflicts of interest, and it is the responsibility of the Chair of the relevant board or committee to ensure such declarations are appropriately considered and acted upon. The IJB has responsibility for conducting, an annual review of the effectiveness of the system of internal control and the quality of data used throughout the organisation. The review is informed by the work of the Senior Management Team who have the responsibility for the development and maintenance of the internal control framework, the work of the internal and external audit teams and other independent inspectorates. Internal Audit undertake an annual programme following an assessment of risk completed during the strategic audit planning process. The appointed Chief Internal Auditor in conjunction with the Head of Audit and Risk, provide an annual report to the IJB PFA giving an independent opinion of the adequacy and effectiveness of the governance framework, risk management and internal controls. Based on the audit work undertaken directly on behalf of the IJB and being informed by internal audit, work undertaken independently by each respective internal audit function within North Lanarkshire Council and NHS Lanarkshire, the Chief Internal Auditor and Head of Audit and Risk is able to conclude that a reasonable level of assurance can be placed upon the adequacy and effectiveness of the IJB’s framework of governance, risk management and internal controls. Roles and Responsibilities The Chief Officer is the Accountable Officer for the IJB and has day‐to‐day operational responsibility to monitor delivery of integrated services, with oversight from the IJB. The IJB complies with the CIPFA statement on ‘The Role of the Chief Finance Officer in Local Government 2014’. The IJB Chief Finance Officer has responsibility for North Lanarkshire HSCP financial arrangements and is professionally qualified and suitably experienced to lead and advise the IJB finance function.
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Page | 22 The IJB complies with the requirements of the Public Internal Audit Standards (PSIAS) and the approved Internal Audit Charter for the IJB. The appointed IJB Chief Internal Auditor has responsibility for the IJB internal audit function and is professionally qualified and suitably experienced to lead and direct internal audit staff. The Internal Audit service operates in accordance with the CIPFA ‘Public Sector Internal Audit Standards 2017’. Board members and officers of the IJB are committed to the concept of sound internal control and the effective delivery of health and social care services. The IJB Performance, Finance and Audit Committee operates in accordance with CIPFA Audit Committee Principles in Local Authorities in Scotland and Audit Committees ‘Practical Guidance for Local Authorities’. The Committee core function is to provide the IJB with independent assurance on the adequacy of the risk management framework, the internal control environment, the integrity of the financial reporting and governance arrangements. In March 2023, the IJB approved a revision to the IJB Performance, Finance and Audit Committee Terms of Reference, delegating the power to approve the IJB Annual Accounts effective from the financial year 2022/2023 and each year thereafter. The PFA Terms of Reference have been revised to account for this change. An update to the North Lanarkshire IJB Governance Document was approved by the IJB on 17 May 2023 which includes IJB Programme of Reports, Equality Impact Assessment, Code of Conduct and Declaration of Interest, Directions, IJB Risk Reporting Process and Risk Reporting Template7. Action Plan To ensure continual improvement of the IJB’s governance arrangements, the following action plan has been agreed. Also included are improvement areas identified by Audit Scotland within their Annual Audit Report. Regular updates on progress of the agreed actions will be presented to and monitored by the IJB Performance, Finance and Audit Committee. 2021/2022 Ref Improvement Area Agreed Action Responsible Person Date 1 Review of Set‐Aside Concept Due to the complexity of the data surrounding this area, it has been agreed with the partner that the current process will remain as described in note 2 Critical Judgments and Estimation Uncertainty, until a decision is taken at a national level. Chief Finance Officer Complete 2 Website Refresh HSCP working group have completed the development of the new IJB website which reflects the current operating model. There is a dedicated team who will take ownership and responsibility for maintaining and updating it. The new website launched at the end of February 2023 with endorsement by the IJB on 22 March 2023. IJB Chief Officer Complete 3 Medium Term Financial Plan The new Medium Term Financial Plan 2023/ 2026 reflects the impact of recovering from Covid‐19 and other challenging factors facing the IJB. The plan was approved by the IJB on 22 March 2023 and aligns to the new Strategic Commissioning Plan 2023/ 2026 and the current IJB Reserves Strategy. Chief Finance Officer Complete 7 North Lanarkshire IJB Governance Document Update 2023
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Page | 23 2022/2023 Ref Improvement Area Agreed Action Responsible Person Date 1 Completion of previous internal and external audit actions. All external and internal audit actions have been completed apart from the Service Level Agreement (SLA) with Children, Families and Justice. This SLA will be revisited once further clarity has been obtained around what services will be part of the new National Care Service. Progress was reported to the PFA Committee in November 2022 and April 2023. Chief Finance Officer Complete (Pending National Care Service) 2 National Care Service To develop a sound understanding of the impact for the NLHSCP of the outputs of the National Care Service legislation. Due to the uncertainty and lack of detail currently available, the revised date of completion has been moved to March 2024. Chief Officer Updated timescale: March 24 3 Implementation of improvement actions identified in the Best Value Self‐Assessment exercise. Both the Strategic Commissioning Plan 2023/2026 and the Medium‐Term Financial Plan 2023/2026, approved at the IJB on 22 March 2023, align to strengthen outcomes against resources. By ensuring good practise and lessons learned, both plans have aligned to future funding and reserves to link with outcomes around the improvement actions in the Best Value Self‐Assessment exercise. Head of Planning, Performance and Quality Assurance Complete 4 Review the IJBs progress in becoming a Category 1 Responder as set out within the Civil Contingencies Act In conjunction with the Local Resilience Partnership, undertake a self‐assessment review against the seven duties, reporting progress to the West of Scotland Regional Resilience Partnership. Report submitted and reviewed by the IJB on 22 March 2023. Chief Officer Complete 5 Accounts Inspection 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. Chief Finance Officer June 2023 6 2022/23 Reserves Strategy The IJB 2022/23 Reserves Strategy was presented and approved by the IJB Committee on 22 March 2023. The Reserves Strategy will continue to be updated in line with the new Strategic Commissioning Plan 2023/2026 and the new Medium Term Financial Plan 2023/2026. Chief Finance Officer Complete 7 Review of Financial Regulations Revised Financial Regulations were approved at the Performance, Finance and Audit Committee on 15 February 2023 and include the services currently delegated by each partner to the IJB and the principal method of accounting for Hosted Services. Chief Finance Officer Complete Internal Audit Opinion Internal control remains, primarily, a management responsibility to ensure that the partnership conducts its business in a manner that has due regard to the principles of good governance. Overall, the results of the work undertaken by Internal Audit including reports produced by External Audit, help to inform an opinion on whether the internal controls the North Lanarkshire HSCP has in place are adequate. The joint internal audit opinion is that reasonable assurance can be placed upon the adequacy and effectiveness of the North Lanarkshire IJB’s framework of governance, risk management and internal control.
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Page | 24 Conclusion and Opinion on Assurance It is our opinion that reasonable assurance can be placed upon the adequacy and effectiveness of the IJB’s governance arrangements. The IJB has adhered to the stated principles of good governance, acted in the public interest, and been committed to continuous improvement. The scrutiny and oversight of the IJB Performance, Finance and Audit Committee contributes effectively to these arrangements. There were no significant control weaknesses, issues, or failures in the expected standards for good governance, risk management and internal control. We consider that the internal control environment provides reasonable and objective assurance that any significant risks impacting on the IJB’s principal objectives will be identified and actions taken to avoid or mitigate their impact and are consistent with the recommendations of the CIPFA/SOLACE Framework (2016). Councillor Ayeshah Khan Chair, North Lanarkshire Integration Joint Board Date: Ross McGuffie Chief Officer Date:
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Page | 25 COMPREHENSIVE INCOME AND EXPENDITURE STATEMENT FOR THE YEAR ENDED 31 MARCH 2023 This statement shows the actual cost of providing services in accordance with generally accepted accounting practices. It includes, on an accrual basis, all expenses and related income. There are no statutory or presentation adjustments which affect the IJB’s application of the funding received from partners. The movement in the General Fund balance is therefore solely due to the transactions shown in the Comprehensive Income and Expenditure Statement. Consequently, an Expenditure and Funding Analysis is not provided in these annual accounts. Gross Expenditure Gross Income Net Expenditure Gross Expenditure Gross Income Net Expenditure £m £m £m £m £m £m 202.610 (1.593) 201.017 Social Care Services 236.972 (2.280) 234.692 74.073 74.073 Health Care Services 74.527 74.527 109.652 109.652 Family Health Services 115.625 115.625 149.126 149.126 Hosted Services 11 159.642 159.642 1.668 (1.668) 0.000 Housing Services 1.886 (1.886) 0.000 0.539 (0.539) 0.000 Transport Services 0.551 (0.551) 0.000 0.214 0.214 Corporate Services 6 0.247 0.247 68.739 68.739 Prescribing 71.332 71.332 65.164 65.164 Set Aside for Hospital Acute Services 69.120 69.120 13.412 13.412 Covid‐19 Costs 10 7.072 7.072 685.197 (3.800) 681.397 Total Cost of Services 736.974 (4.717) 732.256 (702.633) (702.633) Taxation and Non‐Specific Grant Income 5 (709.408) (709.408) (45.098) (45.098) Covid‐19 Funding 10 (1.342) (1.342) 685.197 (751.531) (66.334) (Surplus) or Deficit on Provisions of Services (Movement in Reserves) 736.974 (715.467) 21.506 2021/2022 2022/2023 North Lanarkshire Health & Social Care Partnership Integration Joint Board Note
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Page | 26 MOVEMENT IN RESERVES STATEMENT This statement shows the movement in the year on the IJB’s reserves. The movements which arise due to statutory adjustments which affect the General Fund balance are separately identified from the movements due to accounting practices. General Fund Balance Total Reserves £m £m Opening Balance at 1 April 2021 (53.118) (53.118) Total Comprehensive Income and Expendiutre (Increase) or decrease in 2021/22 (66.334) (66.334) Closing Balance at 31 March 2022 (119.452) (119.452) Opening Balance at 1 April 2022 (119.452) (119.452) Total Comprehensive Income and Expendiutre (Increase) or decrease in 2022/23 21.506 21.506 Closing Balance at 31 March 2023 (97.946) (97.946) Movement in Reserves during 2021/2022: Movement in Reserves during 2022/2023: North Lanarkshire Health & Social Care Partnership Integration Joint Board
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Page | 27 BALANCE SHEET AS AT 31 MARCH 2023 The balance sheet shows the value of the IJB’s assets and liabilities as at 31 March 2023. The net assets of the IJB (assets less liabilities) are matched by the reserves held by the IJB. The Statement of Accounts presents a true and fair view of the financial position of the North Lanarkshire Integration Joint Board as at 31 March 2023 and its income and expenditure for the year then ended. The unaudited accounts were authorised for issue on 21 June 2023. Balance Sheet signed by: Amanda Kilburn FCCA Chief Finance Officer Date: 21 June 2023 31 March 2022 31 March 2023 £m £m 119.452 Current Assets Short Term Debtors 7 97.946 ‐ Current Liabilities Short Term Creditors 7 ‐ 119.452 Net Assets 97.946 119.452 Usable Reserves: General Fund 8 97.946 119.452 Total Reserves 97.946 North Lanarkshire Health & Social Care Partnership Integration Joint Board Notes
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Page | 28 NOTES TO THE FINANCIAL STATEMENTS Note 1. Significant Accounting Policies General Principles The financial statements summarise the transactions of the IJB for the financial year 2022/2023 and its position at 31 March 2023. The IJB was established under the requirements of the Public Bodies (Joint Working) (Scotland) Act 2014 and is a Section 106 body as defined in the Local Government (Scotland) Act 1973. It is a joint venture between North Lanarkshire Council and NHS Lanarkshire. The financial statements are therefore prepared in compliance with the Code of Practice on Local Authority Accounting in the United Kingdom 2022/2023, supported by the International Financial Reporting Standards (IFRS), unless legislation or statutory guidance requires different treatment. Each partner complies with their accounting policies as appropriate. The accounts are prepared on a going concern basis, which assumes that the IJB will continue in operational existence for the foreseeable future. The historical cost convention has been adopted. Accruals of Income and Expenditure Activity is accounted for in the year that it takes place, not simply when settlement in cash occurs. In particular: Expenditure is recognised when goods or services are received, and their benefits are used by the IJB. Income is recognised when the IJB has a right to the income, for instance, by meeting any terms and conditions required to earn the income and receipt of the income is probable. Where income and expenditure have been recognised but settlement in cash has not taken place, a debtor or creditor is recorded in the balance sheet. Where debts may not be received, the balance of debtors is written down. Funding The IJB is primarily funded through funding contributions from its statutory funding partners, North Lanarkshire Council and NHS Lanarkshire. Expenditure is incurred as the IJB commissions specified health and social care services from the funding partners for the benefit of service recipients in North Lanarkshire and service recipients in South Lanarkshire, for services that are delivered under hosted arrangements. Cash and Cash Equivalents The IJB does not operate a bank account or hold cash. All transactions are settled on behalf of the IJB by the funding partners. Consequently, the IJB does not present a ‘Cash and Cash Equivalent’ figure on the balance sheet. There is therefore no requirement for the IJB to produce a cash flow statement. The funding balance due to or from each funding partner as at 31 March 2023 is represented as a debtor or creditor on the IJB’s balance sheet.
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Page | 29 Employee Benefit The IJB does not directly employ staff. Staff are formally employed by the funding partners who retain the liability for pension benefits payable in the future. The IJB therefore does not present a Pensions Liability on its balance sheet. The IJB has a legal responsibility to appoint a Chief Officer. A Chief Finance Officer has also been appointed to the IJB. More details on these arrangements are provided in the remuneration report. The charges for the employing partners are treated as employee costs. Where material, the absence entitlement at 31 March is accrued, for example in relation to annual leave earned but not yet taken. In the case of North Lanarkshire IJB any annual leave earned by the Chief Officer and Chief Finance Officer, but not yet taken is not considered to be material. Provisions, Contingent Liabilities and Contingent Assets Provisions are liabilities of uncertain timing or amount. A provision is recognised as a liability on the balance sheet when there is an obligation on 31 March due to a past event, settlement of the obligation is probable, and a reliable estimate of the amount can be made. Recognition of a provision will result in expenditure being charged to the Comprehensive Income and Expenditure Statement and will normally be a charge to the General Fund. A contingent liability is a possible liability arising from events on or before 31 March, whose existence will only be confirmed by later events. A provision that cannot be reasonably estimated, or where settlement is not probable, is treated as a contingent liability. A contingent liability is not recognised in the IJB’s balance sheet but is disclosed in a note where it is material. A contingent asset is a possible asset arising from events on or before 31 March, whose existence will only be confirmed by later events. A contingent asset is not recognised in the IJB’s balance sheet but is disclosed in a note only if it is probable to arise and can be reliably measured. Indemnity Insurance / Clinical and Medical Negligence The IJB has indemnity insurance for costs relating primarily to potential claim liabilities regarding board member and officer responsibilities through the Clinical Negligence and Other Risks Indemnity Scheme (CNORIS). North Lanarkshire Council and NHS Lanarkshire have responsibility for claims in respect of the services for which they are statutorily responsible for and that they provide. Unlike NHS Boards, the IJB does not have any ‘shared risk’ exposure from participation in CNORIS. The IJB participation in the scheme is therefore analogous to normal insurance arrangements. Known claims are assessed as to the value and probability of settlement. Where it is material, the overall expected value of known claims taking probability of settlement into consideration, is provided for in the IJB balance sheet. The likelihood of receipt of an insurance settlement to cover any claims is separately assessed and where material, presented as either a debtor or disclosed as a contingent asset. Debtors and Creditors Financial instruments are recognised in the balance sheet when an obligation is identified and released as that obligation is fulfilled. Debtors are held at fair value and represent funding due from partner bodies that was not utilised in year. There are no creditor balances.
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Page | 30 Reserves A reserve is the accumulation of surpluses, deficits, and appropriation over a number of years. Reserves of a revenue nature are available and can be spent or earmarked at the discretion of the IJB. Reserves should be split between usable and unusable on the balance sheet. As at 31 March 2023, the usable reserve balance totals £97.946m. There are no unusable reserves. Specific Service Income Income may be received from individuals as a contribution towards the cost of their social care service. The amount collected is allocated to the relevant expenditure category and the net cost is reported in the Comprehensive Income and Expenditure Statement. This is the basis upon which the 2022/2023 annual accounts have been prepared. Note 2. Critical Judgements and Estimation Uncertainty In preparing the 2022/2023 financial statements, the IJB has had to make certain judgements about complex transactions or those involving uncertainty about future events. The critical judgments made in the annual accounts are: Hosted Services Within Lanarkshire, each IJB has operational responsibility for the services which it hosts on behalf of the other IJB. In delivering these services each IJB has primary responsibility for the provision of the services and bears the risk and reward associated with this service delivery in terms of demand and the financial resources required. As such the IJB is considered to be acting as ‘principle’, and the full costs are reflected within the annual accounts for the services which it hosts. This is the basis on which North Lanarkshire IJB accounts have been prepared. Hospital Acute Services (Set‐Aside) The legislation sets out that Integration Authorities are responsible for the strategic planning of hospital services most commonly associated with the emergency care pathway along with primary and community health care and social care services. As the emergency care services in large hospitals, both within Lanarkshire and out of region, are used by the residents of multiple IJBs and are delivered using resources shared with other hospital services, estimating the resource used by each IJB each year involves a complex allocation methodology. This is enabled by NHS Public Health Scotland (PHS) and involves apportioning the hospital expenditure to individual patient episodes, separating out episodes for services delegated to the IJB from those that are not, and assigning these to the relevant IJB based on postcode. The complexity of this exercise means the results are produced at a time lag of over a year. Note 3. Events After the Balance Sheet Date The Chief Finance Officer authorised the unaudited annual accounts for issue on 21 June 2023. Events after the balance sheet date are those events that occur between the end of the reporting period and the date when the statements are authorised for issue. Where events take place before the date of authorisation and provide information about conditions existing as at 31 March 2023, the figures in the financial statements and notes would be adjusted in all material aspects to reflect the impact of this information. There have been no material events since the date of the balance sheet which require revision to the figures in the annual accounts.
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Page | 31 Note 4. Expenditure and Income Analysis by Nature The following table shows the gross expenditure and income for North Lanarkshire IJB against subjective headings: Note 5. Taxation and Non‐Specific Grant Income The following table shows the funding contribution from the two partner organisations: The funding contribution from the NHS Board shown above includes £69.120m in respect of ‘Set Aside’ resources relating to acute hospital services. These are provided by NHS Lanarkshire which retains responsibility for managing the costs of providing these services. The IJB however has responsibility for the consumption and level of demand placed on these resources. Excluded from the funding contribution from the partners above is any specific service income contributions from clients towards the cost of their social care services. In 2022/2023 this income totalled £2.280m and is presented as gross income in the Cost of Services within the Comprehensive Income and Expenditure Statement on page 25. 2021/2022 2022/2023 £m £m Social Care Services 202.610 236.972 Health Care Services ‐ Localities 58.073 58.422 Health Care Services ‐ Area Wide 11.010 11.189 Health Care Services ‐ Out of Area 4.990 4.917 Family Health Services 109.652 115.625 Housing Services 1.668 1.886 Transport Services 0.539 0.551 Hosted Services ‐ Led by North IJB 114.573 125.402 Hosted Services ‐ Led by South IJB 34.553 34.240 IJB Operating Costs 0.214 0.247 Prescribing Costs 68.739 71.332 Covid‐19 Costs 13.412 7.072 Set Aside 65.164 69.120 Income (3.800) (4.717) Total Cost of Services 681.397 732.256 Partners Funding Contributions and Non‐Specific Grant Income (702.633) (709.408) Covid‐19 Funding (45.098) (1.342) (Surplus)/Deficit on Provision of Services (66.334) 21.506 Expenditure and Income Analysis by Nature 2021/2022 2022/2023 £m £m Funding Contribution from NHS Lanarkshire (537.845) (523.649) Funding Contribution from North Lanarkshire Council (164.788) (185.759) Total (702.633) (709.408) Taxation and Non‐Specific Grant Income
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Page | 32 Note 6. IJB Operating Costs North Lanarkshire Council and NHS Lanarkshire provide a range of support services for the IJB including finance, personnel, planning, audit, payroll, debtor, and creditor services. There is no charge to the IJB for these support services. The costs associated with running the IJB are shown in the following table: Note 7. Short Term Debtors and Creditors At 31 March 2023, North Lanarkshire IJB had short term debtors of £97.946m relating to the reserves held in the Balance Sheet. There were no short‐term creditors. Amounts owed by funding partners are stated on a net basis and are classified as short‐term debtors on the basis that these reserves could be utilised at any time. Note 8. Usable Reserves: General Fund The purposes of the General Fund are detailed in the IJB Reserves Policy8 and summarised below: Funding received for a specific purpose and not yet spent will be allocated to a ring‐fences reserve. Funding for future expenditure needs and key financial risks will be allocated to earmarked reserves. A contingency reserve is required to cushion the impact of unexpected events or emergencies. At 31 March 2023 the IJB created earmarked reserves to support the delivery of projects which span financial years and ring‐fenced reserves to enable the IJB to deliver on specific Scottish Government funded programmes. In addition, the contingency reserve has been increased as part of the financial strategy of the IJB. This will be used to manage the risk of any future unanticipated events and support service provision that may materially impact on the financial position of the IJB in later years. 8 IJB Reserves Policy 2021/2022 2022/2023 £m £m Staff Costs 0.183 0.213 Audit Fees 0.028 0.031 Administration Costs 0.003 0.003 Total 0.214 0.247 IJB Operating Costs (Corporate Services) 2021/2022 2022/2023 £m £m NHS Lanarkshire 87.533 62.180 North Lanarkshire Council 31.919 35.766 Total 119.452 97.946 2021/2022 2022/2023 £m £m NHS Lanarkshire ‐ ‐ North Lanarkshire Council ‐ ‐ Total ‐ ‐ Short Term Debtors Short Term Creditors
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Page | 33 The following table shows how reserves are allocated: Note 9. Related Party Transactions The IJB has related party transactions with North Lanarkshire Council and NHS Lanarkshire. In particular the nature of the partnership means that the IJB may influence and be influenced by its partners. Non‐voting board members are not directly employed by NHS Lanarkshire however, a contribution of 50% of the cost of the Chief Officer is made by NHS Lanarkshire along with the full cost of the Chief Finance Officer. This payment is included in the IJB Operating Costs (Corporate Services) in the Comprehensive Income and Expenditure Statement and detailed at Note 6. The financial information contained in the IJB annual accounts excludes any values associated with transactions between each of the partners. This has been removed to prevent double counting. Scottish Government Ring‐Fenced Reserves £m £m Alcohol and Drug Partnership Funding 1.187 3.348 Blood‐Borne Viruses Services ‐ 0.171 Children and Adolescent Mental Health Services 0.900 4.101 Community Living Change Fund 1.298 1.298 Covid‐19 Funding 31.686 0.771 District Nursing ‐ Scottish Government Funded 0.128 0.376 Hospital at Home Services ‐ Support Development ‐ 0.621 Mental Health and Learning Disability Services 0.730 11.290 North Planning Band 2‐4 Posts & Pharmacy Training ‐ 1.106 Ring‐Fenced Reserves ‐ Other Services 1.748 4.495 Scottish Government Ring‐Fenced Reserves Total 37.677 27.577 Earmarked Reserves £m £m Adult Social Care Winter Preparedness Fund 1.941 1.941 Carers Act Support 0.580 2.643 Children and Adolescent Mental Health Services 0.717 0.346 Digital and IT Strategy 0.566 5.630 Earmarked Reserves ‐ Other Services 46.481 5.263 Home Support Resilience 0.217 3.498 Integrated Authority Support 6.076 4.926 IJB Financial Plan 2023/2026 6.818 8.947 Minor Repair and Replacement Programme of Works 1.387 3.390 Social Care Services 4.832 5.216 Speech, Language and Therapy Services 0.807 ‐ Winter Funding Business Case 0.308 5.608 Earmarked Reserves Total 70.730 47.408 Contingency Reserve Total 11.045 22.961 Total North Lanarkshire IJB Reserves 119.452 97.946 USEABLE RESERVES 2021/2022 2022/2023
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Page | 34 The following transactions and balances included in the IJB annual accounts are presented to provide additional information on related party relationships. Note 10. Covid‐19 Costs and Funding The following table shows how additional funding provided by Scottish Government in response to supporting the remobilisation of services and continuing Covid‐19 pressures has been utilised in 2022/2023. The remaining balance of £7k will be carried forward into 2023/2024 to provide PPE to unpaid carers: *Uncommitted Covid‐19 funding totalling £25.916m has been returned to Scottish Government via a local transfer between North Lanarkshire IJB and NHS Lanarkshire. 2021/2022 2022/2023 £m £m NHS Lanarkshire ‐ North Lanarkshire Council (3.800) (4.717) Total (3.800) (4.717) 2021/2022 2022/2023 £m £m NHS Lanarkshire 472.132 496.010 North Lanarkshire Council 213.065 240.964 Total 685.197 736.974 2021/2022 2022/2023 £m £m NHS Lanarkshire (537.845) (523.649) North Lanarkshire Council (164.788) (185.759) Covid‐19 Funding (45.098) (1.342) Total (747.731) (710.750) 2021/2022 2022/2023 £m £m NHS Lanarkshire 87.533 62.180 North Lanarkshire Council 31.919 35.766 Total 119.452 97.946 Income Received Expenditure on Services Provided Funding Contributions Received Debtors NHS Lanarkshire Funding (31.686) North Lanarkshire Council Funding (1.342) Uncommitted Funding Returned to Scottish Government* 25.916 Adjustment to Covid‐19 Reserve 0.033 NHS Lanarkshire Costs 5.730 North Lanarkshire Council Costs 1.342 Total Covid‐19 Costs 2022/2023 7.072 Balance as at 31/03/2023 (0.007) £mDescription 2022/2023
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Page | 35 Note 11. Hosted Services North Lanarkshire IJB act as the lead for a number of delegated services on behalf of South Lanarkshire IJB. It therefore commissions services on behalf of South Lanarkshire IJB and reclaims the costs involved. Since North Lanarkshire IJB is acting as ‘principle’ in these transactions, the total gross expenditure and the consequential reimbursement is included in the Comprehensive Income and Expenditure Statement even though 49% of the hosted budget is consumed by South Lanarkshire. Similarly, South Lanarkshire IJB acts as the lead for a number of delegated services on behalf of North Lanarkshire IJB. The value consumed by North Lanarkshire equates to 51% of South Lanarkshire IJB hosted budget. As this expenditure is incurred for the residents of North Lanarkshire, it is included in the Comprehensive Income and Expenditure Statement. North Lanarkshire Services 2021/2022 Consumed by South Lanarkshire 2021/2022 North Lanarkshire Services 2022/2023 Consumed by South Lanarkshire 2022/2023 £m £m £m £m 1.364 0.739 Blood Borne Virus Services 1.535 0.764 7.157 6.097 Children and Adolescents Mental Health Services 11.127 7.193 11.513 5.619 Childrens Services 12.220 6.035 2.216 1.099 Continence Services 2.452 1.177 3.519 1.864 Dietetics Services 3.753 1.996 2.178 1.264 Hospital at Home 2.166 1.277 3.564 1.077 Immunisation Services 2.473 0.940 ‐ 0.278 Integrated Equipment and Adaptation Store ‐ 0.278 68.844 38.312 Mental Health and Learning Disability Services 74.366 41.490 4.045 2.118 Podiatry Services 4.434 2.250 1.724 0.984 Prisoner Healthcare Services 1.908 0.874 2.809 1.442 Sexual Health Services 2.974 1.541 5.640 2.962 Speech and Language Therapy Services 5.994 3.195 114.573 63.855 Total Services Hosted by North Lanarkshire IJB 125.402 69.010 Host: North Lanarkshire Service Consumed by North Lanarkshire 2021/2022 South Lanarkshire Services 2021/2022 Consumed by North Lanarkshire 2022/2023 South Lanarkshire Services 2022/2023 £m £m £m £m 3.758 6.508 Community Dental Services 4.007 7.081 ‐ ‐ Brain Injury Unit 1.396 1.856 2.929 3.960 Diabetic Services 2.649 5.113 ‐ ‐ Improving Cancer Journey 0.024 0.047 5.180 9.057 Occupational Therapy Services 4.350 7.909 4.509 8.126 Out of Hours Services 4.806 9.003 3.770 7.541 Palliative Care Services 3.738 7.412 5.148 9.632 Physiotherapy Services 5.536 10.427 ‐ ‐ Telehealth 0.362 0.319 0.389 0.657 Primary Care Services 0.452 0.810 8.656 7.177 Primary Care Improvement Fund 6.920 10.973 0.214 0.420 Primary Care Transformation Fund ‐ ‐ 34.553 53.078 Total Services Hosted by South Lanarkshire IJB 34.240 60.950 Host: South Lanarkshire Service
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Page | 36 The table below shows the total of hosted services included in the Comprehensive Income and Expenditure Statement: 2021/2022 £m Hosted Services 2022/2023 £m 114.573 Total Services Hosted by North Lanarkshire IJB 125.402 34.553 Total Services Hosted by South Lanarkshire IJB 34.240 149.126 Total Included in Comprehensive Income and Expenditure Statement 159.642 Note 12. Additional Council Services Delegated to the IJB The following table shows the costs of North Lanarkshire Council services delegated to the IJB. Under the Public Bodies (Joint Working) (Scotland) Act 2014, the IJB is accountable for these services however, they continue to be delivered by North Lanarkshire Council. HSCP monitor the delivery of these services on behalf of the IJB. Note 13. VAT The IJB is not VAT registered and does not charge or recover VAT on its functions. The VAT treatment of expenditure and income within the accounts depends on which of the partner is providing the service as these bodies are treated differently for VAT purposes: Where North Lanarkshire Council is the provider, income and expenditure exclude any amounts related to VAT, as collected VAT is payable to HM Revenue & Customs and all VAT paid is recoverable from it. On a very limited number of items that North Lanarkshire Council are not entitled to fully recover VAT, expenditure for these specific items will include the full cost to the IJB. Where NHS Lanarkshire is the provider, expenditure will include the full cost to the IJB as generally, NHS Lanarkshire cannot recover VAT. The services provided by the Chief Officer to the IJB are outside the scope of VAT as they are undertaken under a specific legal regime. Note 14. External Audit Costs Fees payable to Audit Scotland in respect of external audit services undertaken in accordance with Audit Scotland’s Code of Audit Practice in 2022/23 are £31,470. Audit Scotland did not undertake any non‐audit services. Note 15. New Standard Issued but Not Yet Adopted The Code requires the disclosure of information relating to the impact of an accounting change that will be required by a new standard that has been issued but not yet adopted. The IJB considers that there are no such standards which would have significant impact on its annual accounts. 2021/2022 2022/2023 £m £m 1.668 Housing Services 1.886 0.539 Transport Services 0.551 2.207 Gross Expenditure 2.437 (2.207) Income (2.437) ‐ Net Expenditure ‐ Council Services
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REPORT Item No: 7 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 update on the results of the planned Internal Audit assignment to follow-up the status of the recommendations agreed in respect of previous internal and external audit reports. 2. ROUTE TO THE PERFORMANCE, FINANCE AND AUDIT COMMITTEE 2.1 This paper has been: Prepared By: Audit Team, North Lanarkshire Council ☒ Reviewed By: Chief Finance Officer ☒ Endorsed By: Chief Officer ☒ 3. RECOMMENDATIONS 3.1 It is recommended that the PFA Committee: (1) Acknowledge the contents of the report. 4. VARIATIONS TO DIRECTIONS 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 This report presents the results of the recently completed internal audit work undertaken by North Lanarkshire Council (NLC) and to provide an update on the results of follow-up work which reviewed the extent to which management have implemented those actions previously committed to in response to recommendations contained in previous internal and external audit reports. 5.2 The lead for this audit was the Audit and Risk Manager for NLC. The completed audit report is attached as an appendix. 6. CONCLUSIONS 6.1 The outcome of the follow-up audit concluded the following: 19 agreed actions have been completed. 8 agreed actions are partially implemented (4 of these actions being the same risk) 1 agreed action is not yet due. 3 agreed actions are no longer relevant. SUBJECT: Internal Audit Report – Follow-up Actions TO: Performance, Finance and Audit Committee Lead Officer for Report: Ross McGuffie, Chief Officer Author(s) of Report Amanda Kilburn, Chief Financial Officer DATE: 21 June 2023 Yes No N/A 1
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6.2 Internal Audit concluded that management have taken significant action to appropriately address most of the weaknesses/improvement areas in audit outputs. 6.3 Where Internal Audit consider the actions taken by management are only partially implemented, an action plan has been agreed and is included in the attached report. These actions will be monitored in a report on agreed actions with progress reported to the PFA Committee throughout the year. 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) None. 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 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. 2
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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 ☒ 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 – Internal Audit Report – Follow-Up Actions Chief Finance Officer Members seeking further information about any aspect of this report, please contact Amanda Kilburn on telephone number 07816 126362. 3
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Https://nlcgov.sharepoint.com/sites/AUR-INTERNALAUDITFILES/Shared Documents/Recurring/IJB/2022-23/0500_2023_003 IJB Follow Up/A - Findings and Reporting/A04a 20230606 IJB Follow-Up Final Report v1.0 as issued.docx 1 INTERNAL AUDIT REPORT FOLLOW-UP OF ACTIONS PREVIOUSLY AGREED BY MANAGEMENT IN RESPONSE TO AUDIT RECOMMENDATIONS Contents 1. Work undertaken 2. Summary of progress made on previous recommendations Appendix 1: Management actions assessed as ‘not yet complete’ Appendix 2: Residual risk rating definition Issued to: Chief Officer (North Lanarkshire HSCP) Copied to: Chief Finance Officer Headlines The purpose of this report is to update the Integrated Joint Board (IJB) on the results of Internal Audit’s follow-up work which reviewed the extent to which management have implemented those actions previously committed to in response to recommendations contained in previous Internal and External Audit reports. Information is contained in respect of the last three years External Audit Annual Reports and those actions agreed in response to ‘Red’ and ‘Amber’ Internal Audit recommendations from reports issued. We have also included an assessment of the current position in respect of improvement actions identified by management in the last three years’ Annual Governance Statements (AGS). The status of each agreed action is based on the position as at the time of audit fieldwork which was undertaken in February and March 2023. An update on progress to date regarding the agreed actions was reported to the Performance, Finance and Audit Committee on 19 April 2023, thereafter reviewed by Internal Audit and our assessment of progress updated accordingly. Overall, we have assessed that 19 of the 31 agreed actions have been completed, nine are partially implemented, two are no longer relevant and one where the agreed target timescales are not yet due. One of the actions categorised as being no longer relevant relates to an action in a previous year’s AGS and has been superseded by a similar action in the most recent AGS (2021/22). The other action categorised as no longer relevant relates to action previously included in the AGS which related to the South Lanarkshire IJB as opposed to that of North Lanarkshire. We were pleased to note that management have taken significant action to appropriately address most of the weaknesses/improvement areas in audit outputs. Of the nine actions assessed as partially implemented, four relate to the finalisation of the Service Level Agreement for Children, Families and Justice Services and one relates to the National Care Service proposals. Progression of each of these has been hindered by the uncertainties and delays around the development of the National Care Service proposals and the impacts that may arise as a result. A summary of progress made on previous recommendations is contained at Section 2 of this report. Appendix 1 provides full details of the management actions assessed as ‘not yet complete’. Report status FINAL Audit Ref 0500/2023/003 Date issued 06/06/2023 Audit Team Lynn McCrum and Paula Hendry 4 Appendix 1
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Https://nlcgov.sharepoint.com/sites/AUR-INTERNALAUDITFILES/Shared Documents/Recurring/IJB/2022-23/0500_2023_003 IJB Follow Up/A - Findings and Reporting/A04a 20230606 IJB Follow-Up Final Report v1.0 as issued.docx 2 1. Work undertaken All Internal and External Audit reports contain management responses to audit recommendations which generally include a commitment to specific actions by a stated timescale. The purpose of this report is to update the IJB on the results of Internal Audit’s follow-up work reviewing the extent to which management have implemented those actions previously committed to in response to audit recommendations. Information is contained in respect of the 2019-20, 2020-21 and 2021-22 External Audit Annual Reports and the three Internal Audit reports, with recommendations, issued during 2018-19 and 2019-20. We have also included an assessment of the current position in respect of continuous improvement actions identified by management in the 2019-20, 2020-21 and 2021-22 Annual Governance Statements (AGS) and in the self- evaluation of the North Lanarkshire Health and Social Care Integration Joint Board exercise undertaken in 2021/22. The internal audit reports included within this review are: • Risk maturity assessment (issued August 2019); • Performance management (issued August 2019); and • Due Diligence (issued May 2020). The status of each agreed action is based on the position as at the time of audit fieldwork which was conducted during February and March 2023. An update on progress to date regarding the agreed actions was reported to the Performance, Finance and Audit Committee on 19 April 2023 and thereafter reviewed by Internal Audit and our assessment of progress updated accordingly. The updates on progress to date have been verified on a sample basis by Internal Audit during the preparation of this report. However, it should be noted that this review has focussed on whether planned actions have been completed as previously committed to and has not included detailed testing of whether the implemented actions have been effective in addressing the previous identified weaknesses. This engagement has been conducted by the Internal Audit team at North Lanarkshire Council in accordance with the ‘Public Sector Internal Audit Standards’. The Internal Audit section periodically reports formally on conformance with these standards to the Council’s Audit and Scrutiny Panel. 2. Summary of progress made on previous recommendations 2.1 Table 1 below shows whether management have implemented those actions previously agreed to in response to External Audit recommendations, ‘Red’ and ‘Amber’ Internal Audit recommendations and continuous improvement actions identified by management in the Annual Governance Statements and the self-evaluation exercise undertaken in 2021/22. Overall, 19 of the agreed actions have been completed, eight are partially implemented, three are no longer relevant and the target timescale for the remaining action has not yet passed. Table 1 Source Report Complete Partially implemented Not yet due No longer relevant Total Internal Audit 3 5 0 0 8 External Audit 6 1 1 0 8 Actions in AGS 7 2 0 3 12 Self-evaluation exercise 3 0 0 0 3 TOTAL 19 8 1 3 31 2.2 Internal Audit has reviewed the management progress updates as reported to the Performance, Finance and Audit Committee in April 2023 and the revised implementation dates for all nine recommendations which are partially implemented as listed in Table 1 above. Internal Audit then assessed the significance of non-implementation for recommendations which were not fully implemented to determine the residual risk remaining in relation to the outstanding aspects of the original recommendation. Definitions of the residual risk ratings are provided at Appendix 2. 2.3 Detail in respect of each of these recommendations and the current residual risk assessed by Internal Audit is provided in Appendix 1. In this appendix, we have also made suggestions as to how the Board may wish to consider these issues. 5
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Https://nlcgov.sharepoint.com/sites/AUR-INTERNALAUDITFILES/Shared Documents/Recurring/IJB/2022-23/0500_2023_003 IJB Follow Up/A - Findings and Reporting/A04a 20230606 IJB Follow-Up Final Report v1.0 as issued.docx 3 Appendix 1 Management actions assessed as ‘not yet complete’ Report Details Details from original recommendation Current position per management update Original and revised timescales Internal Audit comment INTERNAL AUDIT Financial due diligence (May 2020) – 2 actions EXTERNAL AUDIT Annual Audit Report 2019/20 – 1 action ANNUAL GOVERNANCE STATEMENT Continuous improvement actions for 2019/20 – 1 action 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. The budget disaggregation exercise has been concluded and the revised IJB direction to NLC issued in 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 NLC Adult Health and Social Care Committee, the NLC Education and Families Committee and the IJB for approval. The Service Level Agreement between Children, Families and Justice Services will be revisited once further clarity has been obtained around what services will be part of the new National Care Service. Original timescale: March 2021 Revised timescales: September 2021 June 2022 Revised timescale to be determined once further clarity obtained regarding National Care Service proposals We are pleased to note that the budget disaggregation exercise has been concluded. We acknowledge that Covid has had a significant impact on the Health and Social Care Partnership which has in turn impacted on the prioritisation of resources. In addition, we acknowledge that further clarity around the services which will be part of the National Care Service is required before the Service Level Agreement between Children, Families and Justice Services can sensibly be finalised. Given the delays in implementation of the remaining actions, we assess the residual risk as ‘High’ and suggest that the Board may wish to consider noting the progress made to date but also request an update on this issue from relevant senior management at the next meeting of the Performance, Finance and Audit Committee. INTERNAL AUDIT REPORT Performance management (August 2019) 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 The Annual Performance Report presented to the Performance, Finance and Audit Committee in February 2022 includes details of the targets and trajectories set for the indicators on the performance scorecard. There is however currently no formal record detailing the rationale for the targets and trajectories set for the indicators on the performance scorecard. The action will now be progressed with a view to completion and reporting to the Performance, Finance & Audit Committee by September 2023. Original timescale: October 2019 Revised timescales: March 2022 September 2023 We were 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 we assess the residual risk as ‘Medium’ and consider it important that the agreed revised timescale of September 2023 is achieved, We suggest that the Board may wish to consider noting the progress made to date and to monitor implementation going forward. 6
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Https://nlcgov.sharepoint.com/sites/AUR-INTERNALAUDITFILES/Shared Documents/Recurring/IJB/2022-23/0500_2023_003 IJB Follow Up/A - Findings and Reporting/A04a 20230606 IJB Follow-Up Final Report v1.0 as issued.docx 4 Appendix 1 (continued) Management actions assessed as ‘not yet complete’ Report Details Details from original recommendation Current position per management update Original and revised timescales Internal Audit comment INTERNAL AUDIT REPORT Performance management (August 2019) Risk: The IJB may not provide adequate performance information to key stakeholders to enable the, to make informed decisions and recommend remedial actions to address concerns arising. The IJB 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, i.e.: • 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 Areas for improvement identified within the performance framework are now reported to the Performance, Finance and Audit Committee, together with proposed actions and progress. The reports do not, however, specifically reference timescales. The annual performance report was submitted to the Performance, Finance and Audit Committee in February 2023 together with a performance update report which included key performance indicators and measures. This report demonstrated that there has been a greater use of benchmarking with other IJBs and trend information. In August 2022, the IJB’s Performance, Audit and Finance Committee endorsed the development of a revised whole system performance framework for the partnership. This will address all outstanding points raised in the finding and will include whole system performance reports that will allow Committee members to exercise effective oversight, scrutiny and challenge. The range of associated performance measures within both the national outcome indicators and the local performance framework will be refreshed alongside the development of the Strategic Commissioning Plan 2023-26 and the continued development of the Programme of Work. Original timescale: October 2019 Revised timescales: March 2022 September 2023 We were 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, We 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 action is required to further improve the control environment we assess the residual risk as ‘Medium’ and consider it important that the agreed revised timescale of September 2023 is achieved. We suggest that the Board may wish to consider noting the progress made to date and to monitor implementation going forward. 7
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Https://nlcgov.sharepoint.com/sites/AUR-INTERNALAUDITFILES/Shared Documents/Recurring/IJB/2022-23/0500_2023_003 IJB Follow Up/A - Findings and Reporting/A04a 20230606 IJB Follow-Up Final Report v1.0 as issued.docx 5 Appendix 1 (continued) Management actions assessed as ‘not yet complete’ Report Details Details from original recommendation Current position per management update Original and revised timescales Internal Audit comment INTERNAL AUDIT REPORT Risk maturity assessment (August 2019) 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 Performance, Finance and Audit 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 There are still a number of reports being submitted to the IJB and Performance, Finance and Audit Committee where the Risk Management section has either not been completed (i.e. it is blank) or has been omitted completely from the implications section of the report. A new IJB Reporting Template has been developed as part of the IJB Governance Documents update and this template now 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. Original timescale: March 2020 Revised timescales: June 2021 June 2022 September 2023 We were pleased to note that there is now a higher percentage of reports presented to the IJB and Performance, Finance and Audit Committee which contain a section on risk. We acknowledge that further steps are planned to increase compliance and fully address this recommendation. We consider the revised timescale to be reasonable and have assessed the residual risk for this recommendation as ‘Low’. Accordingly, we would suggest that the Board may wish to consider agreeing to note the progress made and the revised completion date. ANNUAL GOVERNANCE STATEMENT Continuous improvement actions for 2021/22 Risk: N/A Recommendation: To develop a sound understanding of the impact for the North Lanarkshire Health and Social Care Partnership (NLHSCP) of the outputs of the National Care Service legislation. Category: N/A Due to the uncertainty and lack of detail currently available, this will be revisited once further clarity has been obtained. At the time of writing this report, the Scottish Government had delayed further discussion and consultation in respect of the National Care Service legislation until after the Summer recess. Original timescale: March 2023 Revised timescale: To be determined once further clarity obtained regarding National Care Service proposals We 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, we 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. 8
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Https://nlcgov.sharepoint.com/sites/AUR-INTERNALAUDITFILES/Shared Documents/Recurring/IJB/2022-23/0500_2023_003 IJB Follow Up/A - Findings and Reporting/A04a 20230606 IJB Follow-Up Final Report v1.0 as issued.docx 6 Appendix 2 Residual risk rating definition Internal Audit Assessment of Residual Risk from non-implementation High Non-implementation of actions has the potential to significantly undermine the relevant control environment. Medium Non-implementation of actions has the potential to impact upon the achievement of the control environment. Low Other issues which require management attention but which pose less significant or less immediate impacts to the control environment. 9
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1 REPORT Item No: 8 1. PURPOSE OF REPORT 1.1 This paper is coming to the Performance, Finance and Audit (PFA) Committee for: For approval For endorsement For noting 1.2 This report provides a summary of the year-end position of the North Lanarkshire Health and Social Care Partnership (HSCP) for the financial year 2022/2023 and to seek approval for the transfer of funds to reserves. 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 year-end financial position for 2022/23; and (2) Approve the proposed transfers to General Reserves at para 7.2 and 7.3 of this report. 4. VARIATIONS TO DIRECTIONS 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 This report is based on the financial monitoring reports received from NHS Lanarkshire Director of Finance and North Lanarkshire Council Head of Financial Solutions. The position detailed in these reports is therefore based on the information contained in each partner’s respective financial systems and includes accruals and adjustments in-line with their financial policies. 6. CONCLUSIONS 6.1 Budget monitoring throughout 2022/23 has shown the IJB projecting an underspend, prior to the transfer of year-end balances to General Reserves at the financial year-end. 6.2 As detailed in the table at para 6.4, the IJB final outturn was an underspend of £35.495m. SUBJECT: Financial Monitoring Report 2022/2023 TO: Performance, Finance and Audit Committee Lead Officer for Report: Ross McGuffie, Chief Officer NHSCP Author(s) of Report Amanda Kilburn, Chief Finance Officer DATE: 21 June 2023 Yes No N/A
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2 6.3 Once all ring-fenced balances have been transferred to the relevant reserve in line with Scottish Government guidance, the revised outturn was an underspend of £14.084m. 6.4 The table below shows the 2022/23 outturn position for North Lanarkshire IJB before and after the transfer of Scottish Government and NHS Lanarkshire ring- fenced funding to reserves: Service 2022/23 £m Health Care Services £25.617m Social Care Services £9.878m Total North Lanarkshire HSCP (prior to transfer of ring-fenced reserves) £35.495m Ring-Fenced Funding (£21.411m) Revised Outturn Total 2022/2023 £14.084m 6.5 Subject to IJB approval, this underspend will be allocated to manage, on a non- recurring basis, ring-fenced commitments, additional commitments relating to the Strategic Commissioning Plan and any funding gap which is highlighted in the North Lanarkshire IJB Medium Term Financial Plan 2023-2026. 6.6 There are a number of reasons for the operational underspend of £14.084m (excluding ring-fenced funding), and these include: Employee Costs net underspend of £9.107m: as previously highlighted there are ongoing challenges in terms of recruitment and retention issues across all service areas. For a wide range of posts recruitment has been unsuccessful due to the availability of the skills mix required or the competition being offered by other private and public sectors. These are issues that are being faced by IJBs across Scotland. Payments to Other Bodies net underspend of £1.511m: the underspend is primarily due to the staff shortages and vacancies within the Care at Home sector who provide services to individuals via the self-directed support commissioning framework. There is also an underspend in package costs due to slippage in Self-Directed Support (SDS) start dates. It is anticipated these are in-year underspends only and the full budget will be required in future years. Admin Costs net underspend of £1.431m: within the carers funding there is currently an unallocated budget of £1.8m. Work is continuing to allocate this is relevant carers package in 2022/23. This has been transferred to a dedicated earmark reserve to fund carers pressures in 2023/24. Income over recovery of £6.031m: for social care is due to the drawdown of earmark reserves to offset expenditure relating to winter planning, adaptations, digital and IT and staffing costs associated with services within Muirpark.
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3 Supplies and Services net overspend of £2.531m: the overspend is due to additional purchases of PPE and staff uniform due to the increase in home support staff and costs associated with winter planning. There has also been additional expenditure in relation to aids and adaptations to meet current demand. £1.550m additional income was drawn down from earmarked reserves to offset some of this overspend and is showing in the over recovery of income. Prescribing net overspend of £1.750m: activity and cost per item within prescribing is 3.19% higher compared to 2021/2022. Due to the uncertainty around costs and prescribing activity and the three-month time lag in receiving the data, the volatility experienced within prescribing is likely to continue for the foreseeable future. 6.7 The table below shows the year-end financial position for 2022/23 for each client group separated into pay costs and non-pay costs and excluding ring-fenced reserves: 6.8 Throughout financial year 2022/2023, adjustments are made to the original budget due to additional budget allocations and budget transfers. The table below shows the funding allocations received from Scottish Government during 2022/2023: Scottish Government Allocations 2022/23 £m Multi-Disciplinary Teams 1.743 Community Extended Care Pilot 0.933 Distress Brief Intervention 0.869 ICU Bed Capacity Uplift 0.044 Hospitals at Home 0.250 District Nursing 0.608 Long Covid Support Funding 0.320 Learning Disability Health Checks 0.246 Alcohol and Drug Partnership – Tranche 1 2.179 Alcohol and Drug Partnership National Mission 0.618 Veteran 1st Point 0.126 Child Death Review 0.024 Young Patient Family Fund 0.002 Outcomes Framework 2.773 Family Nurse Practitioner Funding 1.215 Pay Budget Pay Costs Less Ring- Fenced Reserves Pay Variance Non-Pay Budget Non-Pays Costs Less Ring- Fenced Reserves Non-Pay Variance Total Under/(Over) Spend £m £m £m £m £m £m £m £m £m Adult Social Care 87.970 85.969 2.001 153.788 145.911 7.877 9.878 North West Localities 18.374 16.424 (0.404) 1.546 2.014 2.174 (0.160) 1.386 North East Localities 15.475 14.066 1.408 1.511 1.736 (0.226) 1.182 Adult Services 14.553 13.568 (0.283) 0.702 5.670 5.840 (0.170) 0.532 Childrens Services 33.203 28.302 (3.202) 1.699 3.895 4.644 (0.749) 0.950 Mental Health & Learning Disabilities 70.635 68.319 (1.216) 1.100 14.038 6.500 (7.482) 0.057 1.157 Area Wide Services 9.989 9.323 0.665 1.777 1.866 (0.088) 0.577 Other Areas 18.197 15.048 (3.165) (0.016) 78.190 72.344 (5.659) 0.187 0.171 Perscribing - - - 69.582 71.332 (1.750) (1.750) TOTAL 268.396 251.020 (8.270) 9.106 330.466 312.347 (13.141) 4.978 14.084 Client Group Year End Outturn 2022/2023
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4 Mental Health Action 15 3.929 Mental Health Outcomes Framework 2.346 Mental Health Innovation Fund 0.487 Mental Health Perinatal, Infant, Maternity and Neonatal 0.107 Neurodevelopmental Pathway Pilot 0.100 CAMHS Capacity Building for Psychological Therapies 0.845 Dementia Post Diagnostic Support 0.322 Rapid Cancer GI 0.033 Funding for Naloxone 0.031 TOTAL 20.150 7. GENERAL RESERVES 7.1 It is important for the long-term financial stability and the sustainability of the IJB that sufficient funds are held in reserve to manage unanticipated pressures from year to year. The requirement for financial reserves is acknowledged in statue and is part of a range of measures in place to ensure that s106 public bodies do not over-commit themselves financially. 7.2 In closing the annual accounts and in line with the IJB Reserves Policy, the PFA is asked to approve the transfer of an additional £35.495m to IJB reserves as detailed in appendix 4. Summary New Reserves 2022/23 (Pending PFA Approval) £m Scottish Government Ring-Fenced Reserves 18.621 Health Ring-Fenced Reserves 2.790 Total Ring-Fenced Reserves 21.411 Earmarked Reserves 6.199 Contingency Reserves 7.885 Total 35.495 7.3 The increase to reserves will continue to enable the IJB to meet its strategic objectives, and Scottish Government policy requirements. In particular, it is proposed that two new earmarked reserves are created for the following purposes: £0.650m window replacement on Mental Health wards following a contravention of health and safety law notified by the Health and Safety Executive to NHS Lanarkshire Health Board on 30th November 2022. This reserve may need to be increased as detailed costs becomes available. £3.169m social worker regrading of posts, following a range of challenges impacting on the sustainability of the social worker workforce and the consequent vulnerabilities with respect to service delivery. This reserve will cover a three-year period to allow a recurring funding solution to be identified. Additional details regarding this regrading can be found at appendix 5. 7.4 Within the ring-fenced reserves total of £21.411m, there is funding of £2.790m provided by NHS Lanarkshire for unscheduled care pressures in 2023/24. This is to assist the IJB to meet its delegated responsibilities relating to unscheduled care and is in addition to any specific Scottish Government funding such as multidisciplinary teams and Health Care Social Workers funding which the IJB is already deploying.
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5 7.5 The table below shows the final summary position for 2022/23 adjusted for the drawdown of reserves in 2022/2023 and pending approval of the new reserves detailed in appendix 4: 7.6 The IJB contingency reserves currently equate to 3% of the financial envelope. Appendix 6 shows a detailed list of all reserve movement during 2022/23. 7.7 Regular updates will be provided to the IJB throughout 2023/24 as analysis and reviews of all reserves are monitored to ensure they continue to meet on-going pressures and remain fit for purpose. 7.8 Appendix 7 shows all new reserves created in 2022/2023 including a key guidance table showing how these new reserves are aligned to our five ambition statements detailed in the Strategic Commissioning Plan 2023-2026. 8. COVID-19 RESERVES 8.1 Throughout 2022/2023 Covid-19 costs has been reported to the Scottish Government through the Lanarkshire Finance Performance Return (FPR). The Covid-19 costs incurred for the partnership in 2022/2023 totalled £7.072m. 8.2 As previously advised to the PFA Committee, £24.051m of uncommitted Covid-19 reserves were returned to the Scottish Government in January 2023. The remaining Covid-19 balance of £1.865m was also returned in April 2023, bringing the total funding reclaimed by Scottish Government to £25.916m. A small balance of £7k has been retained to provide unpaid carers with PPE. 8.3 The table below shows the movement for the financial year 2022/2023: Summary of Covid-19 Funding and Costs 2022/2023 £m NHS Lanarkshire Funding North Lanarkshire Council Funding Uncommitted Funding Returned to Scottish Government Adjustment to Covid-19 Reserve NHS Lanarkshire Costs North Lanarkshire Council Costs (31.686) (1.342) 25.916 0.033 5.730 1.342 Balance as at 31/03/2023 (0.007) Opening Balance As At 1 April 2022 Proposed Transfers To / From Reserves Drawdown from Reserves Revised Balance As At 31 March 2023 £m £m £m £m NHSL Ring-Fenced Reserves 48.998 (5.562) (15.859) 27.577 NHSL & NLC Earmarked Reserves 30.772 24.521 (7.885) 47.408 NHSL & NLC Risk-Based Reserves 13.478 2.490 (1.067) 14.901 NHSL Contingency Reserves 4.167 4.267 (0.374) 8.060 NHSL & NLC Closed Reserves 22.037 (16.029) (6.008) 0.000 119.452 9.687 (31.193) 97.946Total SUMMARYLEAD
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6 9. VACANCY POSITION 2022/2023 9.1 As highlighted throughout this report, employee costs final outturn created a significant underspend within all services. 9.2 The table below shows the full time equivalent (FTE) vacancy numbers at 31 March 2023 within each service compared against their budgeted establishment: 9.3 To help cover the vacant posts throughout 2022/2023, agency staff, bankaide, overtime and excess part time hours were used. A detailed analysis of these costs is at Appendix 8. SERVICE 2022/2023 Overtime Excess Part Time Bankaide Agency £m £m £m £m North West Locality 0.157 0.048 0.605 0.163 North East Locality 0.097 0.052 0.262 - Adult Services 0.077 0.087 0.224 0.109 Children Services 0.223 0.109 0.427 0.021 Mental Health & Learning Disabilities 0.524 0.101 2.459 3.294 Social Care Services 1.142 - - 0.179 Home Support 4.382 - - - Other 0.037 0.022 0.028 - TOTAL 6.638 0.420 4.005 3.765 10. DELEGATED SERVICES 2022/2023 10.1 The following table shows the costs of other North Lanarkshire Council services delegated to the IJB during 2022/2023. The outturn position at 31 March 2023 is breakeven for both services. Service Expenditure £m Income £m Housing 1.886 (1.886) Breakeven Transport 0.551 (0.551) Breakeven Total 2.437 (2.437) Breakeven Establishment Actual Vacancies FTE FTE FTE North West Locality 384.80 344.36 40.44 North East Locality 322.58 296.00 26.58 Adult Services 277.68 289.71 -12.03 Children Services 571.96 483.62 88.34 Mental Health 1,174.71 1,098.93 75.78 Social Care Services 834.20 653.80 180.40 Home Support 1,000.07 995.99 4.08 Other 130.28 260.79 -130.51 TOTAL 4,696.28 4,423.20 273.08 Service
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7 11. IMPLICATIONS 11.1 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 ☒ 11.2 ASSOCIATED MEASURE(S) Each partner is required to remain within their approved budgetary provision. 11.3 FINANCIAL This paper has been reviewed by Finance: Yes No N/A 11.4 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 Financial Challenges High Amanda Kilburn Prescribing Activity and Costs Very High Ross McGuffie 11.5 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 The Director of Finance of NHSL and the Head of Financial Solutions of NLC both continue to be consulted on the financial position of the NL IJB. ☐ Provide stakeholders with information on how to get involved ☐ Ensure a diverse range of engagement and participation and opportunities are in
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8 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 Financial information is shared with stakeholders on a regular basis and is provided to the PFA and IJB on a quarterly basis. ☒ 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 IJB Financial Plan and Reserves Strategy aligns and supports the IJB Strategic Commissioning Plan to ensure robust financial monitoring and scrutiny. 11.6 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 12. BACKGROUND PAPERS None. 13. APPENDICES Appendix 1 - North Lanarkshire Health and Social Care Partnership Budget Appendix 2 - Hosted Services Led by North Lanarkshire Appendix 3 - Hosted Services Led by South Lanarkshire Appendix 4 – HSCP Final Outturn 2022/23 – Transferred to Reserves Appendix 5 - Social Work Regrading of Posts Appendix 6 - North Lanarkshire IJB General Reserves 2022/2023 Appendix 7 - New Reserves Created in 2022/2023 Appendix 8 - Analysis of Additional Employee Costs Chief Finance Officer Members seeking further information about any aspect of this report, please contact Amanda Kilburn on telephone number 07816 126362.
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9 North Lanarkshire Health and Social Care Partnership Budget Appendix 1 Budget Actual Variance Expenditure 2022/2023 March 2023 March 2023 £m £m £m Health Care Services Locality and Other Services 59.075 49.424 9.651 Addiction Services 6.792 4.219 2.572 Medical and Nursing Directorate 5.644 4.805 0.839 Prescribing 69.582 71.332 (1.750) Out of Area Services 4.571 5.115 (0.544) Area Wide Services 11.766 11.189 0.577 Hosted Services 175.077 160.805 14.272 Family Health Services 115.625 115.625 0.000 Set-Aside Budget 69.120 69.120 0.000 Covid-19 5.730 5.731 (0.000) Total Expenditure - NHSL 522.982 497.365 25.617 Social Care Services Social Care Services Gross Expenditure 241.758 239.996 1.762 Social Care Services Gross Income (2.893) (11.009) 8.116 Social Care Services Net Expenditure 238.865 228.987 9.878 Housing Revenue Account Expenditure 1.870 1.870 0.000 Transport Services Expenditure 0.551 0.551 0.000 Social Care, Housing and Transport Services Net Expenditure 241.286 231.408 9.878 Total Expenditure - NHSL and NLC 764.268 728.773 35.495 Funded By: Annual Budget 2022/2023 £m NHS Lanarkshire Funding (497.820) Social Care Funding (22.964) Resource Transfer (23.421) Commissioned Services (6.721) Scottish Government Funding - Covid-19 and Remobilisation (5.730) Transfer from Reserves (Approved) (19.432) Total Funding - NHSL (576.088) NLC Funding - Social Care Services (185.759) NLC Funding - Housing Services (1.870) NLC Funding - Transport Services (0.551) Transfer from Reserves (Approved) 0.000 Total Funding - NLC (188.180) Total Funding - NHSL and NLC (764.268)
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10 Hosted Services Appendix 2 North Hosted Services March 2023 March 2023 March 2023 March 2023 March 2023 March 2023 March 2023 March 2023 March 2023 Budget Actual Variance Budget Actual Variance Budget Actual Variance 2022/2023 2022/2023 2022/2023 2022/2023 2022/2023 2022/2023 2022/2023 2022/2023 2022/2023 £m £m £m £m £m £m £m £m £m Sexual Health Services 3.146 2.974 0.171 1.604 1.433 0.171 1.541 1.541 0.000 Continence Services 2.402 2.452 (0.050) 1.225 1.275 (0.050) 1.177 1.177 0.000 Immunisation Services 1.918 2.473 (0.556) 0.978 1.534 (0.556) 0.940 0.940 0.000 Speech and Language Therapy Services 6.520 5.994 0.525 3.325 2.800 0.525 3.195 3.195 0.000 Children and Adolescents Mental Health Services 14.679 11.127 3.552 7.486 3.934 3.552 7.193 7.193 0.000 Childrens Services 12.316 12.220 0.096 6.281 6.185 0.096 6.035 6.035 0.000 Integrated Equipment and Adaptations Store 0.567 0.710 (0.142) 0.289 0.432 (0.142) 0.278 0.278 0.000 Dietetics Services 4.074 3.753 0.321 2.078 1.757 0.321 1.996 1.996 0.000 Podiatry Services 4.592 4.434 0.158 2.342 2.184 0.158 2.250 2.250 0.000 Prisoner Healthcare Services 1.784 1.908 (0.124) 0.910 1.034 (0.124) 0.874 0.874 0.000 Blood Borne Viruses Services 1.560 1.535 0.025 0.795 0.771 0.025 0.764 0.764 0.000 Hospital at Home 2.606 2.166 0.440 1.329 0.889 0.440 1.277 1.277 0.000 Mental Health and Learning Disability Services 84.674 74.819 9.855 43.184 33.329 9.855 41.490 41.490 0.000 TOTAL 140.837 126.565 14.272 71.827 57.555 14.272 69.010 69.010 0.000 South Lanarkshire IJB - 49% ShareNorth Lanarkshire IJB - 51% Share Hosted Services Appendix 3 March 2023 March 2023 March 2023 March 2023 March 2023 March 2023 March 2023 March 2023 March 2023 Budget Actual Variance Budget Actual Variance Budget Actual Variance 2022/2023 2022/2023 2022/2023 2022/2023 2022/2023 2022/2023 2022/2023 2022/2023 2022/2023 £m £m £m £m £m £m £m £m £m Community Dental Services 7.856 7.081 0.775 4.007 4.007 0.000 3.850 3.074 0.775 Brain Injury Unit 2.737 1.856 0.881 1.396 1.396 0.000 1.341 0.460 0.881 Out of Hours Services 9.424 9.003 0.420 4.806 4.806 0.000 4.618 4.197 0.420 Palliative Care Services 7.329 7.412 (0.084) 3.738 3.738 0.000 3.591 3.675 (0.084) Physiotherapy Services 10.855 10.427 0.428 5.536 5.536 0.000 5.319 4.891 0.428 Primary Care Services 0.886 0.810 0.076 0.452 0.452 0.000 0.434 0.358 0.076 South Improving Cancer Journey 0.046 0.047 (0.001) 0.024 0.024 0.000 0.023 0.023 (0.001) Occupational Therapy Services 8.530 7.909 0.621 4.350 4.350 0.000 4.180 3.559 0.621 Diabetic Services 5.194 5.113 0.080 2.649 2.649 0.000 2.545 2.464 0.080 Telehealth 0.711 0.319 0.392 0.362 0.362 0.000 0.348 (0.044) 0.392 Sub Total 53.569 49.979 3.590 27.320 27.320 0.000 26.249 22.659 3.590 Ring Fenced Funding Primary Care Improvement Fund 13.569 10.973 2.595 6.920 6.920 0.000 6.649 4.053 2.595 Primary Care Transformation Fund 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.000 Sub Total 13.569 10.973 2.595 6.920 6.920 0.000 6.649 4.053 2.595 TOTAL 67.137 60.952 6.185 34.240 34.240 0.000 32.897 26.712 6.185 South Lanarkshire IJB - 49% ShareLed by South Partnership North Lanarkshire IJB - 51% Share
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11 Appendix 4 Scottish Government Ring- Fenced Reserve NHS Lanarkshire Ring-Fenced Reserve New Earmarked Reserves Realignment to Existing Earmarked Reserves Increase to Existing Contingency Reserves Total Underspend 2022/2023 £m £m £m £m £m £m Alcohol and Drug Partnership Funding 2.572 2.572 Area Wide Services - Refugees and Displaced Persons 0.056 0.056 Blood-Borne Viruses Services 0.025 0.025 Children and Adolescent Mental Health Services 3.201 3.201 District Nursing - Scottish Government Funded 0.376 0.376 Hospital at Home Services - Support Development 0.250 0.250 Learning Disabilities Health Checks 0.246 0.246 Long Covid Pathways 0.320 0.320 Medical Director - Child Death Review Funding 0.012 0.012 Mental Health and Learning Disability Services - Action 15 3.930 3.930 Mental Health and Learning Disability Services - Distress Brief Intervention 3.155 3.155 Mental Health Covid Clinicians (Cossette) 0.200 0.200 Mental Health - Diagnostic Support Service Dementia Post 0.322 0.322 Mental Health Eating Disorders 0.070 0.070 Mental Health Neurodevelopmental Pathways 0.100 0.100 Mental Health Perinatal, Infant, Maternity and Neonatal 0.005 0.005 Mental Health Psychology Posts 0.670 0.670 Mental Health Pharmacy Recovery Plan 0.175 0.175 NES SLA Pharmacy Training 0.173 0.173 North Planning Band 2-4 Posts 0.933 0.933 Upper GI Dietetics Band 4 0.033 0.033 Business Case - Health Care Support Workers, Multi-Disciplinary Teams 1.797 1.797 Unscheduled Care Funding 2.790 0.330 3.120 Scottish Clinical Leadership Fellowship 0.074 0.074 Adaptations Fund 0.289 0.289 Carers Act 2018 - Support 1.800 1.800 Area Wide Services - Pre School Vision Screening (0.075) (0.075) Shielding - Social Care Support Fund (0.038) (0.038) Contingency Balance Held By NHSL 3.265 3.265 Contingency Balance Held By NLC 4.620 4.620 Social Workers Regrading of Posts 3.169 3.169 Mental Health Wards Window Replacement 0.650 0.650 New Reserves 18.621 2.790 3.819 2.380 7.885 35.495 HSCP Final Outturn 2022/2023 - Transferred to Reserves
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12 Social Work Regrading of Posts - Additional Information from Chief Social Work Officer and Head of Adult Social Work Services Appendix 5 Over the past year increasing concerns around the sustainability of the frontline social work force have emerged and been further analysed and considered by the social workforce group, which provides a vehicle to consider cross-cutting professional and workforce issues for all social work care groups. In the context of growing demand and new national investment (some temporary) in posts to address both policy priorities and post Covid backlogs there has been a national shortage of social workers. Detailed local analysis of recruitment and turnover supplemented by intelligence from staff engagement identified challenges with respect both to recruitment and retention in particular of both experienced staff and frontline managers. For experienced staff both salary comparisons with neighbouring authorities and the areas relating to wide working context were identified as problematic, against which previous measures, principally the implementation of a senior practitioner scheme, were insufficiently effective. Resulting vacancy levels and the impact of turnover on experience levels and workforce balance were identified as key risks to service delivery which could not await the outcome of national discussions to address issues. It was also identified that job profiles/descriptions for frontline social workers/senior social workers were outdated and no longer reflected day to day demands, and workforce qualities required to deliver on key priorities specifically the need for empowered and trauma informed practitioners able to operate in an integrated and increasingly complex legislative environment. In response to this a number of actions were proposed and approved by the council’s corporate management team in February 2023 subject to further work on related costs and funding: Continuation of the successful Supported Year in Practice Pilot for Newly Qualified Social Workers – confirmation has since been received that this will receive grant funding from Scottish Government for a further year prior to arrangements being rolled out nationally from 2024. Further work with the council’s Training and Organisational Development Team to bring post qualifying support and training opportunities together into a coherent framework to enhance practice and professional support, CPC, career pathways and succession planning to enhance skills and ensure a clearer and more attractive offer to staff. This will be cost neutral. The re-establishment of a small scale ‘grow your own scheme’ for social workers recruiting from support and para-professional roles within the service. This will be funded for 4 years from an earmarked reserve and government funding targeted at enhancing the social work workforce. There is the potential that this may be supplemented in future by national initiatives in this area. In the interim a minimum of 6 trainees will be supported through these funds. Management initiated re-evaluation of relevant job roles though the council’s job-evaluation scheme to ensure these are reflective of current requirements and demands. This has led to the re- valuation of social worker and NLC occupational therapist roles from NLC10 to NLC11 and senior social worker and relevant team leader roles from NLC12 to NLC13 subsequently agreed in line with NLC processes through the North Lanarkshire Council Workforce Steering Group on 28 April 2023. It is anticipated that this will support the retention as well as recruitment of staff in the current market and importantly ensuring that job roles are fit for the purpose and ambition of the council/partnership. The re-evaluation for Children and Families Social Work will be funded through funding allocated to the Education and Families Service to address a range of cost pressures, whilst funding for the change within Justice will be covered from Section 27 grant. The additional cost for Adult Services will be funded from an earmarked reserve pending approval.
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13 North Lanarkshire IJB APPENDIX 6 Movement on Reserves Audit Trail NHSL & NCL Opening Balance As At 1 April 2022 Proposed Transfers To / From Reserves Drawdown from Reserves Revised Balance As At 31 March 2023 £m £m £m £m NHSL Ring-Fenced Reserves 48.998 (5.562) (15.859) 27.577 NHSL & NLC Earmarked Reserves 30.772 24.521 (7.885) 47.408 NHSL & NLC Risk-Based Reserves 13.478 2.490 (1.067) 14.901 NHSL Contingency Reserves 4.167 4.267 (0.374) 8.060 NHSL & NLC Closed Reserves 22.037 (16.029) (6.008) 0.000 119.452 9.687 (31.193) 97.946 Opening Balance As At 1 April 2022 Transfers To / From Reserves Drawdown from Reserves Revised Balance As At 31 March 2023 £m £m £m £m NHSL Alcohol and Drug Partnership Funding 3.154 2.572 (2.800) 2.926 NHSL Alcohol and Drug Partnership - Local Implementation Plan 0.167 0.167 NHSL Alcohol and Drug Partnership - Long Acting Buprenorphine 0.255 0.255 NHSL Area Wide Services - Refugees and Displaced Persons 0.400 0.056 (0.206) 0.250 NHSL Blood-Borne Viruses Services 0.146 0.025 0.171 NHSL Children and Adolescent Mental Health Services 5.333 3.201 (4.433) 4.101 NHSL Community Living Change Fund 1.298 1.298 NHSL Covid-19 Funding 29.742 (25.950) (3.785) 0.007 NHSL District Nursing - Scottish Government Funded 0.376 0.376 NHSL Hospital at Home Services - Support Development 0.414 0.250 (0.043) 0.621 NHSL Learning Disabilities Health Checks 0.246 0.246 NHSL Long Covid Pathways 0.764 0.764 NHSL Medical Director - Child Death Review Funding 0.021 0.012 (0.021) 0.012 NHSL Mental Health and Learning Disability Services - Action 15 3.019 3.930 (3.019) 3.930 NHSL Mental Health and Learning Disability Services - Distress Brief Intervention 1.552 3.155 (1.552) 3.155 NHSL Mental Health Covid Clinicians (Cossette) 0.200 0.200 NHSL Mental Health - Diagnostic Support Service Dementia Post 0.429 0.322 0.751 NHSL Mental Health Eating Disorders 0.070 0.070 NHSL Mental Health Neurodevelopmental Pathways 0.100 0.100 NHSL Mental Health Perinatal, Infant, Maternity and Neonatal 0.005 0.005 NHSL Mental Health Psychology Posts 0.670 0.670 NHSL Mental Health Recovery Renewal - Facilities Projects 1.840 1.840 NHSL Mental Health Wellbeing in Primary Care Services 0.148 0.148 NHSL Mental Health Pharmacy Recovery Plan 0.175 0.175 NHSL NES SLA Pharmacy Training 0.173 0.173 NHSL North Planning Band 2-4 Posts 0.933 0.933 NHSL Staff Wellbeing 0.254 0.254 NHSL Test and Protect Funding 0.520 0.520 NHSL Third Sector Initiatives To Improve Health 0.306 0.306 NHSL Unscheduled Care Funding 3.120 3.120 NHSL Upper GI Dietetics Band 4 0.033 0.033 48.998 (5.562) (15.859) 27.577TOTAL RING-FENCED RESERVES LEAD SUMMARY Total LEAD RING-FENCED RESERVES Opening Balance As At 1 April 2022 Transfers To / From Reserves Drawdown from Reserves Revised Balance As At 31 March 2023 £m £m £m £m NLC Long Covid Contingency 3.000 (1.051) 1.949 NHSL Prescribing Fund 4.361 4.361 NLC Social Care Demand 6.117 2.490 (0.016) 8.591 13.478 2.490 (1.067) 14.901 Opening Balance As At 1 April 2022 Transfers To / From Reserves Drawdown from Reserves Revised Balance As At 31 March 2023 £m £m £m £m NHSL Contingency Balance Held By NHSL 4.167 4.267 (0.374) 8.060 4.167 4.267 (0.374) 8.060 LEAD CONTINGENCY FUND RESERVES TOTAL RISK-BASED RESERVES LEAD RISK-BASED RESERVES TOTAL CONTINGENCY FUND RESERVES
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14 Opening Balance As At 1 April 2022 Transfers To / From Reserves Drawdown from Reserves Revised Balance As At 31 March 2023 £m £m £m £m NHSL Adult Social Care Winter Preparedness Fund 1.941 1.941 NLC Adaptations Fund 0.289 0.289 (0.289) 0.289 NLC Adult Protection (share with C&F and NHSL) 0.050 0.050 NLC Advocacy Services 0.123 0.061 (0.066) 0.118 NHSL Area Wide Services - Health Promotion - North Lanarkshire Leisure agreement 0.123 0.123 NHSL Area Wide Services - NES Training 0.132 0.132 NHSL Area Wide Services - Primary Care Corporate (iHUB Project - NES funding) 0.034 0.034 NLC Assistive Technology Contract x 12 months (ATC) 0.090 (0.082) 0.008 NHSL Breast Feeding Team (2 year funding) 0.828 0.828 NHSL Business Case - Health Care Support Workers, Multi-Disciplinary Teams 1.794 1.797 (1.794) 1.797 NLC Business Case - Non-Recurring NLC Costs 5.380 0.537 (2.106) 3.811 NHSL Care Homes Allocation 0.318 0.318 NLC Carers Act 2018 - Support 0.852 1.800 (0.009) 2.643 NHSL Champions Board Funding 0.172 0.172 NHSL Children and Adolescent Mental Health Services - Udston Top Up Funding 0.346 0.346 NHSL Childrens Services - Paediatric Band 7, Band 6 x 4.12 WTE, Band 2 x 9.59 WTE 0.645 (0.231) 0.414 NHSL Development of Chryston Community Health Clinic 0.212 0.212 NHSL Dietetics Services - Double Running Costs 0.110 0.110 NLC Digital and IT Strategy Technology Improvements - Community Alarms 0.694 (0.106) 0.588 NLC Digital and IT Strategy Technology Improvements - Home Support Scheduling System 1.000 2.776 3.776 NLC Digital and IT Strategy Technology Improvements - Other 0.566 0.566 NLC Digital and IT Strategy Technology Improvements - SWIS 0.700 0.700 NHSL Discharge Support Workers Band 4 x 2 WTE 0.107 0.107 NHSL Distinction Awards 0.036 0.036 NLC Financial Strategy - Changes to LA Services Muirpark 2.973 (1.874) 1.099 NHSL Forensic Band 3 x 5 WTE 0.147 0.147 NHSL GPIT Reprovisioning Gap 0.181 0.181 NHSL Health Inequalities - Screening 0.098 (0.027) 0.071 NHSL Health Visiting Students/Trainees 0.840 (0.356) 0.484 NLC Home Support Resilience (2 year funding) 3.498 3.498 NHSL HR Employability Team (2 year funding, 50:50 split between North and South) 0.187 0.187 NLC IJB Helpline (2 years funding) 0.600 (0.025) 0.575 NHSL Integrated Authority Support 6.076 (1.150) 4.926 NHSL Kylepark Works 1.000 0.608 (0.030) 1.578 NHSL Learning Disabilities Band 3 x 4 FTE 0.118 0.118 NLC Local Government Pay Award 23/24 2.653 2.653 NLC Mental Health Social Workers 2 x NL10 x 24 months 0.107 (0.038) 0.069 NHSL Mental Health Wards Window Replacement 0.500 0.500 NHSL Minor Capital Works 1.387 (0.225) 1.162 NHSL Neonatal & Paediatrics Dieteics Intervention (3 year funding) 0.550 0.550 NHSL Organisational Development Fund 0.260 0.260 NHSL Paediatric Diabetes Insulin Pumps and Additional Staff 0.908 (0.027) 0.881 NLC Planned Date of Discharge - Discharge To Assess 0.200 0.241 (0.137) 0.304 NLC Planned Date of Discharge - Locality Social Work Manager Post 0.055 0.096 (0.074) 0.077 NHSL Podiatry Services - Foot Screening 0.459 (0.033) 0.426 NHSL Prisioner Healthcare - Transitional Project Band 8A 0.070 0.070 NHSL Psychology Posts 2 x Band 6 0.098 0.098 NHSL Regrading of Posts Including Backpay 0.125 0.125 0.250 NHSL Scottish Clinical Leadership Fellowship 0.045 0.074 (0.019) 0.100 NHSL Sexual Health Services - Forensic Medical 0.222 (0.047) 0.175 NHSL Sexual Health Services - Long-Acting Reversible Contraception (LARC) 0.109 0.386 (0.004) 0.491 NLC Social Care Contracting Staff within Quality Assurance Services 0.047 0.028 (0.072) 0.003 NLC Social Care Regrading of Staff (SSW, SP, SW, OT, TL and TM) 3.169 3.169 NLC/NHSL Staff Training Academy 2.400 2.400 NHSL Stigma Free Lanarkshire (3 year funding) 0.450 0.450 NHSL Supervisor Training 0.077 (0.012) 0.065 NLC Unmet Saving 21/22 - IDS/LSS (merging building Coatbridge & Cumbernauld) 0.086 (0.086) 0.000 NLC Violence Against Women (Joint Initiative with SLC and C&F) 0.030 0.030 NHSL Vulnerable and Complex Cases - Test of Change 1.208 (0.116) 1.092 30.772 24.371 (7.885) 47.258 LEAD EARMARKED RESERVES TOTAL EARMARKED RESERVES 22.037 (16.029) (6.008) 0.000 119.452 9.687 (31.193) 97.946 TOTAL CLOSED RESERVES TOTAL RESERVES
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15 Reserve Title Reserve Description Pending Approval 21 June 2023 Approved by IJB 22 March 2023 Ambition Statement Key Window Replacement on Mental Health Wards To comply with the Notification of Contravention to secure patient accessible windows within Wards 19 and 20 in a closed position pending replacement of a 'Polar' ligature reduction design window. Anticipated timeline is September 2023. 2, 4 Social Worker Regrading To address the immediate and medium-term recruitment and retention challenges with a view to ensuring an empowered and effective social work workforce. This includes a revised and strengthened recruitment model, alongside further work to enhance whole career support and development allied to the wider ambitions of Workforce for the Future. 3 Breast Feeding Team To introduce a peer support model to improve breastfeeding initiation and reduce attrition and to introduce a seven-day support provision to deliver person centred care through the mother's postnatal journey from hospital discharge to one year post birth. 1, 2, 5 Development of Chryston Community Health ClinicTo fund the repatriation of services under 'The Plan for North Lanarkshire' which sets out an estates strategy to develop community hubs and campuses. 1, 5 HR Employability Team To fund a dedicated HR team within health with the cost split 50:50 between North and South Lanarkshire partnerships. 3 Long Covid Pathways To support people with long term effects of Covid-19 where their physical and mental wellbeing has suffered. This earmarked reserve will allow continued investment in recruitment to deliver improved care and support for people living with long Covid and will ensure it remains a priority. 2, 3, 4, 5 Neonatal and Paediatrics Dietetics Support To provide premature babies with dietetic intervention aimed at reducing morbidity and mortality rates, reducing length of hospital stays, improving short and long-term neurodevelopment and growth outcomes and providing support to parents/carers. 1, 2, 5 Organisational Development Fund To support the 2023/24 organisational development plan focussing heavily on sector and unit management team development. 3 Psychology Posts 2 x Band 6 To fund additional posts within Psychology to help with the substantial waiting lists by extending trainee contracts until March 2024. 3, 4 Staff Training Academy To assist the development of staff by offering apprenticeships and support to implement a HSCP 'Grow our Own' initiative in recognition of the ongoing challenges in recruitment and retention and a national shortage of key skills. 3 Stigma Free Lanarkshire To continue investment in addressing challenging mental health stigma and discrimination in line with the outcomes in the Lanarkshire Mental Health Strategy. 2, 4 Vulnerable and Complex Cases To provide co-ordinated, person-centred, care managed approach with individuals who have often become disengaged and need assistance to be re-directed and reconnected to appropriate services within the Health and Social Care settings or the community. 5 Assistive Technology 12 Month Contract To fund a 12-month contract that provides a service to the council in assessing, recommending, and procuring assistive technologies to enable our employees with a disability or impairment to maximise their ability to work effectively. 3, 4 Home Support Resilience To support the effective recruitment and retention of home support staff by maintaining and increasing the number of pool cars available to the service and offering home support worker incentives. 3, 4 IJB Cost-of-Living Helpline To maintain and enhance the existing single point of contact for advice on a range of impacts from the cost-of-living crisis. This would provide one gateway for residents to receive direct advice and where required a direct route to follow up appointments for support. 1, 4, 5 Local Government Pay Award 23/24 To assist with the on-going staffing pay pressure. This will cover 2023/24 financial year only and will be replaced by a recurring budget in 2024/25. 3 Ambition Statement Key Do The Right Thing First Time When people contact our services, we need to respond quickly and effectively, with a focus on helping people to help themselves first. We will continue to develop ‘First Point of Contact’ by incorporating good conversations across the HSCP and prioritising and embedding the whole system approach to get it right first time. 1 Increased Focus on Prevention, Early Intervention and Tackling Inequalities by Working with Communities and People The population and needs analysis highlighted the need to do things differently, to understand the demographic challenges facing North Lanarkshire and to harness the opportunities of people living healthier lives for longer. We need to keep changing the way we deliver services and support people, focusing more on prevention, early intervention, and empowering people to live fulfilling lives. By providing ‘upstream’ support at an early stage, we can reduce the demand on intensive health and care services and re-invest in more community focused support services. By working with our partners in the Third Sector, we can identify, support, and develop local community-based programmes, run by voluntary and independent organisations that focus on the health and care needs of local communities. We will continue to support and empower people to continue to live healthy, meaningful, and more personally satisfying lives as active members of their community for as long as possible by showing ambition and innovation to develop and try new ways of providing services. We value and recognise the vital role local people and communities play by continuing to ensure we listen and provide a voice to their needs and aspirations. We will continue to engage and participate with local people as we extend into the delivery of our partnership priorities. 2 Develop And Support a Workforce for The Future The increase in ageing population of North Lanarkshire is broadly mirrored within the workforce of the Health and Social Care sector, therefore it is important for us to be cognisant of this and ensure mechanisms are put in place to allow flexibility and support to our workforce to ensure their physical and mental health is nurtured. There are also continuing challenges with regards to resourcing, attracting, recruiting, and retaining staff. Whole system planning requires further development to better understand the needs and demands of communities including the public health challenges, the types of roles needed to support different care needs, and the availability of different types of workers over time and geographically. 3 Mental health concerns are continuing to increase in the population which could lead to a greater demand for mental health services and community supports. There is a need for a refreshed and reinvigorated approach to mental health improvement with the focus on the four core areas within the Lanarkshire Mental Health and Wellbeing Strategy: · Good mental health for all · Improving access to mental health supports and services · Children and young people’s mental health and wellbeing · Specialist mental health services Supporting People Through a Whole Family Approach Our aspiration is to support adults and children of all ages with the tools to set, plan and achieve their goals together. This puts wellbeing at the heart of our approach by considering the situation that adults and children live in, who they live with and their family relationships. In practice, this means understanding each person as an individual, as well as recognising the part they play in their family and community. This approach builds on people’s strengths and resilience. 5 STRATEGIC COMMISSIONING PLAN 2023-2026 AMBITION STATEMENT 4Improve Mental Health and Wellbeing Appendix 7NORTH LANARKSHIRE IJB NEW RESERVES CREATED IN 2022/2023:
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16 Analysis of Additional Employee Costs Appendix 8 North West Locality £ North East Locality £ Adult Services £ Children Services £ Mental Health £ Other £ TOTAL £ 1 44,000 32,000 17,500 35,500 209,500 2,000 340,500 2 44,000 32,000 17,500 35,500 209,500 2,000 340,500 3 53,000 34,000 22,000 30,000 205,000 3,000 347,000 4 54,000 30,000 17,000 38,000 216,000 5,000 360,000 5 49,000 33,000 17,000 41,000 212,000 4,000 356,000 6 43,000 31,000 12,000 34,000 196,000 4,000 320,000 7 53,000 32,000 17,000 43,000 221,000 6,000 372,000 8 46,000 33,000 24,000 40,000 186,000 7,000 336,000 9 51,000 -58,000 9,000 7,000 185,000 -14,000 180,000 10 56,000 21,500 25,000 39,500 202,500 3,500 348,000 11 56,000 21,500 25,000 39,500 202,500 3,500 348,000 12 56,000 20,000 21,000 44,000 214,000 2,000 357,000 TOTAL 605,000 262,000 224,000 427,000 2,459,000 28,000 4,005,000 North West Locality £ Adult Services £ Children Services £ Learning Disabiliti es £ Mental Health £ Social Care Services £ TOTAL £ 1 1,396 6,804 9,018 19,329 72,766 109,313 2 406 6,804 1,303 37,927 338,077 384,517 3 2,527 6,804 42,413 184,579 236,323 4 4,348 4,796 37,915 199,682 246,741 5 5,698 4,988 38,211 212,758 261,655 6 759 4,797 1,627 49,939 193,626 250,748 7 2,817 4,796 59,821 234,119 301,553 8 10,554 4,796 97,273 182,799 7,204 302,626 9 11,584 12,168 754 63,042 232,980 13,336 333,864 10 11,285 16,710 4,141 57,024 221,263 20,796 331,219 11 23,686 14,913 24,634 180,893 57,701 301,827 12 87,839 20,190 3,936 222,091 290,700 47,831 672,587 13 32,022 32,022 TOTAL 162,899 108,566 20,779 749,619 2,544,242 178,890 3,764,995 North West Locality £ North East Locality £ Adult Services £ Children Services £ Mental Health £ Social Care Services £ Home Support £ Other £ TOTAL £ 1 13,187 8,071 10,569 12,294 49,952 8,427 109,798 4,808 217,106 2 12,032 8,789 3,582 9,091 42,880 73,558 285,090 1,096 436,118 3 21,425 6,426 4,508 7,572 29,605 76,713 277,793 2,558 426,600 4 12,482 4,153 2,223 16,873 30,022 74,719 290,873 2,923 434,268 5 17,069 10,685 3,218 9,750 53,447 87,187 321,181 1,541 504,078 6 10,687 7,575 4,373 14,542 48,147 76,800 326,698 2,629 491,451 7 13,149 4,503 6,412 21,905 55,807 84,165 362,809 4,290 553,040 8 9,351 9,011 7,230 27,429 58,631 113,755 503,326 2,800 731,533 9 8,914 12,937 5,770 28,958 34,450 118,428 420,088 2,046 631,591 10 10,665 8,985 6,280 27,683 38,918 86,099 254,737 4,842 438,209 11 15,115 7,879 9,800 21,887 39,758 79,279 377,024 2,751 553,493 12 12,745 8,193 13,229 25,238 42,028 96,920 358,412 4,497 561,262 13 165,891 493,738 659,629 TOTAL 156,821 97,207 77,194 223,222 523,645 1,141,941 4,381,567 36,781 6,638,378 North West Locality £ North East Locality £ Adult Services £ Children Services £ Mental Health £ Other £ TOTAL £ 1 6,869 5,164 12,800 6,579 10,496 889 42,797 2 3,401 4,223 7,228 5,775 8,002 796 29,425 3 4,231 6,891 8,791 6,755 9,229 656 36,553 4 3,007 4,827 5,230 8,288 7,947 2,269 31,568 5 3,801 3,348 5,450 7,051 9,240 4,532 33,422 6 3,660 3,937 5,002 11,180 7,207 649 31,635 7 2,077 1,879 6,954 12,542 8,465 1,605 33,522 8 2,447 3,914 6,168 12,599 6,428 1,591 33,147 9 3,517 6,460 8,221 14,474 5,392 1,790 39,854 10 4,663 2,832 7,814 10,241 10,094 1,667 37,311 11 5,211 3,749 5,611 6,717 8,715 2,397 32,400 12 5,098 5,127 8,044 6,407 9,843 3,625 38,144 TOTAL 47,982 52,351 87,313 108,608 101,058 22,466 419,778 BANKAIDE COSTS 2022/2023 OVERTIME COSTS 2022/2023 AGENCY COSTS 2022/2023 EXCESS PART TIME COSTS 2022/2023 Period Period Period Period
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1 REPORT Item No: 9 SUBJECT: Resilience Response TO: Performance, Finance and Audit Committee Lead Officer for Report: Ross McGuffie, Chief Officer North HSCP Author(s) of Report Kirsty Orr, Head of Planning and Development, NHSL Ross McGuffie ,Chief Officer North HSCP DATE: 21st June 2023 1. PURPOSE OF REPORT 1.1 This paper is coming to the IJB Performance, Finance and Audit Committee: For approval For endorsement To note 1.2 This paper sets out the actions being taken in response to current whole system service pressures. 2. ROUTE TO THE IJB PERFORMANCE, FINANCE & AUDIT COMMITTEE 2.1 This paper has been: Prepared Reviewed Endorsed By the command structure in the Health and Social Care Partnership. 3. RECOMMENDATIONS 3.1 The PFA is asked to: (1) Recognise the whole system Operation Flow 2 plans and implementation structures set out in the report; (2) Request future updates on progress. 4. VARIATIONS TO DIRECTIONS 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 Background 5.1.1 NHS Lanarkshire stood down its Live Covid Incident in January 2023, however, the operational pressures emanating from the pandemic recovery have been pronounced, with NHS Lanarkshire in Black status since 27th July 2022. 5.1.2 Operation Flow was developed to create a ‘firebreak’ to rapidly reduce hospital inpatient capacity, then creating the staff capacity to work on service redesign to bring the system as a whole back into equilibrium. Yes No N/A
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2 5.1.3 Following the 9-day firebreak, hospital inpatient capacity reduced by around 15% across Lanarkshire, supporting the system to move from black to red status on 6th March 2023. 5.2 Operation Flow 5.2.1 The IJB received an update on Operation Flow at its meeting on 22nd March 2023 and again at the PFA meeting on 19th April 2023. Operation Flow is the whole system strategic planning approach in Lanarkshire aimed at supporting a sustained recovery of the entire health and social care system. 5.2.2 Following two further face to face planning sessions that brought together leaders from across the whole system, a Task and Finish structure has now been developed to take forward the key actions agreed for Operation Flow 2 (see appendix 1). 5.3 Developing and Implementing Operation Flow 2 5.3.1 As system we have been not able to sustain the improvements in the weeks following the Firebreak period. However, work does continue to support the culture and behaviour change required across our Acute sites to improve efficiency and effectiveness by embedding the flow foundation bundles and pathways 5.3.2 We know that establishing and maintaining good flow across our system is key to the success of Operation Flow 2. Consequently, we have established a task and finish group structure which is underpinned by our new 6 step Flow Model (outlined below and also in Appendix 2) to support delivery of Operation Flow 2. A project plan (appendix 3) which outlines the key objectives for Operation Flow 2 has been developed in collaboration with colleagues across the system and also takes account of the learning from Firebreak. 5.3.3 Operation FLOW 1 involved considerable whole-system development work undertaken jointly by NHS Lanarkshire, Health and Social Care North Lanarkshire, South Lanarkshire Health and Social Care Partnership and Scottish Ambulance Service and this will continue through the duration of Operation Flow 2. 5.3.4 Five Task and Finish Groups have been established to lead in the development and implementation of the key elements aligned to the new flow model. The Task and Finish Groups are accountable to the Executive Flow Oversight Board (EFOB) which reports to Corporate Management Team (CMT). 5.3.5 A summary of each of their key high level objectives is described below: Task and Finish Group 1: Core Group Provides overview and co-ordination for success Ensures Task and Finish Groups, 2, 3, 4 and 5 are on track for delivery Undertakes weekly performance review in relation to progress of attaining trajectory milestones across our 23 Acute sites and system Develop and describe the OOHs Flow Management / On call model Develop and describes the resource plan for Operation Flow 2 Ensures escalation to EFOB Task and Finish Group 2: Pre-Hospital / Avoiding Admission
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3 Describe the operational model required to reduce demand via the FNC Detail the workforce model required which supports admission avoidance and direction to other parts of our system Roll out and expansion of consultant connect for SAS to reduce conveyancing to hospital when it is safe to do so Implement the recommendations of the Strategic Review of Hospital @ Home which supports admission avoidance Development of community access pathways to support people in the community Task and Finish Group 3: Pan Lanarkshire Front Door Redesign Undertake a review of the current “as is” pathways across ED, Acute Receiving and Ambulatory Care to ensure that there is a shared understanding across the 3 sites Undertake a resource review of ED’s shift by shift and complete comparison with 2019 data Develop recommendations which details the Target Operating Model for Font Door Services across Lanarkshire Task and Finish Group 4: Ward and System Flows Establish and embed a NHS Lanarkshire standardised huddle approach and template which embeds ward, site and system level escalation processes to support flow Embed all elements of the Flow Foundation Bundle across all inpatient areas Embed ward beat as part of huddle and flow foundation bundle Develop a consistent and co-ordinated flow management model for NHS L Task and Finish Group 5: Frailty and Off site Beds Develop a Front Door Frailty Rapid Assessment Process Develop and describe the Frailty Model for NHS L Scope the “as is” offsite bed model Develop recommendations that outlines the Target Operating Model for offsite beds to support system flow 5.3.6 We have also established a Data Governance Group which oversees all aspects of system development and ensuring that NHS Lanarkshire is compliant with Public Health Scotland definitions in relation to Urgent and Unscheduled Care. 5.4 Embedding Best Practice, Accountability and Leadership 5.4.1 We know that to deliver the comprehensive plan we will need to work together to ensure that there is: Cohesive Leadership across the Lanarkshire system Ownership by all Operational Leaders in Acute, Community and Social Care, with improvement support, to deliver the pace of change required Clarified roles and responsibilities to develop and deliver the plan Clear measurable objectives across all elements of the plan to demonstrate the impact made and flexibility in our approach, if required, to deliver greater effect
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4 5.4.2 Progressing improvement work across our system is exceptionally challenging within our current resource profile, given that our system continues to be in escalation and full capacity protocols. However, we continue work together across our system to develop and implement change that will improve the efficiency and effectiveness of our system. These actions include: Implementation and embedding of the Flow Foundation Bundle to support good flow across our sectors Embedding structured Hospital Huddles to ensure situational awareness of flow, impact on patient safety and the actions required to respond to pressure Implementation of consistent Escalation triggers and processes ensuring that the is clarity in roles and responsibilities across our wards, sites, sectors and system when responded to blockages and barriers to good flow and safety Ensuring standardisation of patient flows and dispositions across our system Developing and implementing assertive and continuous flow across all our Acute sites. 5.5 Revising the Service Models to Build Capacity and Capability 5.5.1 Through learning from the Firebreak and from shared experiences from other Health Boards across Scotland, we know that there are a number of improvement actions that will require increased capacity and capability to improve flow and demonstrate a positive impact on our performance against the 4-hour target and these include: Reducing demand with Senior Clinical Decision Makers in the FNC and with the Hospital @ Home Service Increased functional site capacity with an expanded minors area in UHW and 7 day opening of Ambulatory Care units across all 3 sites supporting discharge planning co-ordination with additional administrative support to wards Increased service improvement support across the whole system Increased flow management teams within the Acute sites Tackling the blocks to flow by opening the discharge lounge over 7 days Augmented data support for Operation Flow 2 and Trakcare and ensuring that we have access to accurate real time data 5.5.2 Consequently, we are looking at opportunities for investment through internal prioritisation processes and working closely with Scottish Government colleagues around the opportunities for reinvestment to support the project deliverables but also within the context of a financially sustainable plan for NHS Lanarkshire. 5.6 Performance and Monitoring 5.6.1 We have established a robust monitoring process for Operation Flow 2. Each of the Task and Finish Group have developed project plans which outline the tasks that need to be accomplished to achieve the project goals and this detail is reported to Task and Finish Core Group each week. The overarching project plan for Operation Flow 2 provides an overview of progress against each of the high level objectives for the Task and Finish Groups which is reported to EFOB on a weekly basis. A copy of the Overarching Plan is in Appendix 3. 5.6.2 A performance management framework has been established for Operation Flow 2 which is underpinned by objectives and improvement milestones. Performance improvement trajectories have been developed for the Lanarkshire System and
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5 each of the Acute sites. We have established milestones for achievement by 30 June 2023, 31August 2023 and 31 March 2024 (see appendix 4). 5.6.3 Our key objective it to consistently improve NHS Lanarkshire’s performance against the 4-hour standard by achieving 70% against the 4-hour access performance by 31 August 2023 and 90% by 31 March 2024. Crucially, we know that this will significantly improve the clinical safety and experiences for our patients as well as health and well-being of our workforce. The impact of the project actions from each of the Task and Finish Groups will be measured against the: Weekly 4-hour access performance Weekly number 8 hour waits Weekly number of 12 hour waits Acute site occupancy levels, Ward beat rate achieved / week Discharge lunge use Pre-noon discharge rate Delayed discharges / week (Acute sites) Delayed Discharge / Week (Community Hospitals) 5.6.4 A balanced scorecard has also been developed to monitor our progress against the objectives. In addition, Each of the Task and Finish Groups have developed a data measurement framework which details the process measures to deliver the outcome measures. 6. CONCLUSIONS 6.1 There has been a tremendous whole system effort to plan Operation Flow and to enact the firebreak at scale and pace. 6.2 The reduction in occupancy levels across all three sites has allowed NHS Lanarkshire to move from black to red status on 6th March 2022, following over 6 months in black status. 6.3 Attention has now moved to make the most of the system decompression to move forwards with the ambitious change programme identified to ensure the positive performance improvements can be sustained and indeed further improved over time. 7. IMPLICATIONS 7.1 NATIONAL OUTCOMES This relates to all nine national outcomes. 7.2 ASSOCIATED MEASURE(S) A weekly performance framework has been developed to track progress. 7.3 FINANCIAL This paper has been reviewed by Finance: Yes No N/A 7.4 RISK ASSESSMENT/RISK MANAGEMENT
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6 Risk IJB 17/22 sets out the unscheduled care challenges currently being faced in the Lanarkshire system. 7.5 PEOPLE The Strategic Planning Group has increased in frequency to quarterly throughout the pandemic to support engagement with staff, service users and carers and staff roadshows have also recommenced on a quarterly basis. 7.6 INEQUALITY & FAIRER SCOTLAND DUTY Yes No N/A 8. BACKGROUND PAPERS None. 9. APPENDICES Appendix 1: Operation Flow 2 structure Appendix 2: Flow Model Appendix 3: Programme Plan Appendix 4: Performance Plan ............................................................................. CHIEF OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact Ross McGuffie on telephone number 01698 752 591.
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7 Appendix 1: Operation Flow 2 structure
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8 Appendix 2: 6 Step Flow Model
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9 Appendix 3: Project Plan
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10 Appendix 4: Improvement Milestones
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1 REPORT Item No: 10 SUBJECT: Prisoner Healthcare TO: Performance, Finance & Audit Committee Lead Officer for Report: Maggs Thomson, Head of Head, North HSCP Author(s) of Report Jim Duffy, General Manager, Adult Health Services Unit, North HSCP DATE: 21 June 2023 1. PURPOSE OF REPORT This paper is coming to the IJB for: For approval ☐ For endorsement ☐ To note ☒ 1.2 This paper sets out an overview of the Prisoner Healthcare service within North Lanarkshire 2. ROUTE TO THE BOARD This paper has been: Prepared By: ☒ Reviewed By: ☒ Endorsed By: ☐ Prepared by J Duffy General Manager, Adult Health Services Unit, North H&SCP. Reviewed by M Thomson
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2 3. RECOMMENDATIONS 3.1 It is recommended that the IJB for Performance, Finance and Audit Committee supports; (1) The creation of a Project Board, overseeing the implementation of improvement plans relating to HIS recommendations, internal Service Review actions and MATS Standards. (2) The ongoing funding and support for the Fixed Term Senior Improvement Manager position. (3) The work associated with locally identified Milestones for the service, as noted in the Annual Delivery Plan for 2023/24 as per summary table below Table 1- Annual Delivery Plan 2023/24 Summary Summary We aim to deliver against 2022 HIS Inspection Recommendations and against all remaining actions from our internal Service Review in 2022, and to deliver MATS in Justice. We aim to end 2023/24 with plans for sustainable performance and future delivery against the changes. Q1 1. Senior Service Improvement manager in post and inducted. 2. Measurable advancement evident in the delivery of the 6 priority recommendations from the 2022 HIS inspection. 3. Advancement in the acquisition of a LES for GP services. 4. Improvement Plan in place for HIS recommendations and actions from NHSL service review, feeding into established Performance Review Processes. Q2 1. LES agreed, or advancement on contingency plan if LES unsuccessful. 2. Measurable advancement and delivery of 6 HIS priority areas. 3. Measurable advancement in NHSL service review actions. 4. New Team leader in post and Return to full shift nursing coverage (9pm). Q3 1. Host return visit/inspection by HIS and report on delivery against 6 priority recommendations including GP services. 2. Workforce Model review planned and date identified to commence work. 3. Measurable improvement in the management of LTC in the prison population under the newly created structure with nursing staff and GP services jointly leading. 4. Established Programme Board for justice related services with prison healthcare a central component in conjunction with MATS standards. Q4 1. Measurable delivery of all actions from the NHSL service review. 2. Measurable delivery and maintenance of all recommendations from HIS inspection. 3. Consultative and preparation work complete for Workforce Model review and plan in place to begin implementation.
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3 4. VARIATIONS TO DIRECTIONS? Yes ☐ No ☐ N/A ☒ 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 Background 5.1.1 Responsibility for the provision of healthcare in prisons transferred from the Scottish Prison Service (SPS) to the NHS in November 2011 and for HMP Shotts in Lanarkshire, it is now the responsibility of the North Lanarkshire H&SCP. HMP Shotts, a 538 place, maximum security prison for convicted adult males serving a sentence of four years or longer has a healthcare team that comprises of three sub-teams teams of Primary Care team, Addictions Team and Mental Health Team. 5.1.2 It is an isolated professional working environment, and there are significant cultural challenges related to partnership working with the Scottish Prison Service (SPS). The previous permanent on-site Senior Nurse model has been replaced with a Senior Nurse and Service Manager ‘in reach’ model providing regular presence on- site and work with the Teams. 5.1.3 Over the last 24 months the healthcare team has experienced significant and sustained staff shortages across all disciplines. This has impacted on the team’s ability to provide adequate staffing and maintain a safe skill mix. This included the lack of GP cover from 1:30pm onwards. 5.1.4 Due to the apparent challenges, the Nurse Director commissioned a ‘deep dive Service Review to be undertaken. This was completed in March 2022 and an action plan was developed identifying planned improvement actions. 5.2 Her Majesty’s Inspectorate of Prisons for Scotland Inspection 5.2.1 Her Majesty’s Inspectorate of Prisons for Scotland (HMIPS) undertook an inspection of HMP Shotts from 09- 22 May 2022, supported by Healthcare Improvement Scotland (HIS) who reviewed Prisoner Healthcare under Standard 9: Prisoner Health & Wellbeing. (HIS noted that an internal Service review had taken 4. Commencement of work on plan to provide sustainability and maintenance of the delivery of HIS recommendations and Service Review actions (audit cycle, reporting mechanisms etc.). 5. Measurable improvement in service performance and compliance as agreed in performance framework/KPI process.
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4 place ahead of their inspection and commented that this had been an area of good practice). 5.2.2 Resultantly, the nurse staffing recruitment and retention issues and associated subsequent impact on patient care, resulted in a grading of ‘Poor’ for NHS Lanarkshire. Whilst the report recognised the considerable efforts made to support the healthcare needs of patients in HMP Shotts, HIS noted; Five quality indicators were rated as satisfactory, Six quality indicators were rated as generally acceptable Five quality indicators were rated as poor. 5.2.3 There were 12 examples of good practice and 22 recommendations for improvement which include 6 priority recommendations. The Inspection Report is listed in Section 8.. 5.3 Progress to Date 5.3.1. As noted in the full report, there were 22 Recommendations. The present status of progress is detailed within Table 2 and a breakdown of these recommendation are detailed within Appendix 1 – HIS Review Recommendations Update . Table 2. Current Position on HIS Recommendations Criteria No of Recommendations Current Position on Open Recommendations RED AMBER GREEN Total Recommendations 22 0 Open Recommendations 16 0 13 3 Closed/Complete Recommendations 6 0 6 5.4 Service Review Model 5.4.1 The Internal NHSL Service Review produced an action plan with 32 Actions. The present status of progress of these actions are detailed within Table 3 and a further breakdown of these actions are detailed within Appendix 2 -Service Model Review Update. Table 3. Current Position on Service Review Actions Criteria No of Actions Current Position on ‘Live’ actions RED AMBER GREEN Total Actions 32 0 Open/Ongoing Actions 10 0 4 6
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5 Closed/Complete Actions 22 0 22 5.4.2 The implementation of the HIS recommendations and the actions from the Service Review has been formally supported by North Lanarkshire H&SCP with fixed-term funding for a Senior Improvement Manager, who will oversee and co- ordinate Improvement work to ensure the delivery of all Recommendations and Actions. 5.4.3 Additionally, it is planned that the work required in conjunction with associated work (specifically MATS in Justice) will be managed under the oversight of a Programme Board. 5.4.4 The Senior Service Improvement manager is now in post and is currently developing an amalgamated Implementation and Improvement plan which will be presented at the initial meeting of the Programme Board in June 2023. 5.4.5 Work is ongoing on staff recruitment and retention with a continued plan for Recruitment events, an application for a Secure Environment Allowance to S.T.A.C. and a current piece of work to create a Local Enhanced Service for the provision of GP cover, with one interested practice currently engaging in fact-finding and observation/participation in GP work as a way of assessing compatibility. 6. CONCLUSIONS 6.1 The management of Service Improvement and MATS standards is essential, and it is imperative that the improvement agenda is supported and implemented. 6.2 In order to meet the healthcare needs of prisoner patients, it is essential that the detailed recommendations and actions, including an improved workforce model are implemented. 6.3 The continued endorsement of and support for the incumbent Senior Service Improvement Manager post (Fixed Term for 18 months) is central to success in delivery. 6.4 achievement of our key Q1-Q4 Milestones in the Annual Delivery plan is essential to evidence the required improvement.
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6 7. IMPLICATIONS 7.1 NATIONAL OUTCOMES Link(s) to National Health & 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 ☒ 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) HIS Standard 9: Prisoner Health & Wellbeing. The identified actions and service and quality requirements as noted in the internal Service Review. Compliance with MATS Standards Generic management standards and performance requirements (including Financial balance and staff governance measures). 7.3 FINANCIAL 7.3.1 The Summary finance position for Prisoner Healthcare to the end of reporting year 2022/23 (and subsequently updated to present for the purposes of this report) is illustrated below. (Full detailed accounts are available). 7.3.2 There was an overspend mainly in non-pay which was largely characterised by the costs associated with the supply of medicines which when isolated as a cost on its own experienced an overspend of circa £170k in 2022/23. The supply of Buvidal is a significant contributory cost within this. Table 4- Summary Financial Position Nhsl Prisoner Healthcare Month 12 2022/2023 Report Refreshed On 18- May-23
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7 Annual Budget YTD Budget YTD Actuals YTD Variance Period Budget Period Actuals Period Variance Pay 1,347,509 1,347,509 1,325,641 21,868 107,431 120,768 (13,337) Non Pay 436,188 436,188 582,202 (146,014) 36,349 212,103 (175,754) Nhsl Prisoner Healthcare Total 1,783,697 1,783,697 1,907,844 (124,147) 143,780 332,871 (189,091) Staffing cost variances due to staffbank and agency nurse cover were largely tempered by the high nursing vacancy factor, as recruitment and retention of nursing staff continues to be a challenge. Pays therefore show as an underspend for 2022/23. 7.3.3 This paper has been reviewed by Finance: Yes ☒ No ☐ N/A ☐ 7.4 RISK ASSESSMENT/RISK MANAGEMENT Relevant Risk Register Details Current Risk Level Risk Owner 1. Healthcare Provision for HM Prison Shotts: Recruitment & Retention issues mean that we are unable to provide cover between 18.00 and 21.00 hrs. A safe alternative is in place until staffing levels improve. High J Duffy Relevant Risk Register Details Current Risk Level Risk Owner 2. Illicit substance misuse in prisoner group resulting in Ambulance conveyance to ED and admission to acute hospital. Low J Duffy Relevant Risk Register Details Current Risk Level Risk Owner 3. Nurse Staffing levels at HM Prison Medium J Duffy
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8 Shotts: Turnover and vacancy factor is high and this has resulted in costs for Staffbank and agency nurse cover. Actions and mitigation in place to address this issue. 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 A programme Board is being established for prisoner healthcare and MATS standards. Multiple stakeholders will be included. Discussion is ongoing on how best to incorporate prisoner/family inclusion. ☒ Provide stakeholders with information on how to get involved Information on engagement will emerge form Programme Board actions □ Ensure a diverse range of engagement and participation and opportunities are in place to suit different needs Not yet in place but to be developed at and Overseen by Programme Board □ Measure how well we involve community stakeholders in the planning, design and delivery of our services Not yet in place but to be developed at and Overseen by Programme Board □ Provide regular feedback on how stakeholder engagement and participation is shaping and influencing service development and delivery Not yet in place but to be developed at and Overseen by Programme Board □ Provide support to enable stakeholder representatives to participate meaningfully and confidently at meetings Not yet in place but to be developed at and Overseen by Programme Board □ Develop participation guidelines to ensure a common understanding and set of expectations for both stakeholders and partnership staff Not yet in place but to be developed at and Overseen by Programme Board □ Support engagement planning and participation in localities, taking account of Not yet in place but to be developed at and Overseen by Programme Board
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9 7.6 INEQUALITIES & FAIRER SCOTLAND DUTY EQIA Completed & Fairer Scotland Impact Assessment Form Completed and attached to report: Yes ☐ No ☒ N/A ☐ EQIA added to website: Yes / Date added ☐ No ☐ N/A ☒ 8. BACKGROUND PAPERS Paper 1 HMIPS-HMP Shotts Report on Full Inspection 9. APPENDICES Appendix 1- HIS Review Recommendations Updated 17th May 2023 Appendix 2- Service Model Review Update 17th May 2023 CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact the following; Maggs Thomson, maggs.thomson@lanarkshire.scot.nhs.uk other engagement activity and local plans across the Community Planning Partnership
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10
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11 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
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Paper 1 Report on HMP Shotts Full Inspection 9-20 May 2022
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CONTENTS Introduction and Background Key Facts Overview by HM Chief Inspector of Prisons for Scotland Human Rights Based Approach Overview Summary of Inspection Findings Standards, Commentary and Quality Indicators Standard 1 Lawful and Transparent Custody Standard 2 Decency Standard 3 Personal Safety Standard 4 Effective, Courteous and Humane Exercise of Authority Standard 5 Respect, Autonomy and Protection Against Mistreatment Standard 6 Purposeful Activity Standard 7 Transitions from Custody to Life in the Community Standard 8 Organisational Effectiveness Standard 9 Health and Wellbeing ANNEXES Annex A Summary of Recommendations Annex B Summary of Good Practice Annex C Summary of Ratings Annex D Prison Population Profile on Annex E Inspection Team Annex F Acronyms used in this Report EVIDENCE REPORT The full inspection findings and overall rating for each of the quality indicators.
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1 INTRODUCTION AND BACKGROUND This report is part of the programme of inspections of prisons carried out by Her Majesty’s Inspectorate of Prisons for Scotland (HMIPS). These inspections contribute to the UK’s response to its international obligations under the Optional Protocol to the UN Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT). OPCAT requires that all places of detention are visited regularly by independent bodies known as the National Preventive Mechanism (NPM); which monitor the treatment of and conditions for detention. HMIPS is one of 21 bodies making up the NPM in the UK. Her Majesty’s Chief Inspector of Prisons for Scotland (HMCIPS) assesses the treatment and care of prisoners across the Scottish Prison Service (SPS) estate against a pre-defined set of Standards. These Standards are set out in the document ‘Standards for Inspecting and Monitoring Prisons in Scotland’, published in May 2018 which can be found at https://www.prisonsinspectoratescotland.gov.uk/standards. The Standards reflect a rights based approach to an independent inspection of prisons in Scotland and are also designed to provide information to prisoners, prison staff and the wider community on the main areas that are examined during the course of an inspection. Our report provide assurance to Ministers and the public that inspections are conducted in line with a framework that is consistent and that assessments are made against appropriate criteria. While the basis for these Standards is rooted in International Human Rights treaties, conventions and in Prison Rules, they are the Standards of HMIPS. This report and the separate ‘Evidence Report’ are set out to reflect the performance against these standards and quality indicators. HMIPS assimilates information resulting in evidence-based findings utilising a number of different techniques. These include: Asking the Governor or Director in Charge for a self-evaluation – summary of their progress against previous recommendations, the challenges they face and the successes they have achieved. Obtaining information and documents from the SPS and the prison inspected. Shadowing and observing SPS and other specialist staff as they perform their duties within the prison. Interviewing prisoners and staff on a one-to-one basis. Conducting a pre-inspection health and wellbeing survey of prisoners, and focus groups with both prisoners and staff. Observing the range of services delivered within the prison at the point of delivery. Inspecting a wide range of facilities impacting on both prisoners and staff. Attending and observing relevant meetings impacting on both the management of the prison and the future of the prisoners such as Case Conferences. Reviewing policies, procedures and performance reports produced both locally and by SPS Headquarters (SPS HQ) specialists.
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2 HMIPS is supported in our work by inspectors from Healthcare Improvement Scotland (HIS), Education Scotland, Scottish Human Rights Commission, the Care Inspectorate, where appropriate the Children and Young People’s Commissioner for Scotland, and guest inspectors from the SPS. The information gathered facilitates the compilation of a complete analysis of the prison against the standards used. This ensures that assessments are fair, balanced and accurate. In relation to each standard and quality indicator, inspectors record their evaluation in two forms: 1. A colour coded assessment marker (APS TO INSERT) 2. A written record of the evidence gathered is produced by the inspector allocated each individual standard. It is important to recognise that although standards are assigned to inspectors within the team, all inspectors have the opportunity to comment on all findings at a deliberation session prior to final assessments being reached. This emphasises the fairness aspect of the process ensuring an unbiased decision is reached prior to completion of the final report. This report provides a summary of the inspection findings and an overall rating against each of the nine standards. The full inspection findings and overall rating for each of the quality indicators can be found in the ‘Evidence Report’ that will sit alongside this report on our website.
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3 Key Facts Location HM Shotts is situated in the countryside, south of the M8 motorway near the Lanarkshire village of Shotts. Role HMP Shotts is a maximum security prison for long-term adult male prisoners. It also houses a national facility within its boundaries, the National Integration Centre (NIC), which holds adult male prisoners who are in the initial stages of sentences of 8 years or over and prepares them for the eventual movement to mainstream establishments Accommodation There are two main residential units; Lamont Hall and Allanton Hall. There is also a 14 cell Separation and Reintegration Unit (SRU). All accommodation is designed for single occupancy and each cell has an integrated toilet and shower. Design capacity The design capacity is 538. Date of last inspection: 21 August – 1 September 2017 Healthcare provider: NHS Lanarkshire Learning provider: Fife college
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4 Overview by HMCIPS The Vision for Justice in Scotland 2022 aims to have effective, modern person-centred and trauma-informed approaches to justice in which everyone can have trust. Her Majesty’s Prison (HMP) Shotts was completely rebuilt in 2012 and has been well designed, with single cell accommodation for 553 and facilities fit for its purpose of holding long term adult male offenders. The prison was still in good physical order. The prison seeks to provide a secure, safe, caring and productive environment, while providing opportunities for offenders to come to terms with their sentences and address their offending behaviour. HMP Shotts was the first full inspection where HMIPS’ health and wellbeing survey was completed prior to the inspection; this provided valuable information to guide the focus of the inspection. Like the rest of the SPS, HMP Shotts has faced significant challenges over the last few years from the global pandemic. Staff shortages were evident across the establishment with healthcare delivery, access to employment, staff training, staff and prisoner engagement and evening activities detrimentally impacted. This was compounded by a period of significant incidents prior to the inspection, mostly substance related, that had affected the confidence of the prison. The national introduction of photocopying of prisoner mail, however, has led to a clear and welcome reduction in drug related incidents, and prisoners also reported they felt safer. This report identifies a number of areas of good performance which are worth celebrating, and which I hope will be taken up by other prisons in Scotland; for example good use of multi-disciplinary approaches to substance misuse, health promotion, and assisting with induction and adjustment to prison. We also saw good use being made of the Prisoner Information Channel. Most significantly, however, HMP Shotts is the first public sector prison in Scotland to install a digital ‘kiosk’ system. Used in many other jurisdictions, the positive benefits are clear; the system enables prisoners to exercise control and independence (and reduces paperwork for staff) by electronically choosing their meals, booking their own visits, buying canteen goods and checking their spend balance. HMIPS welcomes this initiative and looks forward to seeing this innovation extended into the cellular accommodation and rolled out across the estate. HMP Shotts houses the National Integration Centre (NIC) which holds approximately 60 adult male offenders who are in the initial stages of a long or life sentence and prepares them for eventual movement to mainstream prisons. We saw clear evidence of constructive relationships between staff and prisoners, resulting in suitably designed activities for each prisoner. As in the 2017 report, it was encouraging to see the operation of a Personal Officer scheme at its best.
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5 The staff who worked in the SRU demonstrated a high level of commitment and skill in working with often troubled and sometimes challenging prisoners. Good team working was evident, with investment in relationships producing positive results. Across the prison the Integrated Case Management (ICM) system was well established with a clear focus on identifying and meeting the needs of individual prisoners. Staff responsible for the operation of ICMs made effective arrangements to promote the involvement of all prisoners and, where appropriate, family members. Despite staffing constraints, HMP Shotts are to be commended for increasing the offending behaviour programme delivery during COVID-19 and for the resumption of Education and chaplaincy activities. We would nevertheless now strongly urge the early resumption of a return to a full regime. The report also highlights other areas where improvements can be made. Unfortunately, the significant and sustained pressures on healthcare staff and the detrimental impact on patient care resulted in a grading of ‘Poor ‘for NHS Lanarkshire but we nevertheless recognise the considerable efforts made in difficult circumstances by staff within HMP Shotts and the North Lanarkshire Health and Social Care Partnership (HSCP) to support the healthcare needs of patients in HMP Shotts. Despite the well-established ICM process, the waiting list for prisoners to progress to the National Top End (NTE) meant prisoners were delayed in progressing through their sentence. This problem is not exclusive to HMP Shotts and must be addressed by the SPS. Echoing the 2017 inspection report, we were concerned that long term prisoners were released back into the community from HMP Shotts without any formal opportunity to develop key life skills as part of preparation for release during their sentence. Prisoners due for release from the prison after many years also reported that they lacked confidence about important parts of their integration plans, especially housing options and access to mental health support. We were impressed by the responsiveness of HMP Shotts management team to issues raised during the inspection, which provides hope for early successes in returning to a full regime, staff and prisoner engagement, re-energising the equality and diversity (E&D) agenda, and the development of a pre-release life skills opportunity. We were concerned, however, that the Senior Management Team (SMT) and a number of management posts below that had been occupied on a temporary promotion basis for over two years; this was not conducive to stability and longer term planning so we urge the SPS to secure some more permanent arrangements as soon as possible. We were also aware that there had been tensions prior to our inspection between the trade union side and the SMT, which had been de-stabilising; it was encouraging to hear both sides say relationships were improving and we welcome continued engagement towards shared goals.
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6 We made 65 recommendations in total, but we would encourage a focus by the SPS on firstly stabilising a permanent management team structure and on the following key recommendations: Recommendation 14: The Violence Reduction Group should meet more regularly to review violence reduction and ensure actions are taken, and the Violent Incident Review (VIR) form submitted to Intelligence Management Unit (IMU) following a Violent Incident Review Panel should be taken to the Violence Reduction Group meeting for consideration as required by the strategy document Recommendation 15: SPS Anti-bullying Strategy ‘Think Twice’ requires to be re- launched to overcome the identified deficits e.g. only 40% of the staff are trained. Posters should be replenished across the establishment and a re-audit of incidents should take place to ensure all incidents of bullying, intimidation or harassment are investigated and taken seriously Recommendation 21: HMP Shotts should increase the C&R competency of staff to the accepted level as a priority. Recommendation 22: HMP Shotts must ensure that all planned removals are recorded unless there is reasonable mitigation. Recommendation 33: SPS HQ should review the policy for implementing a national waiting list for access to programmes and its capacity for delivering programmes against demand to ensure there is no detrimental effect on the care of individuals in custody or their ability to progress. Recommendation 35: HMP Shotts should continue to support ICM staff to address the backlog and bring all case conferences up to date. Recommendation 41: HMP Shotts should prioritise re-energising the E&D agenda, including regular meetings of the E&D committee with prisoner representation, development of an E&D action plan, more systematic monitoring of data to avoid unintentional bias with employment, education and discipline, etc., and provide comprehensive training for the E&D Manager. Recommendation 44: North Lanarkshire HSCP must ensure that all prisoners transferred to HMP Shotts are reviewed by a nurse before being admitted into the prison. Recommendation 48: North Lanarkshire HSCP must revise without delay, the process in place when identifying long term health conditions and provide assurance that patients are reviewed in line with what is equitable in the community to address health inequalities. Recommendation 52: North Lanarkshire HSCP as a matter of urgency must review the medical cover available in the afternoons to: (i) ensure the risk to patients is reduced. (ii) support nursing staff in dealing with emergency situations.
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7 Recommendation 57: As a priority North Lanarkshire’s HSCP must action the recommendations made in their service review regarding pharmacy provision and support to provide a service equitable with the community Recommendation 62: NHS Lanarkshire HSCP must ensure that all staff managing complaints receive training to ensure that all complaints are correctly managed. Recommendation 65: North Lanarkshire HSCP must demonstrate implementation of recommendations from service review and provide clear pathways to support staff on site in HMP Shotts in the absence of senior staff. Finally, we would like to thank all the staff, partners and prisoners in HMP Shotts for their time and commitment to the inspection.
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8 Human Rights Based Approach Overview HMIPS is a Human Rights organisation. As such, we ground all of our inspections in Human Rights principles. Our standards are written with the international human rights framework in mind, and our inspectors apply these standards through a human rights based approach. The human rights-based overview of the inspection of HMP Shotts follows the PANEL headings, illustrating how human rights are applied to the inspection as a whole. This overview is not exhaustive of all human rights observed and engaged, but is intended as a brief synopsis of the implementation of a human rights-based approach in HMP Shotts. HMIPS’ human rights-based approach to inspection is a critical element of ensuring both that the human dignity of the prisoner is upheld and that prisons are places of productive, positive and useful education, work and interaction, leading to better outcomes in reducing recidivism and keeping our communities safer. Overview While there may not have been sufficient human rights language built into policies and actions at HMP Shotts, it was clear that the establishment respected basic principles of human rights in their day-to-day outcomes. This was pleasing to observe. As we will go onto report, the establishment did not have adequate human rights based infrastructure built into their procedures. Prisoners were not routinely consulted on matters that affected their lives and there were only very early signs of a participatory model returning to HMP Shotts, post COVID-19. The Governor and Dep. Governor exhibited a strong grip of human rights principles, dealing with human rights and equality matters in an appropriate, swift and effective manner when they reached them. Due to a mix of high staff turnover, capacity issues and the pandemic, this approach had unfortunately not trickled down to middle and front line managers who demonstrated gaps of experience and competency of these matters. This was no fault of the personnel in question, but a reflection of the need of the establishment to run up to date and robust training to all staff, and HMIPS would encourage the SPS and HMP Shotts to do so. The SPS have a positive obligation under article 2 of the ECHR right to life, and the CPT statement of principles reinforced that in the context of COVID-19 “The basic principle must be to take all possible action to protect the health and safety of all persons deprived of their liberty. Taking such action also contributes to preserving the health and safety of staff.” HMIPS do not underestimate the strain COVID-19 placed on establishments. It was right and proper that protecting the health and safety of both prisoners and staff took priority over certain functions of prison management. We now expect prisons to put in place mechanisms to restore regime, meaningful activity and engagement at pace. Too often during the course of this inspection, inspectors were told that activities had
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9 been paused due to the pandemic, without the accompanying rationale, risk assessments or mitigations we would expect. As we will go on to report, prisoners need to be consulted, feel empowered and have meaningful say over their lives. With cancelling of Prisoner Information and Action Committees (PIACs), for example, this minimised the opportunity for this to occur. To the establishment’s credit, it seemed various activities we would expect were beginning to be reinvigorated, but this was not happening at the sort of pace inspectors would like to see. Overall, HMP Shotts was an establishment that respected the basic foundations of a human rights approach in their outcomes. HMIPS would encourage the establishment to go further, embedding the culture within staff of all levels, and establishing a firmer grip of human rights and equality throughout their processes. PANEL Participation “Prisoners should be meaningfully involved in decisions that affect their lives” Despite a background of a good participatory model in the past, which HMIPS have previously been pleased to report – disappointingly, at the time of inspection HMP Shotts demonstrated neither consistent nor robust examples of prisoner participation. PIACs can be a good opportunity to meaningfully involve prisoners in decisions that affect the prison. Unfortunately, these were not utilised at HMP Shotts. While there was a plan to re-establish a PIAC model, they had been suspended throughout the pandemic which significantly hampered prisoner’s ability to feel that their voice mattered. It was also noted by inspectors that the National Induction Presentation did not cover PIACs, which meant a key vehicle for prisoners to be represented was not being brought to the attention of newly arriving individuals. While staff and prisoner relationships were good, it was clear to inspectors that prisoners in general did not feel that their opinions, views and thoughts were a priority to staff in decision making. HMIPS encourages HMP Shotts to develop their PIAC model further. While it does not involve cumbersome work, a good PIAC model can greatly influence the participatory success of an establishment and help make prisoners feel heard and engaged. If the establishment had concluded that a formal PIAC model was unachievable due to the pandemic, HMIPS would have hoped to see more informal, yet meaningful, attempts at consultation by staff to mitigate this. We saw no such evidence. The only exception to this was the good practice demonstrated by the library team who actively sought feedback on the library stock, rules, service and environment. The library assistant engaged prisoners who attended the library, and importantly, those who didn’t by seeking feedback on the halls. She displayed the feedback quarterly and reported back to all service users what had been changed as a result of opinions and views gathered. Inspectors were impressed by this approach and it
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10 represented very good practice indeed. HMIPS would encourage HMP Shotts to take elements of this practice and incorporate it throughout the prison. Inspectors marked the E&D provision of the establishment as poor in QI 8.1. This was for three main reasons: 1) The E&D Committee had been suspended for a prolonged period of time and had only just begun to be reinvigorated. E&D concerns do not cease due to the pandemic and it is incumbent on the establishment to actively ensure those with protected characteristics and the most vulnerable are not being disproportionately affected by prison rules, especially during a pandemic. Inspectors were not satisfied that HMP Shotts demonstrated they had the appropriate mechanisms in place to assess if this was occurring. 2) There was a lack of awareness and competency amongst staff of their obligations concerning E&D, including members of the E&D Committee. The Committee were well intentioned, but did not have sufficient training to perform their role. The E&D Manager was being supported by a member of the SMT, but disappointingly had received no training in E&D matters. It is important that prison staff receive E&D training on how to respect the rights and meet the specific needs of detainees in situations of vulnerability, and the skills necessary for working with them. Rule 75 of the Mandela Rules is clear that the prison administration has to ensure the continuous provision of in-service training courses with a view to maintaining and improving the knowledge and professional capacity of its personnel, after entering on duty and during their career. 3) There was no local action plan, strategy or policy. What intentions the Committee were able to provide did not include focussing on systemic issues vulnerable individuals may be experiencing and were instead more focussed on awareness raising. HMIPS would expect to see a combination of both approaches in the Committee’s plans. There had also been no outreach to prisoners to have a prisoner representative on the E&D Committee. This is a key part of ensuring minority groups within an establishment are represented. Although inspectors were told this was in process and would hopefully be occurring shortly. Inspectors found a lack of awareness among prisoners of available processes where they could influence decision-making. In general, it was clear to inspectors that participation had not been a priority for the prison in recent times. There were very early signs of a participatory model returning to HMP Shotts, but this must be developed further to embed a culture and meaningful involvement of prisoners in decision making. Components to the principle of participation include that it must be active, free and meaningful and give attention to issues of accessibility, including access to information in a form and a language that can be understood. HMIPS would expect that any barriers to participation are identified and that those prisoners would be assisted to overcome them in order to meaningfully participate.
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11 Accountability “There should be monitoring of how prisoner’s rights are being affected as well as remedies when things go wrong” There was a framework of administrative accountability in the prison. However, effective accountability based on human rights standards were not consistent at the time of the inspection. This is not to say that human rights were readily ignored; however reference to standards, rules and human rights-based criteria were minimal. HMIPS found prisoners had little faith in the complaints system and a low level of confidence. On review of PCF1 and PCF2 complaints, inspectors found responses to be timely, robust and appropriate. In particular, PCF2 responses were worthy of mention, the Governor took time to investigate matters diligently and provided full responses to those submitting complaints. The Governor (or Deputy Governor) would frequently meet with prisoners who had submitted PCF2 complaints to discuss their concerns and follow up with a written note. HMIPS were pleased to see the senior management of HMP Shotts took complaints seriously and dealt with them robustly. That said, the establishment should take more steps to recognise the disconnect between prisoners and the complaints system. Prisoners need to be assured that their voice is listened to and that authorities are accountable when things go wrong. Despite the process appearing robust when complaints were received, more effort should be taken to provide prisoners with confidence in the process. More widely, HMIPS have concerns about the extent to which the SPS complaints matches the best practice model articulated by the Scottish Public Services Ombudsman, but HMP Shotts implemented the current system effectively. However, in line with our remarks above around the E&D processes at HMP Shotts, inspectors did have concerns around the use of equality and diversity form (EDF) complaints. An EDF acts as an addendum to a PCF complaint where the complainer believed the issue to concern an E&D matter. Where such a form was attached, the complaint was sent to the E&D manager to investigate and reported back separately. These complaints should be reviewed by the E&D Committee to identify systemic issues that may be going wrong and address them prison-wide. While not unique to HMP Shotts, inspectors found this process to be lacking. The process of dealing with an EDF complaint did not differ in any clear way, in either process or outcome, from a standard PCF complaint – rendering it without value. HMIPS would strongly encourage SPS HQ to re-examine processes and procedures in place around E&D complaints. Internal audits from the establishment were mixed, but mostly positive. Compliance processes appeared to be highly efficient and well managed. The establishment had taken decisive action to address the areas of poor performance identified in the previous HMIPS inspection report. Of some concern was the PRL audit around E&D which suggested a 100% compliance rate. This was not in line with inspector’s findings and we would suggest HMP Shotts review their internal reporting.
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12 NON-DISCRIMINATION “All forms of discrimination must be prohibited, prevented and eliminated. The needs of prisoners who face the biggest barriers to realising their rights should be prioritised.” Non-Discrimination requires the duty bearer to go further than not actively discriminating – it is not a passive duty but an active one, to make deliberate efforts to prevent discrimination from occurring in all forms. In this regard, inspectors saw positive examples from HMP Shotts in almost all of our standards. Induction material was provided in a number of different languages and the establishment had a good procedure in place for use of translation services where necessary. The induction officer and the librarian had a good working relationship where she would advise the library of any arriving prisoners who spoke a foreign language, allowing the library to source material which the prisoner could access. The library in general had a good selection of foreign language books, although it was disappointing to hear that the main supplier of foreign books to the library had recently gone out of business. The library was actively seeking a new supplier and it is hoped this can be achieved without delay. Foreign national prisoners reported feeling safe and having their basic needs met. A personal emergency evacuation plan (PEEP) list was provided and the requirements of individuals spoken to confirmed they should be on the list. Officers demonstrated good knowledge of the individuals and the background behind their requirements. Accessible cells were of a good standard and met the needs of those occupying them. In general, prisoners were supported to practice their religion and afforded the appropriate faith based meal by the Kitchen. Inspectors were informed that HMP Shotts had previously had a policy whereby Jewish prisoners requesting a Kosher meal were required to prove their religious heritage to be eligible for a Kosher meal. This was poor practice, and HMIPS are pleased to hear it has been overturned by the current prison administration. Inspectors were informed of an occasion where the previous policy had mistakenly been applied by a member of staff, and we would encourage the establishment to ensure all staff are up to date with policy to ensure this is not repeated. The chaplaincy was excellent and, despite staffing issues, were supporting prisoners of all faiths and none. Access to “enhanced work parties” which paid slightly more and were for low risk prisoners was not equal for protection and non-protection prisoners. HMIPS recognise the difficulty in allocating work in a large prison with a varied population, but we encourage the establishment to try to afford equitable access across the population.
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13 Empowerment “Everyone should understand their rights, and be fully supported to take part in developing policy and practices which affect their lives” Much of the discussion above around participation and accountability also applies to empowerment – prisoners cannot be empowered if they do not have opportunities to participate or do not have recourse to hold authority to account. We would expect prisoners to understand their rights and be fully supported in utilising them. Inspectors were pleased to note that prisoners could easily request maintenance issues to be logged, mattresses replaced or their cell to be painted. This level of empowerment over their own environment was pleasing to observe. Information provision was adequate, with copies of the prison rules, SOPs, and legislation available on request. This could be improved by having the material in easy reach of prisoners without having to request it. It is also important from an empowerment perspective for prisoners to know what sort of legal texts are available to them, while it is reassuring that the prison make the material available to prisoners, this should be signposted better. HMIPS found discipline hearings and case conferences supported prisoners well, allowing them to understand the actions taken against them. There was time taken to explain decisions and the actions prisoners could take if dissatisfied with any outcomes. Inspectors found that generally prisoners understood why they were being managed in a certain way, and what was expected of them to turn their situations around, particular when being managed under rule 95. HMP Shotts piloted a Kiosk system which allowed prisoners to use a computer system in their hall to access important material, make meal choices and other functionality. Once this system is fully exploited, this will be a good example of empowerment. The establishment must be careful to ensure individuals of all technical and literacy ability are supported to use the system, but in general HMIPS are very supportive of its incorporation and extension. HMIPS would like to see prisoners at the centre of policy and decision making, with more engagement and involvement at all levels. LEGALITY “Approaches should be grounded in the legal rights that are set out in domestic and international laws” A human rights-based approach requires the recognition of rights as legally enforceable entitlements and is linked to national and international human rights law. The UK must respect the UN Standard Minimum Rules for the Treatment of Prisoners (Nelson Mandela Rules); the European Prison Rules; The Convention against Torture, including the Optional Protocol and others. It is important that all categories of prisoners enjoy the full range of human rights and that staff are
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14 adequately supported. Inspectors have identified areas where they believe further action is required, in particular to ensure that more marginalised prisoners do not fall through the gap. The realisation of human rights is facilitated in practice by both the provision of information and the need for proactive action to be taken to ensure prisoners are accessing their rights in practice. A human rights-based framework is concerned with anticipating areas of prison life where problems are likely to arise, responding to prisoners needs as they are raised and building in monitoring mechanisms to ensure systems are improved through experience. This is the sort of human rights infrastructure which could be further developed at HMP Shotts. Inspectors did not find practice which directly called into question the legality of the establishment, but we do encourage HMP Shotts to work harder to actively apply a human rights based approach in their activities.
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15 STANDARDS, COMMENTARY AND QUALITY INDICATORS STANDARD 1 - LAWFUL AND TRANSPARENT CUSTODY The prison complies with administrative and procedural requirements of the law, ensuring that all prisoners are legally detained and provides each prisoner with information required to adapt to prison life. The prison ensures that all prisoners are lawfully detained. Each prisoner’s time in custody is accurately calculated; they are properly classified, allocated and accommodated appropriately. Information is provided to all prisoners regarding various aspects of the prison regime, their rights and their entitlements. The release process is carried out appropriately and positively to assist prisoners in their transition back into the community. Inspection Findings Overall Rating: Satisfactory performance In this standard, one quality indicator was not applicable, seven were rated as satisfactory performance and one was generally acceptable giving an overall rating of satisfactory performance. There was one example of good practice and two recommendations for improvement. HMP Shotts was a long-term establishment that did not receive prisoners directly from court, only transfers from other establishments. Therefore, new arrival numbers were low and every prisoner had spent time in another establishment prior to arriving. For this reason, prisoners already knew their release dates and had a good understanding of how prisons in Scotland run. The prison also had the benefit of knowing who was arriving and when, which allowed them to classify prisoners in advance and agree their location within the prison. If a prisoner attended court whilst in custody and the outcome affected their release dates, there were efficient processes in place to inform prisoners and interested parties of their new dates. Due to the low number of prisoners arriving, inspectors were only able to observe one new admission during the inspection. However, staff were able to clearly explain the processes, which were supported by Standard Operating Procedures (SOPs). A Reception Risk Assessment (RRA) and First Night Admissions Checklist were completed for every prisoner, and inspectors were content that all prisoners were assessed regarding their ability to understand and had the opportunity to engage with the admissions process. Prisoners were provided with sufficient information about HMP Shotts via the First Night in Custody Checklist and the National Induction Presentation (NIP), which was offered to all prisoners. The induction officer proactively met with every prisoner to encourage them to attend and establish their background, and then tailored it to their needs. It was delivered on a one to one basis or occasionally in small groups and was well received by prisoners. A helpful Family Information Awareness Package and face to face induction session was available to friends and family of prisoners in
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16 HMP Shotts. SPS HQ need to review the NIP and booklet to ensure that it provides up to date information to prisoners. There were good processes in place for liberating prisoners and the release process ran smoothly. The staff undertaking the admissions, induction and liberations process were friendly, polite and professional, and knowledgeable about their role. Prisoners spoken to were content that they had received the information they required. In terms of the PANEL principles for this Standard: Participation. Prisoners were invited to engage in the admissions process via the RRA form and the First Night Admission Checklist. Both of which were completed in a confidential setting. Accountability. There were efficient processes in place for admission to and liberation from HMP Shotts. During the reception process and on arrival at the hall, prisoners were provided with information about their entitlements. The Links Centre Officer met with every prisoner in advance of their induction and tailored the presentation to suit their needs. The officer also met with them in advance of their liberation to offer support and guidance appropriate to their needs e.g. benefits advice, applications for ID. Non-discrimination and equality. Prisoners were classified and allocated to an area in the prison in advance of them arriving, so they were quickly placed in the area that best suited their needs. Prisoners that required additional assistance with the admissions process were identified on arrival at reception. Translation services were available and guidance for staff on how to use them. Prisoners were offered guidance and support in advance of their liberation date. Empowerment. Prisoners were provided with an Admission Information Pack in reception and were taken through a First Night Admissions Checklist on arrival at their residential hall. There was sufficient information provided in these to enable the prisoner to know their rights in advance of attending a full induction session, which provided further valuable information. The checklist and the RRA enabled staff to identify prisoners with additional needs. All documentation was available in nine other languages, braille and British Sign language (BSL). Legality. Staff followed the lawful procedures and completed them in a professional manner. Encouraging observations The Family Information Awareness Package for families and friends of prisoners
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17 Emerging concerns SPS HQ should take action to update the NIP and booklet to ensure it provides up-to-date information to prisoners. The Link Centre Officer responsible for delivering induction was a singleton post and there was no cover during absence.
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18 Quality Indicators 1.1 Upon arrival all prisoners are assessed regarding their ability to understand and engage with the admission process. Rating: Satisfactory performance HMP Shotts did not receive prisoners directly from court, therefore the opportunity to observe the admissions process was greatly reduced. However, staff were able to walk inspectors through the process and although only observing one admission, standards were fully met. The reception area was quiet and calm due to the low number of admissions, which contributed to a relaxed experience for those arriving. If more than one prisoner arrived at reception, they were brought off the escort van one at a time and processed at the staff desk, which allowed for confidential discussions to take place. Assessing their ability to understand and offering an opportunity to engage in the admissions process was done via the RRA form. Reception staff asked many of the RRA questions whilst searching the prisoner in a private setting, which reduced the admission time and made the process more relaxed. Reception officers were friendly, polite and professional when interacting with prisoners. An RRA was also completed for those returning from court or hospital and all prisoners coming through reception saw a nurse in a private room. Foreign national prisoners were directed to the language identification charts to ascertain which language they spoke. There was a folder held with instructions on how to use translation services, but inspectors were advised that it was rarely required. There were two SOPs covering the admissions process, one of which was specifically for prisoners’ subject to or suspected to be infected with COVID-19. Inspectors observed that staff followed the instructions laid out. Inspectors were informed that admissions could be processed quite quickly dependent upon how much property came with them. Inspectors spoke to prisoners who had recently been admitted and they were all positive about the experience and the staff working in reception. Reception staff had received relevant training to carry out their role. 1.2 On admission, all prisoners are provided with information about the prison regime, routine, rules and entitlements in a form that enables the prisoner to understand. Rating: Satisfactory performance Prisoners arriving at HMP Shotts had already spent time in another establishment. Therefore, they had an understanding of how prisons run, and the core screen paperwork had already been completed and information recorded on PR2.
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19 New admissions were provided with an Admission Information Pack in reception, written by the person responsible for delivering induction. The pack provided prisoners with enough of an understanding about how HMP Shotts ran and their entitlements until they could be offered a fuller induction. The pack was available in nine different languages, BSL and braille, and staff were aware of how to use interpretation services if required. With the exception of the race relation statement, there was no information displayed on the walls of the reception or holding areas. Inspectors were informed that the TVs with an information channel and posters had been removed as they were being destroyed. HMP Shotts should consider reintroducing them to reinforce the information provided in the pack and also help prisoners pass their time in reception. There were no peer supporters working in the reception area and HMP Shotts should consider adding peer supporters in this area. On arrival at their hall of allocation, prisoners were taken through a First Night Admissions Checklist by residential staff, usually in the evening once prisoners had been locked up to allow officers sufficient time with people. Again prisoners had gone through a first night in custody process at their receiving prison, but it was helpful to provide further information relevant to HMP Shotts. They were also provided with a Health and Safety Policy and an SPS booklet. The Checklist identified communication barriers, which allowed officers to tailor their delivery to suit the person’s needs. It was signed by the prisoner and the residential officer, assured by an FLM and sent to the induction officer within 48 hours, to help form the basis of the prisoner’s induction into Shotts. There was a First Night in Custody Protocol available to staff to ensure consistency in the process. Prisoners spoken to were content that they were provided with enough of an understanding of how the prison ran during the admissions process. 1.3 Statutory procedures for identification and registration of prisoners are fully complied with. Rating: Satisfactory performance The admissions process SOPs covered the identification and registration of prisoners, and reception staff were observed to complete the process as instructed. This included checking the Prisoner Escort Record (PER) and querying any issues/concerns with escorting staff, completing the seven-point warrant check and confirming the prisoner’s identity using the warrant for reference. The PER should identify any special needs, including risk factors and the RRA provided a further opportunity for this. As reported in QI 1.1, an RRA was completed for those returning from court, which took account of any changes of circumstances and needs that may arise as a result of this.
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20 PR2 was updated as appropriate and the warrant was then passed to the Criminal Desk. See QI 1.7 for more about this process. 1.4 All prisoners are classified and this is recorded on the prisoner’s electronic record. Rating: Satisfactory performance As reported previously, HMP Shotts did not receive prisoners straight from court. They were transferred in from another establishment, which meant that the prison knew in advance who was arriving and on what date. The Population Manager at HMP Shotts managed this process, with input from the Prison Management Meeting. The Population Manager had built up good relationships with other establishments and liaised with them about transfers in and out of HMP Shotts. He had various spreadsheets in place to manage the process efficiently. He arranged for the necessary background checks to take place and allocated prisoners to a suitable location in the prison before they arrived. A weekly email was sent to interested parties on a Friday for the week ahead, detailing all transfers in and out of the establishment. PR2 was updated as appropriate. The exception to this was prisoners eligible for placement into the National Induction Centre (NIC), where the NIC manager managed transfers in and out and arranged for background checks to be completed before accepting them. 1.5 All prisoners are allocated to a prison or to a location within a prison dependent on their classification, gender, vulnerability, security risk or personal medical condition. Rating: Satisfactory performance As reported in QI 1.4, HMP Shotts were aware of prisoners due to arrive in their establishment in advance. Other establishments contacted the Population Manager at HMP Shotts with requests to transfer prisoners to them, and HMP Barlinnie issued a weekly list of long-term prisoners (LTPs) waiting to transfer to a long-term establishment. The Population Manager used a database and spreadsheet to manage this process. He arranged for the necessary checks to be completed, allocated them a location in the prison before they arrived, and informed reception staff where the prisoner should be located. If a prisoner with accessibility needs was on the list to transfer in, they would not be taken unless there was an accessible room available for them. The Population Manager could not recall this ever having been an issue.
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21 The NIC manager managed this process for those being placed in the NIC. Eligible prisoners were interviewed and must agree to participate in the NIC regime before being accepted. Prisoners who request protection were assessed prior to going on protection and were reviewed annually. 1.6 A cell sharing risk assessment is carried out prior to a prisoner’s allocation to cellular accommodation. Rating: N/A All prisoners held in HMP Shotts at the time of the inspection were placed in single cell accommodation, therefore there was no requirement for cell sharing risk assessments. 1.7 Release and conditional release eligibility dates are calculated correctly and communicated to the prisoner without delay. Rating: Satisfactory performance The staff on the Criminal Desk within HMP Shotts were responsible for the calculation of release dates, therefore all warrants were passed to them by reception. Because HMP Shotts did not receive prisoners directly from court, they did not provide those arriving with release dates as they would already know them. However, the Criminal Desk rechecked the calculation to be confident that the dates were correct for those in their care. If a prisoner attended court whilst in custody and the outcome affected their release date, reception notified the Criminal Desk and passed the warrant to them. The Criminal Desk recalculated their release dates and updated PR2 within 24 hours. There was an assurance process in place whereby the manager checked and signed off the calculation and confirmed the date on PR2. A critical dates template was then sent to the prisoner to inform them of their new dates and an email was issued to relevant staff attaching the warrant and sentence calculation. If their dates were not affected following a court appearance, the criminal desk emailed staff to inform them of any additional charges and confirmed no change to their release dates. Staff confirmed that there were good relationships in place with the Crown Office and Procurator Fiscal Service (COPFS) should they need to query anything on the warrant. To date there had been no detainee or liberations in error at HMP Shotts. There were two members of staff working on the Criminal Desk. Both were competent in warrant identification and calculation and they covered for each other during leave periods. The processes in place were efficient and there was a suitable assurance process in place. All paperwork was stored and destroyed appropriately.
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22 1.8 All prisoners attend an induction session as soon as practicable, but no later than one week after arrival, which provides a thorough explanation of how the prison operates and what the prisoners can expect, including their rights and obligations. Rating: Generally Acceptable performance HMP Shotts received a low number of new admissions, and during the pandemic this was further reduced. Prisoners arriving had already completed national induction at their previous establishment. The Links Centre Officer was responsible for delivering induction to new admissions and was clearly enthusiastic about her role. She was notified of new admissions via the First Night Admissions Checklist sent to her from residential hall. She proactively arranged to meet with every new admission to encourage them to attend induction, and to find out their background and identify any communication needs so that she could tailor the presentation to suit. It was delivered on a one to one basis or occasionally in small groups. Translation services were used for foreign nationals as required and had recently been used to communicate with a Vietnamese prisoner. The National Induction Programme (NIP) was used as the basis for the induction and text was added to provide information pertinent to HMP Shotts. Inspectors noted that the NIP did not cover (PIAC), which is an important vehicle for prisoners to have their say and influence decisions that affect their life. HMP Shotts updated their presentation during the inspection. HMIPS ask that Scottish Prison Service Headquarters (SPS HQ) update the presentation to include this. Inspectors observed delivery of the NIP to a new admission who had not been to prison before. It was very clearly delivered, in a supportive but professional style, and tailored to suit the individual. It provided a thorough explanation of how the prison operated. Prisoners spoken to were positive about the information provided to them during induction. Those that did not wish to attend induction were provided with an NIP booklet, which was available in nine other languages, braille and BSL, and non-attendance was recorded on Prison Records System (PR2). No follow-up action was taken, but inspectors were not overly concerned as they would have received induction before arriving at HMP Shotts. Inspectors noted that the induction booklet was out of date, e.g. it talked about smoking in cells which was no longer permitted and referred to Visiting Committees. SPS HQ should take action to update the booklet and reissue it to prisons. Induction was delivered as quickly as possible but not always within seven days. This was because the Links Centre Officer was a singleton post and the officer had other duties to attend to. There was also no cover when the officer was absent. Inspectors were not overly concerned about this because new admissions would have received the NIP before arriving at HMP Shotts. They were also given the Admissions Information Pack in reception and taken through the First Night Admissions Checklist on arrival at their residential hall. However, HMP Shotts should aim to deliver an induction to all new admissions within the agreed seven days.
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23 HMIPS were pleased to hear that HMP Shotts issue a Family Information Awareness Package to families and friends of prisoners, along with the offer of a face-to-face Family Induction that had been delivered in both the prison and in the community. This is considered good practice. Recommendation 1: SPS HQ should take action to update the NIP and booklet to ensure it provides up to date information to prisoners. Recommendation 2: HMP Shotts should arrange cover for the Links Centre Officer when they are absent. Good practice 1: HMP Shotts issue a Family Information Awareness Package to families and friends of prisoners. 1.9 The procedures for the release of prisoners are implemented effectively with provision for assistance and basic practical arrangements in place. Rating: Satisfactory performance Standard 7 will report on how the release process proactively facilitates the prisoners transition back into the community. For those being liberated, the Parole Board for Scotland sent the license conditions to the Criminal Desk. All paperwork was then sent to the relevant Unit Manager to sign off and they met with the prisoner one or two days in advance of their release to talk them through their license conditions and provide them with a copy. The Criminal Desk sent out a liberation list mid-way through the month for the following month, so that all relevant staff had a few weeks’ notice of prisoners due for release. Prior to release, the Links Centre Officer offered support to prisoners with benefit entitlements including community care grants, assisted them to make an application for a basic bank account and a citizen card photographic ID. She also offered advice about transport to their destination and location of GP surgeries. On their date of release, prisoners attended the prisoner reception area where they were reminded of their license conditions. All personal property and money stored on their behalf was returned to them and signed for, with the exception of their mobile phone that was returned to them at the front of house before leaving the establishment. They were offered holdalls to place their property in which provided them with privacy on release. Every effort was made to coincide their release time with transport links and appointments made in the community, and inspectors witnessed this happening. For those that required it, Naloxone was placed in their property by healthcare staff in advance of their release date. If required, prisoners being liberated were offered a travel warrant to provide them with a means to reach their destination. Stocks of appropriate clothing were held in reception should prisoners require it. Prisoners were also invited to participate in an exit interview to allow the prison to review their experience of HMP Shotts. They were then escorted to the front of house reception area where their details were checked again and they were permitted to leave the establishment.
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24 Inspectors were able to observe two liberations during the inspection, and followed them on their journey, from being brought to the prison reception area from their residential hall to being released through the front of house reception. The process ran smoothly and staff dealt with the prisoners really well, providing reassurance for those who were nervous about being released. The Criminal Desk sent a notification to interested parties, such as Police Scotland to inform them that a prisoner had been liberated and attached their licence conditions. An SOP was available to staff to cover the release process.
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25 STANDARD 2 - DECENCY The prison supplies the basic requirements of decent life to the prisoners. The prison provides to all prisoners the basic physical requirements for a decent life. All buildings, rooms, outdoor spaces and activity areas are of adequate size, well maintained, appropriately furnished, clean and hygienic. Each prisoner has a bed, bedding and suitable clothing, has good access to toilets and washing facilities, is provided with necessary toiletries and cleaning materials and is properly fed. These needs are met in ways that promote each prisoner’s sense of personal and cultural identity and self-respect. Inspection Findings Overall Rating: Generally acceptable performance In this standard, four quality indicators were rated as satisfactory, one was rated as generally acceptable and one was rated as poor, giving an overall rating of generally acceptable performance. There was one example of good practice, and eight recommendations for improvement. HMP Shotts was built in 2012 with all cells being single occupancy. The original operational capacity was 553 but was increased to assist with population issues during COVID-19. The four accessible cells were of a good size and practical construction, containing the necessary equipment and mobility aids for the occupants. The prison buildings were found to be in good condition, fit-for-purpose, and to have good levels of cleanliness. All areas had cleaning schedules and each residential area had at least one prisoner trained in dealing with biohazard incidents. Although biohazard kits were available, the contents varied in every hall and the majority of staff were not aware that an up-to-date ‘grab box’ was available for use. The standard of prisoners bedding, mattresses etc. was of an appropriate quality in most cases with the majority of prisoners having their own personal bedding. The prison laundry worked well with efficient processes in place, however It was noted a need for an improved method around the securing of laundry bags to prevent loss or damage. Prisoners were given free access to essential toiletries on the halls, with adequate items in stock. In addition, the prison canteen offered a good range of toiletries to suit all budgets. Although Inspectors were informed that there had not been a PIAC in respect of the canteen since February 2020 due to COVID-19 restrictions, they were plans in place to restart them at the end of June 2022, giving prisoners the opportunity to influence the items available for them to purchase.
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26 Prison issued clothing was held in a store room located on each residential area and found to be well stocked. HMIPS found that prisoners knew the process in respect of requesting clothing and would receive it with little or no delay. Prisoners ordered their meals through the new Kiosk system, which clearly displayed nutritional information and allergens contained in all choices. However, updates to the Kiosk were required to make the process run more smoothly. A process was in place to cater for those that required a special diet and inspectors were pleased to see a varied bespoke menu in place for one prisoner with health issues. Overall cleanliness of the pantries was good, but there was room for improvement with regards to dealing with waste food products from the previous day’s meals. Although issues around the corrosion of microwave ovens were highlighted in an internal audit in February this year, this had yet to be addressed. A significant number of prisoners (75%) expressed dissatisfaction with the overall quality of food in HMP Shotts, with most stating that it was ‘soggy’ or ‘stodgy’. Having observed the food trolleys, which were loaded and sent to the halls as close to meal time as possible, there still seems to be an issue with the quality which could be related to the type of trolley being used. We encourage HMP Shotts to review their trolleys and look at those in HMP Low Moss, where the food trolleys were found to have less detriment on the condition of food arriving at the halls. Food was not always temperature checked at the point of service and very few prisoners serving food wore the appropriate PPE. Only one area was observed securing the pantry door to prevent unwarranted access during meal service. In multiple locations some items were placed on a dining table where self-service appeared to be the norm. This was concerning for potential cross contamination as well as portion control. Training records were reviewed and showed that only 77% of prisoners working in the Catering Department had completed the required Food Hygiene certification, with only 50% of prisoners trained. In terms of the PANEL principles for this standard: Participation: PIACs in respect of the canteen had not been held since February 2020, it was encouraging to see that they were scheduled to start again in June 2022 but this was not met at the time of the inspection. Staff and prisoners were aware of how to raise maintenance issues and they were generally dealt with promptly, replacement clothing, bedding, towels and toiletries were readily available on request and in good supply. Accountability: There were a number of checks and assurances within this standard including mattresses being replaced on request and each hall being allocated three new mattresses a month with a rotational change every three years to ensure they were fit-for-purpose. A process was in place for access to the laundry by all prisoners three times a week and for the supply and replacement of clothing.
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27 There was a good maintenance and prevention programme in place through the “Agility” platform to ensure issues were prioritised and dealt with efficiently. Non-discrimination and equality: Inspectors did not witness any direct discrimination during the inspection. Empowerment: Prisoners had access to the basic requirements for a decent life and understood the process for raising maintenance issues, obtaining clothing and essential hygiene items. Prisoners were permitted to wear their own personal clothing whilst in the halls. Legality: Inspectors did not find anything during the inspection of this standard that compromised any domestic or international laws. Encouraging observations The size and layout of the accessible cells. The planned return of PIACs for the prisoner canteen process. Cleanliness and general condition of the prison. Maintenance programme had a low number of outstanding jobs and the majority were dealt with within the allocated timescales. Emerging concerns The high proportion of prisoners who complained about the food quality The solution for securing prisoners laundry bags was to tie a sock around the neck of the bag so it can be identified by the prisoner alone, this process was explained as part of the induction process and is far from professional. Numbered ties should be considered as a secure way of identifying property in the laundry. Biohazard ‘grab kits’ require to be monitored and maintained on each hall. All prisoners involved in food production or service should be appropriately trained to carry out these duties. All prisoners serving food should be wearing the appropriate PPE. All areas should be checking food temperatures and recording it appropriately. The prison should adhere to point of service processes to ensure that all food is served in conditions that comply with all Food Hygiene requirements. All equipment with signs of corrosion should be replaced. There is a need to review the delivery equipment from the Catering Department to Halls to deliver a better quality product at point of service.
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28 Quality Indicators 2.1 The prison buildings, accommodation and facilities are fit-for-purpose and maintained to an appropriate standard. Rating: Satisfactory performance The general feel around the prison was of a clean and well maintained establishment with buildings that were fit-for-purpose. There was no evidence of structural issues, graffiti or walls requiring painting or repair; the paintwork throughout the prison was fresh and well maintained. A good process was in place on each level within both halls for painting, with equipment held within each hall and paint sourced through the maintenance team. Prisoners could easily request their cell to be painted and this was facilitated by the nominated prisoner painting party within that hall. This process worked well. Inspectors looked at the four accessible cells within the prison and sought the views of three of the occupants. The cells were a good size with large glass fronted wet rooms containing all of the necessary equipment and access handles for those with mobility issues to comfortably use. Occupants confirmed the cell facilities met their requirements and that staff were attentive to their needs. All of the accessible cells were found to be clean and fresh. A safer cell was located on the ground floor of Allanton and Lamont halls. Both were not in use at the time of the inspection, but were very clean and contained the basic necessary equipment with the beds consisting of a mattress located on a concrete plinth. It was noted that the safer cell in Allanton had just been painted. All cells were fitted with adequate sanitation facilities and the intercom call points were found to be in good working order. The maintenance process worked well within the prison, prisoners were aware that they reported a fault to staff who then created a job request to the maintenance team via the “Agility” system. The job was given a priority rating and progressed, prisoners reported to inspectors that they received a good service and repairs were carried out in good time. Prisoners and staff were clear on how to report maintenance issues and were very complimentary about the effectiveness of the estates team. The maintenance programme was viewed and at the time of inspection had a 91.6% completion rate with only 6.72% jobs outstanding, this equated to five jobs and the inspectors found that all were delayed for good reason such as awaiting parts or specialist involvement. The prison maintenance team had three larger projects running at the time of the inspection, the fitting of LED lighting throughout the prison, the fitting of a macerator machine in the waste system and an upgrade to the hot water system.
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29 2.2 Good levels of cleanliness and hygiene are observed throughout the prison and procedures for the prevention and control of infection are followed. Cleaning materials and adequate time are available to all prisoners to maintain their personal living area to a clean and hygienic standard. Rating: Satisfactory performance The prison was found to have very good levels of cleanliness throughout and cleaning schedules for the prison in general and residential halls were in place. The industrial cleaning team were responsible for cleaning most areas of the prison. This team was considerably smaller than it was pre-COVID-19, but the quality of the staff was high. Hall pass men were responsible for cleaning the residential areas. Prisoners were encouraged to keep their cells tidy and those that were unable, were assisted by hall pass men. Relevant training records were kept by the prison including prisoner’s biohazard and British Institute of Cleaning Sciences (BICS) qualifications, and there were sufficient cleaning materials held on the halls. The industrial cleaning staff were responsible for the training of hall pass men, the green pass cleaners for specific areas in the prison and those from the work party. Prisoners spoken to confirmed that they had received relevant training and were confident in their work. Each hall had at least one pass man trained in dealing with biohazard incidents. Inspectors requested to view the cleaning process and found that the contents of the biohazard kits varied in every hall. When requested, the majority of staff produced an outdated kit and were not aware that an up-to-date grab box was available for use. However, when these grab boxes were inspected some were found to be missing essential content. Recommendation 3: Biohazard kits throughout the prison should be refreshed and communication improved to make staff and prisoners aware of availability and access for use. 2.3 All prisoners have a bed, mattress and pillow which are in good condition, as well as sufficient bedding issued by the prison or supplied by the prisoner. The bedding is also in good condition, clean and laundered frequently. Rating: Generally acceptable performance A number of prisoners beds, mattresses and bedding were inspected and found to be in good condition. Some prisoners reported that the mattresses were too thin but they had the ability to request a replacement mattress at any time. Their name would be placed on a list and each hall was allocated three mattresses a month to distribute. If a prisoner required a mattress in an emergency one would be provided. Inspectors were informed that a three-year mattress replacement programme was underway.
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30 The prison laundry worked well with efficient processes in place. The laundry work party consisted of 24 prisoners pre-COVID-19 but was operating adequately at the time of inspection with a team of six. Laundry staff reported that the washing machines were over 10 years old and starting to show their age but a replacement programme was anticipated to be starting soon. Induction training was provided by staff working in the laundry and a workshop training record was kept. Work wear, personal clothing and bedding can all be washed at the laundry. Prisoners put items in a net bag and place them in a large container on each hall for collection three times a week. It was noted by inspectors that the net bags were sealed by tying a sock around the neck, and prisoners reported that they recovered their laundry by identifying their bag by the sock. There was no fixed process in place for recovering lost laundry items, prisoners were advised in the information packs provided during the admission process that items placed in the laundry system were done so at their own risk. A small number of prisoners complained to inspectors that laundry bags often went missing. Laundry staff were not aware of this being an issue and a check of prison systems showed that there had been no complaints made regarding laundry over the preceding six months. Recommendation 4: Numbered ties for securing laundry bags should be provided so prisoners property can be identified. 2.4 A range of toiletries and personal hygiene materials are available to all prisoners to allow them to maintain their sense of personal identity and self-respect. All prisoners also have access to washing and toileting facilities that are either freely available to them or readily available on request. Rating: Satisfactory performance Prisoners were given free access to essential toiletries on the halls and inspectors found adequate items in stock on all residential areas. In addition, the prison canteen offered a good range of toiletries to suit all budgets. Inspectors were informed that there had not been a PIAC in respect of the canteen since February 2020 due to COVID-19 restrictions. Inspectors were pleased to hear that a PIAC was scheduled for the end of June 2022 and prisoners would be given the opportunity to influence the items available to them. All cells within HMP Shotts had showers and toilets therefore prisoners were free to use them whenever they pleased. The washing facilities in the accessible rooms were excellent with plenty of space and access points. The proposed upgrade of the hot water system will ensure the continued provision of sufficient washing facilities in the future. There was a sufficient stock of towels that were in good condition and laundered regularly.
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31 2.5 All prisoners have supplied to them or are able to obtain for themselves a range of clothing suitable for the activities they undertake. The clothes available to them are in good condition and allow them to maintain a sense of personal identity and self-respect. Clothing can be regularly laundered. Rating: Satisfactory performance All prison issued clothing was held in the store room located on each hall. Inspectors found sufficient stocks of clothing in all sizes in all halls, and there was a combination of new and recycled clothing available with additional stock held in the laundry. Prisoners reported that they knew the process in respect of requesting clothing and receive it with little or no delay. It was noted that jeans were limited in number on some halls and staff explained that this was due to the supply being suspended due to COVID-19 restrictions. It was found that demand for jeans had, however, dropped therefore any shortage was not proving to be an issue. It may be that the current rule of prisoners not being required to wear jeans during visits is a contributory factor and this may change should this rule be revoked in the future. Outdoor jackets were of high visibility and good quality, with prisoners reporting they were fit-for-purpose. There were adequate jackets in stock and available if required. Prisoners were permitted to wear their own clothing in residential areas to allow them to maintain a sense of personal identity. See QI 2.3 in respect of information about the laundry. 2.6 The meals served to prisoners are nutritionally sufficient, well balanced, varied, served at the appropriate temperature and well presented. Meals also conform to their dietary needs, cultural or religious norms. Rating: Poor The meals provided were on a three-week set menu cycle. Meals were ordered through the new Kiosk system, which clearly displayed nutritional information and allergens contained in all choices. However, any special dietary needs were ordered separately and tracked by the catering staff, due to the Kiosk system requiring further updates. Additionally, prisoners reported some issues in regards to re-ordering when the same choice(s) was wanted in future weeks. It was also reported by catering staff that amendments to the menu were not possible until the system was fully updated. Catering staff identified several groups of prisoner who were following cultural or religious dietary requirements. However, one prisoner with significant health concerns required more substantial adjustment, and as such, a bespoke menu which retained variety and met their nutritional needs had been created for them. This was seen as good practice, being able to resource and accommodate a tailored service for those who needed, whilst achieving a high volume output service function that was key to the establishment.
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32 Overall cleanliness of the pantries was generally good. However, both sections of Lamont Level 1 and 2 could be improved. These areas consistently showed signs of waste food products from the previous day’s meals. Additionally, whilst checking equipment a significant number of microwave ovens were found to be corroded, with the potential for flaking debris to contaminate food during cooking. Disappointingly, it appeared that this was identified during internal auditing in February this year, but had not yet been addressed. The internal audit appeared to have been very robust and identified a number of issues which remained as actions still requiring to be addressed. A significant number of prisoners expressed dissatisfaction with the overall quality of food in HMP Shotts, with most stating that it was ‘soggy’ or ‘stodgy’. The food trolleys were witnessed being loaded and sent to the halls as close to meal time as possible, and there was equipment within the pantry areas (air fryers) to re-fresh some products but, on such a scale this would seem impractical. The food trolleys appeared to be common to other establishments with the exception of HMP Low Moss, where the food trolleys more effectively maintain the condition of food arriving at the halls. Point of service for meals appeared a little less consistent across the establishment. Although some areas appeared to be carrying out temperature checks at the point of service this was not witnessed in all areas. Additionally, very few prisoners serving food were observed wearing the appropriate PPE. Only one area was observed securing the pantry door to prevent unwarranted access during meal service. Indeed, on a number of occasions and locations, the pantries were found to have numerous prisoners preparing their own food whilst service was on-going; and on more than one occasion servers were observed eating whilst serving. In multiple locations some items, such as soup, custard and salad were placed on a dining table where self-service appeared to be the norm. This was concerning for potential cross contamination as well as portion control (a prisoner was observed moving between sections because custard had run out in their section). Training records were reviewed and showed that only 77% of prisoners working in the Catering Department had completed the required Food Hygiene certification. Of those prisoners listed for pantry duties, this was found to be slightly less than 50% trained in Food Hygiene, which may be reflective of their awareness to wearing PPE and not eat whilst serving food. Indeed, catering supplies were checked and there appeared to be an abundance of PPE available. Catering staff absence had affected, and remained an issue for the Catering Department and requisite training. Good Practice 2: Catering staff provide consultation and provision for those with additional dietary necessities. Recommendation 5: HMP Shotts should ensure Kiosk updates are completed timeously to prevent frustrations with the ordering of special diets. Recommendation 6: HMP Shotts should ensure all prisoners involved in food production or service are appropriately trained to carry out these duties.
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33 Recommendation 7: HMP Shotts should ensure that all food is served by the appropriate person who must always be wearing appropriate PPE in conditions that comply with all Food Hygiene requirements. HMP Shotts should also ensure consistent checking and recording of food temperatures. Recommendation 8: HMP Shotts should replace all equipment which has signs of corrosion, or equipment which is known to be faulty. Recommendation 9: HMP Shotts should implement the required actions from previous catering audit in February 22, and re-audit to measure compliance. Recommendation 10: HMP Shotts should review their delivery equipment from the Catering Department to Halls to ascertain if improved heat holding can be achieved, and subsequently deliver a better quality product at point of service.
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34 STANDARD 3 - PERSONAL SAFETY The prison takes all reasonable steps to ensure the safety of all prisoners. All appropriate steps are taken to minimise the levels of harm to which prisoners are exposed. Appropriate steps are taken to protect prisoners from harm from others or themselves. Where violence or accidents do occur, the circumstances are thoroughly investigated, and appropriate management action taken. Inspection Findings Overall Rating: Generally acceptable Performance In this standard, one quality indicator was rated as good, two were rated as satisfactory, and four were rated as generally acceptable performance giving an overall rating of generally acceptable performance. There were four examples of good practice and 10 recommendations for improvement. The prison had largely emerged from the limitations and consequences of COVID-19, and it felt safe and ordered. Prisoners managed under Talk To Me (TTM) were managed with care, compassion and understanding. TTM case files checked had some gaps in relation to completion and HMP Shotts should continue to take action to improve this. In relation to taking care of prisoners whose appearance, behaviour or background left them at heightened risk of harm, the positive impact the introduction of photocopying of prisoners’ mail had in mitigating the risk of illicit substances being introduced to the prison was acceptable. The experiences of staff in 2021 in managing those under MORS appeared to be such that the staff placed even greater value on the 40% reduction pro rata in cases so far in 2022. A multi-disciplinary approach was being applied to support those at heightened risk of harm due to mental health and/or substance misuse. Residential staff were able to identify and signpost to appropriate stakeholders and there were opportunities for prisoners to self-refer to available health improvement activities. A prisoner information channel (PIC) was a major feature of Fife College’s contribution to health improvement activities, in collaboration with various internal and external partners. Custody Adjustment Support and Transition (CAST) Pathway within the NIC had at its foundations, residential staff and Physical Education Instructor (PEI) based delivery of induction, accredited START programme and other training courses with input from Fife College, the Health Improvement Practitioner and other stakeholders. .
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35 Procedures in support of violence reduction strategy were evident across the establishment. However, it was noted that the SPS Anti-Bullying Strategy ‘Think Twice’ required to be re-invigorated. There was a fully equipped C&R store and a well organised Command Room, supported by comprehensive contingency plans. COVID-19 had affected competencies, with the suspension of training with only 20 of the required 31 C&R trainers in post. Worryingly, in common with other establishment, there was a lack of any desktop or live exercise within the past 12 months, with the last Local Incident Management (LIM) exercise pre-dating COVID-19. The Health & Safety Management system in place was found to be compliant, managed by two qualified part-time Health & Safety Managers responsible for providing competent advice. However, fire evacuation drills should re-commence as soon as reasonably practicable, supported by briefings where necessary to ensure staff are proficient in procedures. In terms of the PANEL principles for this standard: Participation. TTM practices were person-centred. Individuals were encouraged to participate in case conferences and staff/prisoner relationships appeared good and supportive. There were opportunities for positive engagement by those otherwise at risk of harm or abuse from others through self-referral, multi-disciplinary meeting or by embracing the health improvement activities offered. Accountability. Compliance processes for assuring essential procedures in caring for those at risk of suicide or self-harm including the SPS Suicide Strategy - TTM, Management of an Offender suspected to be at Risk due to the ingestion of a Substance (MORS) and Notification of Concern (NOC) were highly efficient and well managed. The TTM system was well established and there was a robust assurance process was in place that reported monthly to SPS headquarters. Documentation was completed to a high standard and any slippages were identified and actioned through the assurance process. As COVID-19 restrictions reduced, there had been monthly Multi-disciplinary Team meetings. Meetings were well attended, and minutes demonstrate they were prisoner focussed. It was noted that the SPS Anti-bullying Strategy ‘Think Twice’ required to be re-invigorated. Non-discrimination and equality. Although the establishment demonstrated a positive approach to equality, the recently planned Equality & Diversity meeting had not taken place and should be convened at the earliest opportunity. Empowerment. Most of the prisoners reported feeling safe and the prison was well ordered with staff demonstrating control. Prisoners provided feedback that the information on prisoner information channel (PIC) had been useful quoting the use of breathing exercises. There was evidence of prisoners reporting being bullied and the perpetrators challenged.
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36 Legality. The application of the Prisons and Young Offenders (Scotland) Rules appeared legitimate at the time of inspection, with no evidence found of any non-compliance in terms of procedures observed and checked. The Health & Safety Management System was mature and provided a good basis for culture. Encouraging observations Compliance processes assuring essential procedures in caring for those at risk of suicide or self-harm including TTM, MORS and NOC were highly efficient and well managed. Health Promoting Friday incorporating ‘Neil’s hugs foundation’, ‘library man group’ and ‘trauma (NHS information session), etc., in collaboration between Fife College, SPS and NHS Mental Health Team, Health Improvement Practitioner and Addictions Caseworker and North Lanarkshire Council. Open to mainstream and protection prisoners (full parity). Prisoner Information Channel. Podcasts from positive peers, Enhanced Addictions Caseworker, NHS advertisements, mental health support, meditation, self-help, music requests, etc. Fife College. Use of Library in mental health provision. “Education and conversation in Art classes”, work with men with speech and language communication deficits, low literacy learners and dyslexia friendly learning. Residential Officer and Physical Education Instructor based delivery of Custody Adjustment Support and Transition (CAST) Pathway within the National Integration Centre (NIC) incorporating induction, training courses and case conferencing with input from Fife College, Health Improvement Practitioner and other stakeholders. Management of Health & Safety across Prisoner Employment and Training department including risk assessment, safe systems of work and training arrangements. Emerging concerns SPS HQ should reinstate Psychological input into CAST Pathway case conferencing within the NIC. There should be improved administration around completion of TTM case files. A regular review of violence reduction should be reintroduced. All VIR forms following a Violent Incident Review Panel should be taken to the Violence Reduction Group meeting for consideration as required by the strategy document. The SPS Anti-bullying Strategy ‘Think Twice’ should be re-launched with information and training provided as only 40% of staff had been trained since July 2021 Posters require to be replenished across the establishment in relation to on the ‘Think Twice’ and violence reduction. Staff were not always clear on processes to follow after a staff alarm and should be reminded of correct protocols Conduct a review of incident command role holders to ensure adequate cover for the establishment, and that role holders are competent.
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37 Contingency exercise arrangements to be reviewed. There had not been any Contingency exercise arrangements within past 12 months with the last Local Incident Management (LIM) exercise pre-COVID-19. Fire evacuation drills should re-commence as soon as reasonably practicable supported by briefings where necessary to ensure staff are proficient in procedures. Due to the length of time since the last Noise Assessment taking place, this should be reviewed in line with policy by a competent person.
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38 Quality Indicators 3.1 The prison implements thorough and compassionate practices to identify and care for those at risk of suicide or self-harm. Rating: Generally acceptable performance Prisoners managed under the SPS TTM Strategy in HMP Shotts were managed with care, compassion and understanding. Information shared between the NHS and the SPS at case conferences was appropriate and justified in terms of respecting confidentiality, whilst managing the individual’s risk of suicide and self-harm. In an observed case conference, it was noted that the prisoner was only given access to the case file ten minutes before the conference, resulting in frequent objections to some of the information recorded in the case file. The residential First Line Manager (FLM) who chaired a case conference was not a regular SRU FLM. Whilst a residential officer was present, it was apparent that the Chair lacked direct knowledge of the prisoner which could affect the ability to assess risk and any changes needed to the care plan. One individual had been managed on TTM for an extended period of time. An attempt to remove the individual from TTM and manage him under the SPS self- harm policy some time ago had been unsuccessful, but it was encouraging to see arrangements being made for a multi-disciplinary meeting to consider options again. Compliance processes were highly efficient and well managed in assuring essential procedures in caring for those at risk of suicide or self-harm including TTM, Management of an Offender suspected to be at Risk due to the ingestion of a Substance (MORS), Notification of Concern (NOC) and the operational readiness of Crash Packs (first-aid kits). TTM live case and reception risk assessment (RRA) audits covering the previous three months were reviewed and most reported all being in order and no action being required. Some actions had been identified such as the pre-case conference healthcare assessment taking place at the same time as the case conference and signatures must be added. Actions had been taken to communicate and correct these issues, however during a review of live TTM cases files the pre-healthcare risk assessment had been recorded at the same time as the case conference. There were also some good examples of the process working where a change of circumstance form was completed indicating an increase of maximum contact intervals from 60 minutes to 15 minutes. Action taken to ensure consistency with family engagement was also evident.
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39 Minutes from quarterly local suicide prevention meetings over the past nine months were evidenced, and information was shared from the Suicide Prevention Coordinator forum at SPS HQ. Safer cells were regularly used for prisoners being managed under MORS and this was evidenced with nine safer cell checklists reviewed between February and March 2022. The procedure surrounding completion of a checklist prior to a safer cell being used appeared well established and was confirmed by the assurance process. MORS was found to be well administered with examples reviewed; the procedure appeared well established and assurance checks were evidenced. Three listeners were operating in the prison and was an appetite to increase the number of listeners through recruitment and training irrespective of how often listeners were being accessed by the prisoner population. Recommendation 11: HMP Shotts should ensure that prisoners are given the opportunity to access information on their case file prior to the case conference. Recommendation 12: HMP Shotts should be proactive to encourage all prisoners on TTM to have family engagement and continue to take action to improve administration matters around completion of TTM case files. 3.2 The prison takes particular care of prisoners whose appearance, behaviour, background or circumstances leave them at a heightened risk of harm or abuse from others. Rating: Good performance A PEEP list was provided and the requirements of individuals spoken to confirmed they should be on the list. Officers demonstrated good knowledge of the individuals and the background behind their requirements. It was clear that the introduction of the photocopying of prisoner’s mail had reduced the risk of illicit substances being introduced to the prison. In the first three months of 2022 there were 46 occasions of prisoners being managed under MORS compared to 312 occasions in 12 months of 2021. This represented a 40% reduction pro rata. There were two individuals who were refusing to return to main circulation. There was good evidence of positive engagement with officers and the NHS mental health team who were attempting to persuade them to engage with the rest of the population. It was encouraging to attend a Prisoner Management meeting, where they were attempting to transfer both individuals. Multi-disciplinary Substance Misuse Meetings started in January and took place monthly as had Multi-disciplinary Mental Health Team Meetings. These were well attended, purposeful and an ‘information from prison officers’ section provided officers with the opportunity to raise concerns about individuals in an appropriate forum, with relevant stakeholders present. Minutes of both meetings referred to
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40 liaison with the NHS Mental Health Team, which was an obvious strength in both meetings. It was clear from speaking to a range of staff that a Health Improvement Practitioner and Enhanced Addictions Caseworkers were making significant inroads in communicating with prisoners on both physical and mental health and addiction services through a number of initiatives. All opportunities to engage with the prisoner population were being utilised including a four-week course shared as a podcast on the prisoner information channel (PIC) with prisoners providing feedback that they had been using the information shared such as ‘rest and repair’ breathing exercises. The Offender Outcomes Unit Manager further intended to introduce ‘Recovery and Support Representatives’ to assist in support of peers. Foreign national prisoners reported feeling safe and having their basic needs met. Reception and Link Centre, in delivering induction procedures, demonstrated use of global language services both via telephone and in person. Fife College in the Learning Centre also aided foreign national prisoners with ESOL courses. Fife College in collaboration with the SPS, NHS Mental Health Team, Health Improvement Practitioner, Enhanced Addictions Caseworker and North Lanarkshire Council. Good examples include the NIC Custody Adjustment Support and Transition (CAST) programme for individuals sentenced to eight years and above; Health Promoting Friday’s incorporating ‘Neil’s hugs foundation’; ‘library man group’ and ‘trauma (NHS information session). Management plans were focussed on reintegrating individuals into mainstream environments where they had earlier displayed vulnerabilities. An excellent Lamont Hall and NIC management plan was evidenced from December 2021, comprising seven stages of a person-centred approach ranging from planning and engagement with NHS, providing the individual increasing time in hall to integration and induction following a consolidation phase allowing reflection and exploration of issues. Good Practice 3: Multi-disciplinary approaches in Health Promoting Friday incorporating ‘Neil’s hugs foundation’, ‘library man group’ and ‘trauma (NHS information session), etc. Good Practice 4: Prisoner Information Channel. Podcasts from positive peers, Enhanced Addictions Caseworker, NHS advertisements, mental health support, meditation, self-help, music requests, etc. Good Practice 5: Residential staff and PEI based delivery of CAST Pathway within the NIC incorporating induction, training courses and case conferencing with input from Fife College, Health Improvement Practitioner and other stakeholders. Recommendation 13: SPS HQ to reconsider with Psychological Services, return of psychology input into CAST Pathway case conferencing within the NIC.
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41 3.3 Potential risk factors are analysed, understood and acted upon to minimise situations that are known to increase the risk of subversive, aggressive or violent behaviour. Additionally, staff are proactive in lowering such risks through their behaviours, attitudes and actions. Rating: Generally acceptable performance Violence reduction and anti-bullying posters were visible throughout the prison. The Violence Reduction Strategy was available on the SharePoint site accessible to all staff. HMP Shotts has a Violence Reduction Group (VRG) that reviews violent and serious incidents that occur. Although well attended, the last meeting took place in September 2021. During that meeting they reviewed the last five months’ intelligence and incidents which highlighted a number of recoveries. Further information such as the updates from the halls contained useful information. One violent incident that occurred was tracked in terms of the violence reduction strategy flowchart. A comprehensive Residential FLM and Duty Manager overview had been provided on the VIR form, and a Violent Incident Review panel was awaited. The strategy document requires the VIR to be submitted to the Intelligence Management Unit (IMU) within 48 hours after a Violent Incident Review panel is completed. The IMU advised this was not the case on every occasion, but it was assuring that the IMU track and issue reminders until the Violent Incident Review panel is completed, and form submitted. A very organised IMU was delivering a well-developed SPS Intelligence Framework and action dissemination, with proactive and engaging IMU FLM and analyst staff. A strategic threat assessment was evidenced which identified current threats to the establishment along with regular Tactical Tasking and Co-ordination Group (TTCG) meetings. A prisoner profile was under development for the violent incident that had occurred. Recommendation 14: The Violence Reduction Group should meet more regularly to review violence reduction and ensure actions are taken, and the VIR form submitted to IMU following a Violent Incident Review Panel should be taken to the Violence Reduction Group meeting for consideration as required by the strategy document. 3.4 Any allegation or incident of bullying, intimidation or harassment is taken seriously and investigated. Any person found to be responsible for an incident of bullying, intimidation or harassment is appropriately reprimanded and supported in changing their behaviour. Rating: Generally acceptable See QI 3.3 relating to the Violence Reduction Strategy that provided the prison with a coordinated approach to reducing violence. In the absence of a Violence Reduction Group meeting since September 2021 there is a general acceptance that
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42 the SPS Anti-bullying Strategy ‘Think Twice’ required to be re-launched to ensure staff were aware and knowledgeable. One ‘suspected bullying report (SBR) form’ from April 2022 was reviewed and actions taken found to meet the standard’s requirements. Of the six violent incident report forms submitted since September 2021 relating to prisoner-on-prisoner assault, on five of the six occasions, individuals were separated and on two of the occasions a transfer was arranged for a perpetrator. An induction package ‘respect me’ along with autism awareness and disability as well as hate crime courses were delivered within the NIC. Consideration should be given to rolling these packages out to the wider prison population, beyond the dissemination that occurs as men move from the NIC to general population. Up until March 2020 a training programme was in place for the SPS Anti-bullying Strategy ‘Think Twice’, with 40% of staff recorded as trained at that time. COVID-19 had affected this. SPS Anti-bullying Strategy ‘Think Twice’ was included in the induction package, which continued to be bespoke at this time as the prison emerged from COVID-19 and was covered in the induction booklet provided. It was encouraging to attend a Prisoner Management meeting, and see the robust approach to prisoner need. Recommendation 15: SPS Anti-bullying Strategy ‘Think Twice’ requires to be re-launched to overcome the identified deficits e.g. only 40% of the staff are trained. Posters should be replenished across the establishment and a re-audit of incidents should take place to ensure all incidents of bullying, intimidation or harassment are investigated and taken seriously. 3.5 The victims of bullying or harassment are offered support and assistance. Rating: Satisfactory performance A number of opportunities for prisoners to appropriately raise concerns or be identified by staff were evidenced against QI 3.2. Similarly, good staff/prisoner relationships were demonstrated across the establishment which created an environment where concerns were more likely to be raised with staff. An example of this was observed on one hall when eye contact with a prisoner at meal time raised suspicions with staff that something was amiss. The officer took the opportunity later to speak with him out of sight of other prisoners. In the NIC inspectors observed an FLM meeting with a prisoner who was in prison for the first time, where concerns had been raised in relation to demeanour. Whilst no concerns were identified in relation to bullying or harassment, the FLM was able to offer him support with the impact that missing his family was having on him.
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43 In most occasions the perpetrator of an assault was relocated and only one occasion the victim was moved. 3.6 Systems are in place throughout the prison to ensure that a proportionate and rapid response can be made to any emergency threat to safety or life. This includes emergency means of communication and alarms, which are regularly tested, and a set of plans for managing emergencies and unpredictable events. Staff are adequately trained in the roles they must adopt according to these plans and protocols. Rating: Generally acceptable performance SOP 202 ‘security staff alarm response’ was provided and described primary and secondary alarm responders, that were not specifically designated. Personal alarms carried were separate to the staff radio system. Inspectors noted that SOP 202 ‘security staff alarm response’ was past its review date and should therefore be reviewed. SOP 909 relating to medical emergencies during patrol and night shifts was also provided, including reference to code red and code blue arrangements along with arrangements for contacting the Scottish Ambulance Service. There was a fully equipped control and restraint (C&R) store in preparation for any eventuality. The equipment store was well managed, in support of a very organised command room and further supported by comprehensive contingency plans, log operating system and CCTV facilities. Contingency plans evidenced that there were nominally sufficient number of incident command role holders to enable HMP Shotts to deal with level two and three incidents, and a good assurance process that checked that there was suitable staffing in place. There was no evidence of any desktop or live contingency exercises within the past 12 months, and the Local Incident Management (LIM) exercise pre-dated COVID-19. Whilst accepting the impact of COVID-19, a review should be conducted to ensure command role holders are adequately trained and contingency exercise recommenced. HMP Shotts had recently appointed a new Staff Training Manager who was still in the process of verifying numbers trained in role and competency relating to C&R refresher training dates. He reported that COVID-19 had further affected competencies with only twenty of the required thirty-one C&R advanced trained staff in post. Recommendation 16: Conduct a review of incident command role holders to ensure consistent and adequate cover for the establishment and that role holders are adequately trained. Recommendation 17: Contingency exercise arrangements to be reinvigorated.
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44 Recommendation 18: Rapid planning is required to ensure a full complement of advanced C&R trained staff are in post in readiness for a proportionate and rapid response to any emergency threat. 3.7 The requirements of Health and Safety legislation are observed throughout the prison. Rating: Satisfactory performance Signed policy statements recognising management responsibility for Health & Safety (H&S) and Fire Safety were provided. A Risk Assessment register was available which could be sourced in the prison SharePoint site along with an excellent suite of risk assessments and safe systems of work (SSOW). The site could be accessed by all staff and on reviewing some examples, regular review periods were demonstrated. Fire risk assessments were evidenced with signatures of the Governor in Charge and Health and Safety Manager. Those responsible for H&S had the required qualifications to carry out their role professionally. There had been no Scottish Fire & Rescue Service or Health & Safety Executive activity in recent years and no respective audit actions. Excellent workplace inspection records existed, which showed all departments being inspected monthly between April 2021 and April 2022, except one department on two separate occasions. An assurance report was completed weekly by FLMs that included quality of cell searches, operational readiness, checks of crash packs and C&R equipment. It incorporated a Unit Manager check and contributed to an assurance regime, as did completion of three PRL audits on a monthly basis, co- ordinated by the Business Improvement Department. These scheduled programmes created a culture of assurance and contributed to the compliance and H&S agenda across the prison. H&S Committee had met of six occasion in the previous fifteen months. Whilst minutes of two meetings held in 2022 evidenced union and senior management attendance, it was evident that there was no FLM, residential officer or estates manager in attendance. The H&S Committee should consider inviting them to attend in order to ensure appropriate consultation with all employees. Accident investigation procedures were in place where responsible managers were provided 14-days to return an investigation into any reported accident. Evidence provided relating to fire evacuation exercise, were from 2018 and subsequent records advised that the Governor in Charge had instructed exercises be postponed as a result of COVID-19. No evidence of replacement activities such as briefings or toolbox talks was provided. The culture of H&S was observed within the workshops as outstanding and an example of good practice, particularly arrangements around machine safety, signage, risk assessment and training. Work units and outside areas visited were clean to a very high standard, role modelled by the whole team responsible for the department.
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45 An impressive training regime was evidenced covering a number of prisoner training courses that included H&S manual handling, fire awareness, hand-injury awareness and emergency response. Safety documentation available included risk assessments and SSOWs that had been reviewed in the past 12 months, along with noise assessments where the hazard had been identified. Although these assessments should have been reviewed in 2021. A ‘Shotts safety tracker’ was evidenced with some open actions relating to a lack of first aiders from 2021 and an issue from 2018 relating to prisoners using bedding they had been able to purchase/be issued, which didn’t meet rating standards in line with the SPS Fire Safety Manual and UK fire prevention regulations. HMIPS recommend action is taken to progress and appropriately close these actions. Good Practice 6: Management of H&S across the regimes department including risk assessment, SSOW and training arrangements. Recommendation 19: Fire evacuation drills should re-commence as soon as reasonably practicable, supported by briefings where necessary to ensure staff are proficient in procedures. Recommendation 20: Noise Assessments should be reviewed by a competent person.
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46 STANDARD 4 - EFFECTIVE, COURTEOUS AND HUMANE EXERCISE OF AUTHORITY The prison performs the duties both to protect the public by detaining prisoners in custody and to respect the individual circumstances of each prisoner by maintaining order effectively, with courtesy and humanity The prison ensures that the thorough implementation of security and supervisory duties is balanced by courteous and humane treatment of prisoners and visitors to the prison. Procedures relating to perimeter, entry and exit security, and the personal safety, searching, supervision and escorting of prisoners are implemented effectively. The level of security and supervision is not excessive. Inspection Findings Overall Rating: Satisfactory performance In this standard, one quality indicator was rated as good performance, six were rated as satisfactory performance and three were rated as generally acceptable performance, giving an overall rating of satisfactory performance. There was one example of good practice and six recommendations for improvement. HMP Shotts felt secure with regards to security both within the residential areas, regimes buildings and around the perimeter. There was a good suite of relevant SOPs available to assist staff in their understanding of what was required to carry out their role. There was also good evidence of assurance processes and risk assessments. HMP Shotts was still working through the consequences of the COVID-19 restrictions, with low numbers attending work or education. As restrictions ease the numbers moving around the prison will increase. Staff will need to adjust to the large movement of prisoners, particularly those who have joined since the pandemic and have not experienced this before. A priority for HMIPS is to encourage HMP Shotts to increase staff that are competent in Control and Restraint (C&R) and Personal Protection Training (PPT). In terms of the PANEL principles for this Standard: Participation: It is fundamental that prisoners feel part of the process and not the subject of it. This was evident when looking and observing reintegration or management plans for the SRU, self-representations at discipline hearings and case conferences, as well as case conferences relating to Special Security Measures (SSM). Prisoners reported that they had been communicated to with regards to decision taken about them, and were aware how and when to challenge these decisions as seen in one discipline hearing. Accountability: Individualised reintegration plans were evident where discipline hearings were observed. Judgements and punishments were on a case to case basis with no apparent use of a tariff system. There were assurance systems in place for sample cell and area searching, but this was not always completed. There was robust assurance in regard to vehicle and perimeter searching with good
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47 assurance processing place. There was a process in place to assure that C&R removals were legitimate and lawful, however some planned removals had not been recorded and were not mitigated by the Head of Operations. Non-discrimination and equality: There was no evidence of any discrimination against prisoners. There was no evidence of targeting of particular prisoner cohorts either in searching or drug testing. It was pleasing to see the care taken with those that were most at risk to ensure that their rights were upheld and that measures, such as those reported in QI 4.4, were only in place for the minimum amount of time. Empowerment: Discipline hearings and case conferences supported prisoners in allowing them to understand the actions taken against them. There was time taken to explain decisions and the actions prisoners could take if dissatisfied with any outcomes. Inspectors found that generally prisoners understood why they were being managed in a certain way, and what was expected of them to turn their situations around, particular when being managed under rule 95 Legality: For this standard it was clear that prisoners held under various rules or procedures were done so lawfully. With regards to the possession of illegal items, the prison was proactive in restricting the introduction of these items both through the vehicle lock and the perimeter. Although there is a caveat of COVID-19 and the importance of social distancing, it was found that in some cases staff involved in a C&R removal were past their refresher dates. However, the removals were carried out as per C&R guidelines. Encouraging observations The areas around the perimeter were clear of rubbish, maximising the opportunity to recover illicit items thrown over the perimeter. Emerging concerns HMP Shotts should look to increasing the C&R competency of their staff to the accepted level as a priority. HMP Shotts must ensure that all planned removals are recorded unless there is reasonable mitigation The Prison Monitoring and Assurance Group (PMAG) should intervene and take the decision as to where a prisoner should move to when it is clear that prisoner cannot be reintegrated into the holding prison. HMP Shotts should ensure that all cells are searched at least once per quarter and consider carrying them out at different times.
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48 Quality Indicators 4.1 Force or physical restraints are only used when necessary and strictly in accordance with the law. Rating: Generally acceptable performance. Force or physical restraint, known as Use of Force (UOF) must be undertaken in accordance with Rule 91 of the Prisons and Young Offenders Institutions (Scotland) Rules 2011. UOF did not appear to be overused. All were checked by the Head of Operations to ensure compliance, with an initial check carried out by the IMU. Any trends or hotspots where UOF had been used were then highlighted to the Tactical Tasking and Coordination Group for any action. Staff were guided by a UOF SOP as well as an SOP regarding the video recording of removals, a requirement when the removal is planned. Both SOPs were accessible via the local SharePoint site. The IMU kept a database of all removals, along with any video footage linked to planned removals and it was retained for the required three-year period. The camera used to record UOF was stored in an area easily accessible by an FLM. Ten UOF were checked from the last 12 months. The report writing was of a good standard and highlighted any issues staff experienced, when change overs occurred and the reasons as well as where staff were replaced to uphold the guidelines about searching. On three occasions when the UOF was planned, there was no footage available and no mitigation offered. On a number of occasions nurses were not available to assess the prisoner once the removal was completed. This was either due to the time of the removal i.e. after 18:00 when there were no NHS staff in the prison, or due to NHS staff shortages. However, there was evidence that C&R removals had been recorded when checking the IMU data base. An inspector also viewed a live removal from the Electronic Control Room (ECR). It was clear that it was managed well with the removal being recorded. Under SPS PRL 2.3.4.2: Control & Restraint, only prison staff assessed as competent to do so took part in C&R removals. A concern for HMIPS was the level of staff competence in C&R. Staffed trained in C&R phase one was at 53% with C&R phase 2 at 86%, and those required to be competent in PPT was at 16%. Staff involved in UOF were checked against staff training records. Two FLMs supervising a removal and seven staff who took part in a removal were out of competency. However, this was during COVID-19 where social distancing was being adhered to and C&R training had not taken place. Staff competency in C&R needs to be addressed as a priority. Recommendation 21: HMP Shotts should increase the C&R competency of staff to the accepted level as a priority.
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49 Recommendation 22: HMP Shotts must ensure that all planned removals are recorded unless there is reasonable mitigation. 4.2 Powers to confine prisoners to their cell, to segregate them or limit their opportunities to associate with others are exercised appropriately, and their management is effected with humanity and in accordance with the law. The focus is on reintegration as well as the continuing need for access to regime and social contact. Rating: Generally acceptable practice When inspectors visited the SRU it was almost at full capacity. This had been the case for some time other than for short periods where numbers had dropped slightly. When inspecting the SRU, 14 prisoners were located within the Unit. Nine were on rule 95(11), three on rule 95(12), including one prisoner on special security measures (SSM), and two were on a refusal to return to association (RRA) following the end of their rule, one of which had been on a RRA for a 92 days. A sample of rule 95(11) and 95(12) rules were checked on PR2 where prisoners had been in the SRU for between 18 to 116 days. All prisoners were found to be held lawfully, case conferences, self-representations and narratives had been downloaded into the Community Integration Plan (CIP) on PR2. The narratives were of good quality and there was at least one record for each week. If something significant occurred this was recorded at the time. Each prisoner had an individualised reintegration plan for returning to a residential area or their move to another SRU. However, there appeared to be some difficulty in moving prisoners out of the SRU, even to their prison of allocation. One example showed the prison attempting to move a prisoner to a number of prisons without success. Work needs to done to assist in moving prisoners between SRUs, The Prison Monitoring and Assurance Group (PMAG) should take a more active role in deciding transfers, preventing long term stays in SRUs and inhibiting the potential for a return to normal location. Prisoners reported a good understanding of their situation and confirmed that they had received their entitlements of access to fresh air, a shower, the satellite gymnasium and the phone, with most having access to in cell telephony. All prisoners had access to visits as well as a virtual visits console within the Unit. However, prisoners could not access evening visits due to the SRU being on patrol. The SRU had a reasonable book and CD library along with a selection of clothes and trainers for those who arrived with no belongings. There were a number of prisoners held under rule 95 in the residential areas, their regime was checked and confirmed that they were receiving their entitlements. HMIPS were informed that recently the prison had increased the operational capacity to include some cells in the SRU. If a prisoner was removed to the SRU and placed on a rule 95(11), his cell was cleared and filled by a transferred prisoner and therefore no longer allocated to him. If it was deemed appropriate to revoke the rule earlier than planned it was difficult to re-integrate the prisoner as he no longer had a cell to go to, and therefore prisoners may be held in the SRU longer than necessary.
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50 HMIPS are of the view that the SRU cells should not be part of the occupancy level of a prison. Every prisoner allocated to that prison must have a cell to return to at whatever time was deemed appropriate and not risk being kept in an SRU longer than necessary. Recommendation 23: The PMAG should intervene and take the decision as to where a prisoner should move to when it is clear that a prisoner cannot be reintegrated into the holding prison. Recommendation 24: SPS HQ should consider reducing the occupancy levels at HMP Shotts so as not to include the SRU. 4.3 The prison disciplinary system is used appropriately and in accordance with the law. Rating: Satisfactory performance HMP Shotts had held approximately 550 disciplinary hearings since the 01 January 2022. It was reported that since the introduction of photocopying prisoners personal mail the number of disciplinary reports had reduced. During the inspection a number of hearings were observed and were found to be well run. Where prisoners were included, they articulated that they understood the process, confirmed they had received the charge within the specific time and were clear on the outcome. Where a punishment was deemed appropriate they understood how to appeal the outcome. Where a prisoner challenged the legality of the report, the adjudicator suspended the hearing in order for an investigation to take place. The paperwork was completed as per SPS guidelines on disciplinary hearings 2018, and although some of the narratives could have been more explanatory the adjudicators worked well with the information they had. A local adjudication audit is carried out by the Deputy Governor on 10 random cases per month. This audit revealed a number of examples where the paperwork was not up to standard and was actioned to remedy the mistakes. The Deputy Governor also ensured he observes at least one disciplinary hearing for each adjudicator annually. A recent PRL audit undertaken in April 2022, indicated 100% compliance, with good narratives and evidence downloaded. Inspectors also observed the process undertaken where a prisoner did not wish to attend and had pleaded guilty in their absence. This process was followed well. 4.4 Powers to impose enhanced security measures on a prisoner are exercised appropriately and in accordance with the law. Rating: Satisfactory performance HMP Shotts had six prisoners on enhanced or SSM in the past 12 months and had a useful SSM flowchart to ensure compliance with the policy. During the inspection there was only one person on SSM, who was located in the SRU and had been under these measures for an extended period of time. The SSM was well
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51 documented and had described various stages of these measures, from having to have three officers attend to him wearing full PPE to a stage where he was being managed under normal SRU conditions unless he left the Unit. At this point he was subjected to the hand cuffing policy and this measure was accepted as the correct action to take at this stage to manage his risk. Reading the narratives, it was clear that risk assessments had continued to be utilised in efforts to reduce the SSM. The prisoner had attended most cases and there was evidence that there was a person centred approach. Inspectors attempted to engage with the prisoner but he declined. 4.5 The law concerning the searching of prisoners and their property is implemented thoroughly. Rating: Generally acceptable practice The regularly searching of prisoners and their property is necessary to ensure the safety and wellbeing of all prisoners and staff, and to minimise the threat to stability of the prison. It is the HMIPS view that it is also important that searching is not targeted to certain individuals without due cause. HMIPS were content that this was not an issue at HMP Shotts. Recently, the process that all cells should be searched at least once every quarter had been reintroduced after a period of time during the pandemic where the SPS had reduced searching significantly in order to adhere to social distancing. All areas had a searching record that annotated when cells and areas were searched, and although there was a weekly audit carried out by a residential FLM to ensure compliance, the completion of quarterly searches had not always taken place. Apart from tactical searching most prisoners and their property appeared to be searched at the same time every day. This could present a risk whereby prisoners could ensure their cells were clear of any illicit items during this time. HMIPS would ask HMP Shotts to consider carrying out quarterly searches at random times of the day rather that at the same time. An SOP on prisoner searching was available for staff to reference in SharePoint, which outlined the requirement for any search to be person-centred and to encourage positive engagement. Due to limited opportunities to observe a search this was not tested. When asked, prisoners confirmed that searches had taken place, that it was to help keep them safe and that they had been conducted fairly. There was no evidence of any complaints around searching. The National Dog Unit was utilised regularly and was on site during the inspection. However due to its workload, booking them to attend could be difficult. When possible, the prison uses them to search cells, mail, staff and prisoners as well as visitors. They can also be used purely as a deterrent, and its HMIPS view that it would be beneficial if the prison had their own dog unit to utilise on a daily basis. Recommendation 25: HMP Shotts should ensure that all cells are searched at least once per quarter and consider carrying them out at different times.
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52 4.6 Prisoners’ personal property and cash are recorded and, where appropriate, stored. The systems for regulating prisoners’ access to their own money and property allow for the exercise of personal choice. Rating: Satisfactory performance HMP Shotts transferred prisoners in from other prisons, therefore property and personal cash was already recorded in the SPS systems. All property arriving in reception was checked but not always in the presence of the prisoner. Due to COVID-19 restrictions still being in force, space was limited. If there were more than two prisoners arriving at the same time, prisoners did not stay in reception other than to fulfil the basics requirements of the admission process. This allowed prisoners to be removed from the escorting transport as quickly as possible. After completing the property check, the prisoners card was brought to the residential area to be signed by the prisoner. There did not appear to be any issue with prisoners not being present, but the reception will revert to previous practice once guidelines allows. Any issues the prisoner had about missing items was dealt with by a residential officer. In most cases there would be a request for the previous property card to be scanned to the prison to check against what had arrived. It would be helpful if it was common practice for a copy of the previous property card to be included with the transfer documentation. One issue that reception found was there were no national items in use list. This could cause issues, particularly when a prisoner arrived from another prison with items not permitted in HMP Shotts. Prisoners were able to access their property through a request book on the hall, which was supported by an SOP that outlined the various reasons why prisoners may wish to do so. Any property arriving in the reception was dealt with when time allowed, normally on the same day which resulted in no back log. Single items such as a watch were taken up to the prisoner for allocation, with items such as footwear required to arrive at reception before being replaced. This process was a result of previous incidents where prisoners had not handed in their old footwear. Any cash arriving in the mail was managed through a robust recording system. Prisoners family and friends could transfer money electronically which arrived at SPS HQ. The amounts received were then distributed to each prison, and the prisoners personal cash account updated. In both cases the money was in the prisoners account on the same working day. Due to COVID-19 restrictions it was not possible at this time to hand in cash or property at the prison. This meant that families had to pay for deliveries and it was difficult if purchases need to be returned, which could also be costly. The valuable property is held in a bag in a lockable cabinet, and were individually listed on the prisoner property card. However, these bags were not sealed. New bags had been purchased with seals but were not large enough to hold some prisoner’s valuables. New bags had been ordered.
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53 The key for the valuables cabinet was kept in a safe with a pin code. However, this was accessible by multiple staff, including the night shift manager, where the car keys were held. When HMIPS raised the risk of too many staff having access to the safe the prison reacted positively and purchased another safe for reception use only. Recommendation 26: SPS should consider including a copy of the sending prison property card with the transfer documentation. 4.7 The risk assessment procedure for any prisoner leaving the prison under escort is thorough and implemented appropriately. Any restraint imposed upon the prisoner is the minimum required for the risk presented. Rating: Satisfactory performance The risk assessment procedure for any prisoner leaving the prison under escort was thorough and implemented appropriately. An FLM, when picking the escorts, ensured that the person in charge was out of probation. Gender balance was also taken into account for searching and medical procedures. The FLM carried out an assessment of the escort using PR2, and also consulted the enhanced escorting list for those requiring special procedures. The list had good information to help understand the issues that could arise while out on escort. A personal escort approval certificate/risk assessment was attached to the PER. The sheet included information of the past history of escorts, risks factors, rationale for hand cuffing, instructions if the prisoner becomes unruly. If hand cuffs were to be removed due to a medical request, the action the escorting team should take was included. Where an enhanced escort was to take place the police were contacted. The receiving hospital was also contacted for all escorts. A review of the frequently used locations was carried out by the IMU, and although this has not been undertaken for some time, inspectors were satisfied that nothing had changed since the last review. 4.8 The law concerning the testing of prisoners for alcohol and controlled drugs is implemented thoroughly. Rating: Satisfactory Performance HMP Shotts did not test for alcohol but had a Mandatory Drug Testing (MDT) Unit. Inspectors visited the MDT which was staffed full-time Monday to Friday, by three staff. Prior to COVID-19 the prison was able to test approximately 1500 per year, and although this had dropped during the pandemic it appeared they had kept up with demand testing of 630 in 2021. At the time of the inspection they had tested 295. The MDT Unit tested prisoners for various reasons including for progression, where prisoners were tested within three months of transferring to the National Top End or open conditions, for Integrated Case Management (ICM), for enhanced work sheds, those who had been identified through intelligence reports, suspicion and on
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54 the request of a prisoner. There did not appear to be any discrimination in the testing process whether it was targeted testing or for those requiring it. Although the process was not tested in a live situation, inspectors were taken through the MDT process and were satisfied that it was fair and lawful. Staff were very experienced. They were able to demonstrate the process well and explained the steps taken dependant on the test result. There were no recent records of complaints about the MDT process. 4.9 The systems and procedures for monitoring, supervising and tracking the movements and activities of prisoners inside the prison are implemented effectively and thoroughly. Rating: Satisfactory performance Inspectors observed the movement of prisoners to work and education on numerous days during the inspection. Although numbers were not at the level pre-COVID-19, the route was well controlled and effectively supervised. FLMs from regimes were responsible for the movement off prisoners to and from the work areas. Each hall was moved in a controlled manner to minimise the risk of enemies meeting and to keep mainstream and protection prisoners apart. In most cases each work party was escorted by the officer in charge of that workshop and repeated at the end of the work period. Those going to education was picked up prior to the route moving by the education operations officers. All prisoners walked through a metal detector when leaving the residential areas and on returning from their place of work or education. All prisoners leaving work parties were hand wanded on exit and then walked through a metal detector. A percentage of which were asked to walk past the cell sense detector. If any prisoner was carrying anything of bulk, they were required to put this through the x-ray machine. There was no mandatory strip searching during route movements, but where required the prisoner was taken to the reception area to be searched. Inspectors also observed the process for moving prisoners who were at risk i.e. from the SRU, and this was also completed in a controlled manner. Good communications within the prison was observed allowing the transit of those presenting a risk to be safe. 4.10 The procedures for monitoring the prison perimeter, activity through the vehicle gate and for searching of buildings and grounds are effective. Rating: Good performance An inspector accompanied officers during their perimeter security checks, which were carried out on a minimum of three occasions per day, covering the early, back and night shift. On the perimeter checks a member of staff from each shift carry out a observational check of the perimeter fencing, with each staff member undertaking a third of a physical check known as a ‘push and pinch test’, checking the integrity of the perimeter, ensuring that a complete physical check is carried out every 24 hours.
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55 During the perimeter checks it was also observed that officers ensured that all vehicles were locked, and that there were no illicit items thrown over the walls. It was noted that there was no rubbish on view and therefore it was easy to spot packages that had been thrown over the perimeter. Any items found were placed in a production bag and sent to the IMU accompanied by a report from the officer, detailing the find. This is important in tracking the most vulnerable points for packages to be thrown over, days and times. The perimeter checks were also observed from the ECR. The ECR kept a record of checks and they were uploaded onto the SharePoint site, with an FLM checking them at least once per week. The access and egress of vehicles was observed. Staff communicated well with the drivers and ensured that they followed the guidelines with regards to identifying themselves and items not permitted i.e. personal communication devices. Once the staff member was content with the drivers credentials a thorough search of the vehicle took place, which was carried out when the vehicle left the prison. A number of search aids were at the disposal of the member of staff. When GEOAmey transport visited the prison a list of all registration numbers were available to staff, and if the number was not in the list then the transportation would be refused entry and the company contacted. A number of SOPs covering all aspects of this QI were available for reference by staff. Good practice 7: The areas around the perimeter were clear of rubbish maximising the opportunity to find items thrown over the perimeter.
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56 STANDARD 5 - RESPECT, AUTONOMY AND PROTECTION AGAINST MISTREATMENT A climate of mutual respect exists between staff and prisoners. Prisoners are encouraged to take responsibility for themselves and their future. Their rights to statutory protections and complaints processes are respected. Throughout the prison, staff and prisoners have a mutual understanding and respect for each other and their responsibilities. They engage with each other positively and constructively. Prisoners are kept well informed about matters which affect them and are treated humanely and with understanding. If they have problems or feel threatened they are offered effective support. Prisoners are encouraged to participate in decision making about their own lives. The prison co-operates positively with agencies which exercise statutory powers of complaints, investigation or supervision. Overall Rating: Satisfactory performance In this standard, one quality indicator was rated as good performance and seven were rated as satisfactory, giving an overall rating of satisfactory performance. There was one example of good practice and one recommendation for improvement. The overall impression at the time of the inspection was of a calm and well run establishment. Staff and prisoner relations appeared positive with a light and friendly atmosphere in most areas. Staff and prisoners addressed each other by their first names and appeared to have good relations. The regime was still restricted somewhat by COVID-19 however there were opportunities for all prisoner groups to spend significant time out of their cells whether attending work parties, education, PT, exercise or general association on the hall. It was noted that with the exception of mealtime numbers checks, the halls were generally unlocked for most of the day. This was appreciated by the prisoners having been restricted for much of the last two years. Activities such as education and PT are timetabled by flat to preserve the internal COVID-19 bubbles. This has worked well and has been scheduled to limit clashes where a particular flat would have two activities offered at the same time. There continues to be disruption within the work parties due to offender outcomes staff being deployed to the halls to cover staff shortages in the residential areas. This is in turn limiting opportunities for prisoners to engage in meaningful activities on a regular basis. In addition, there are no opportunities for protection prisoners to engage in enhanced workshops that would increase their wage earning potential. The PIC is very impressive and contains a broad mix of programming interspersed by adverts and announcements for internal courses and opportunities. In addition, it carries instructional videos to assist prisoners with using the kiosk system and carrying out a lateral flow test among other things. During the inspection there were no IPMs on site however staff and prisoners were aware of who they were and information on how to contact them was displayed
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57 clearly in all halls. It was stated by one individual in particular that having left a message on the prison phone system the IPMs got in touch quickly to discuss his issue. Prisoner Complaint Forms were freely available on all flats and there was a robust recording system in place to track the complaint from beginning up to external remedies where required. In terms of the PANEL principles for this Standard: Participation. Prisoners were fully involved in the ICM and Risk Management Team (RMT) process with regard to pre-release and progression. Families were invited to participate in the ICM process at the behest of prisoners. There had been no PIAC meetings since the start of COVID-19 and this had led to a reduction in user voice with regard to the current regime. Accountability. Progression was a common complaint and echoes the number of complaints received by HMIPS where progression is seen as unfair. Delays in assessment and offending behaviour programme availability are issues for both HMP Shotts and SPS HQ. Non-discrimination and equality. The current regime for education, PT and programmes allows equal opportunity for all prisoners to attend these sessions. Protection prisoners did not have the opportunity to attend the enhanced work party and were therefore denied the chance to increase their wage earning potential. Empowerment. Given that the population of HMP Shotts was long-term prisoners, the opportunities for support and engagement was clear across the establishment. Legality. There were no issues found around this point. Encouraging observations The current regime has been designed to minimise clashes between education, PT and exercise sessions. This reduced the times where an individual would have to forgo one activity to attend another. The PIC currently in use was of a very good standard and was well maintained by two individuals, with support from the education department. Emerging concerns A Recovery Café and Whole Mind Café were previously facilitated in the Tabernacle (TAB) within the Links Centre to support individuals with addiction and mental health issues. Since COVID-19 began these had not been held. Not all prisoners fit to work were currently required to do so. This had raised some concern with regard to motivating individuals when a return to a full regime was implemented. Certain work parties were also operating sporadically at times due to shortages in the residential areas. Programme delivery currently runs alongside the national waiting lists which could cause delays in getting programmes started due to availability of transfers
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58 from other establishments to fill the classes. This was having an impact on the number of courses that can run in the year. This is causing concern for all prisoners.
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59 Quality Indicators 5.1 The prison reliably passes critical information between prisoners and their families. Rating: Satisfactory performance Prisoners were afforded the opportunity to phone their family by the hall staff/manager following transfer. This was particularly important for individuals returned to closed conditions from HMP Castle Huntly, as generally these transfers were not pre-planned and the opportunity to contact family prior to transfer would be limited. Discussions with residential staff evidenced that contact between prisoners and families was such that it would more often be the prisoner who was passing information to staff in respect of ill health or bereavement of a family member. This information was generally received by the prisoner or a request would come from outside, usually via the ECR, for the individual to phone home. It was suggested that in the majority of cases the prisoner would be expecting such news and would be prepared for it. The hall staff would discuss this situation in private and remind the individual of support available including the chaplaincy service and listeners. In the event of a death of a relative, the relevant paperwork would be commenced and used to confirm details and inform the process should the individual request to attend the funeral. Family members were regularly invited to participate in the RMT process, and the sharing of this information was conducted following written confirmation from the prisoner. The prisoner provides the details of who they wished to be invited into this process. Information was available on hall notice boards advising prisoners that Families Outside could offer assistance to register and set up friends and family on the Virtual Visit platform. The Link Centre officer and Family Contact Officer (FCO) promoted family contact through physical and virtual visits, and could link with Families Outside to support friends and families if required. Information from the Links Centre Officer suggested that they work with the FCO promoting and supporting family contact. This was facilitated through the induction process and in the visitors waiting area where staff interact with friends and family prior to visit sessions. There was no FCO on duty during the visit as one was on leave and the other had been reassigned to another role due to staff shortages; worryingly this appeared to be an ongoing situation. 5.2 Relationships between staff and prisoners are respectful. Staff challenge prisoners’ unacceptable behaviour or attitudes and disrespectful language or behaviour is not tolerated. Rating: Satisfactory performance. During discussion with both staff and prisoners there was a reciprocal feeling of mutual respect and healthy relationships. There were no issues around
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60 unacceptable behaviours or language during the visit. Interactions were jovial and good natured. An individual had a request regarding when he would receive an Xbox that he had ordered, staff contacted the reception and were able to provide an update that the item was in reception and would be issued later in the day. The prisoner was content that this had been checked and that there was a positive outcome. A number of visits to the SRU by the team throughout the inspection reported that relationships appeared to be generally positive, and that the area was calm and the staff appeared relaxed and confident. Offender Outcomes staff appeared to have positive relationships with those in the work party. All individuals were engaged in their respective tasks and the workshops had a general air of productivity with a relaxed atmosphere. There were no obvious examples of inappropriate interaction during the visits. Two sheds were closed due to staffing issues in the halls. This had been a regular occurrence. 5.3 Prisoners’ rights to confidentiality and privacy are respected by staff in their interactions. Rating: Good performance During the visit there were various interviews being conducted on the halls from chaplaincy support, the Imam and NHS colleagues. All of these interactions were conducted in side rooms offering appropriate levels of confidentiality and privacy. Prisoners also sought and were granted permission to use these rooms while conversing with the inspection team. During discussions, interview room doors were closed in order that the conversations or treatments remained private. Prisoners were called down to the desk by name however no details of what they were required for were relayed in this manner. This information was passed once the individual had reached the main desk. In most cases the individual was aware of who was looking for him or where he was required to go, i.e. visits/surgery. White boards and desks appeared clear of individual’s personal details and paperwork. 5.4 The environment in the prison is orderly and predictable with staff exercising authority in a legitimate manner. Rating: Satisfactory performance There appeared to be limited interactions between staff and prisoners, however they were conducted in an appropriate manner. While some individuals were at work or at exercise at various times during the inspection, those left on the hall appeared to be content filling their time with social activities such as pool and snooker or in the company of their peers either in cell or in the communal areas. Those on the hall were happy to report that they spent more time out of cell in general association with the current regime than before COVID-19. They were generally only locked up for a numbers check prior to meal times.
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61 Following complaints HMIPS received regarding staff dealing with an incident in the NIC earlier this year, CCTV was viewed and the incident was explained by the IMU manager. It would appear from the footage that this situation could have escalated had it not been for the swift and professional actions of staff. There were no concerns that this incident was dealt with in a heavy handed way and staff acted appropriately given the seriousness of the situation. Throughout the visit staff interacted with prisoners in an appropriate manner and were happy to take time to discuss any issues with an individual and explain the rationale behind the decision making process. There were issues around the restricting of work parties either due to social distancing in the workshops or Offender Outcomes staff being utilised to run the residential regime. This led to a stop/start approach in some work areas which was unsettling for individuals who relied on routine. 5.5 Prisoners are consulted and kept well informed about the range of recreational activities and the range of products in the prison canteen as well as the prison procedures, services they may access and events taking place. The systems for accessing such activities are equitable and allow for an element of personal choice. Rating: Satisfactory performance Various posters were displayed on noticeboards advertising support groups such as AA/CA/Recovery Café/Whole Mind Café. These were accessed by asking hall staff to contact the relevant facilitators. At present only AA and CA were taking place. The Recovery Café and Whole Mind Café had been curtailed due to COVID-19 and had yet to restart. There were further outlets for information sharing on the hall kiosk system. Staff on duty at the time appeared not to be well informed about the system or how to access it. The most that they could confidently do was print out menus which was done on an app on SPIN terminals not on the kiosk. No one had a staff login that could demonstrate the options available. One prisoner was asked to demonstrate the system and was very competent and complimentary about its functionality. He shared that the younger prisoner group were supporting those that were not as well versed with technology. There was a PIC available to all that had been very well set up by two prisoners. This PIC automatically plays a weeks’ worth of content. It was set up to show various programmes from documentaries to comedy shows and films. In the “ad breaks” between shows the two individuals who run the system had made short presentations showing education opportunities/courses/how to videos for the kiosk system and lateral flow testing among other information. The clips were animated to keep them engaging for the target audience. The system also played podcasts created in education which again had added graphic content to make them more
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62 appealing to the viewer. This is considered good practice and a model that could be copied in other establishments. Good Practice 8: PIC showing clips including how to use the kiosk systems 5.6 Prisoners have access to information necessary to safeguard themselves against mistreatment. This includes unimpeded access to statutory bodies, legal advice, the courts, state representatives and members of national or international parliaments. Rating: Satisfactory performance Copies of prison rules were available from staff in the halls for prisoner use. In addition, the prison library was well stocked with reference materials including: Prison Rules and Directions, European Prison Rules, SPS Operating Standards, Prisoner and Criminal Procedure Act, Data Protection information, European Convention on Human Rights Legislation. Legal representative visits were booked and accessed through the visit area. These appointments were conducted either face-to-face or virtually. In general face-to-face visits were conducted in the closed visit area, however legal representatives requiring to go through paperwork could request a larger non-segregated area in which to conduct the meeting. During the inspection the area was visited twice and on both occasions it was virtual meetings taking place. These appeared to be progressing with no technical issues. Court appearances could also be conducted in this area via a dedicated video link. During the visit period there were no court hearings viewed. 5.7 The prison complaints system works well. Rating: Satisfactory performance Prisoner Complaint forms (PCFs) were freely available in halls and staff were aware of where to find them on SharePoint should they require more copies. The process, stages and relevant timescales were displayed within the halls on noticeboards. Some individuals were less than assured by the complaints process and stated that they would ask for a photocopy of the complaint in order that they could evidence submission of the form as they often disappeared. As there was no paper trail in this instance there is no way to confirm if it was actually happening. Staff on the flats would, in most cases, attempt to resolve any issues prior to the need to submit a formal complaint. HMIPS highly recommends extending the use of the kiosk stem to include a complaints process. A selection of PCF 1 and 2 forms were sampled. They all appeared to be well managed. A date stamp on the front of the form indicated when the complaint had been received from the FLM and further action dates such as Internal Complaints
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63 Committee (ICC), GIC, etc. These appeared to be followed through in a timeous manner up to the completion of an ICC where appropriate. The spreadsheet allowed for tracking of the complaint through to the Scottish Public Service Ombudsman (SPSO) for action. The responses appeared to be relative and proportionate to the complaint. There were instances of multiple complaints from the same individual on a similar vein submitted on the same day. All of them were answered individually and appropriately. Once a complaint had been received the details were logged on a spreadsheet and scanned to a file on SharePoint. The spreadsheet was completed for all stages of the process and any complaints that were still active were highlighted in red text. On at least one occasion, related to the removal of a mobile phone, the governor upheld the reasoning of the ICC in rejecting the appeal however indicated that the handset should be returned to the individual to allow continued family contact. Recommendation 27: Consideration should be given to extending the kiosk system to include an electronic complaints process. 5.8 The system for allowing prisoners to see an Independent Prison Monitor works well. Rating: Satisfactory performance All halls had information displayed promoting the services available and contact details of the IPMs. IPMs could also be contacted for free via the PIN phone system and the prison issue mobiles. Individuals spoken to during the visit reported that the system was working well and IPMs responded to messages in a timely manner. While information was displayed on notice boards there did not appear to be numbers displayed around the PIN phones. There were no IPMs on site during the visit however prisoners did comment that there were frequent visits and the IPMs were visible within the establishment.
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64 STANDARD 6 - PURPOSEFUL ACTIVITY All prisoners are encouraged to use their time in prison constructively. Positive family and community relationships are maintained. Prisoners are consulted in planning the activities offered. The prison assists prisoners to use their time purposefully and constructively and provides a broad range of activities, opportunities and services based on the profile of needs of the prisoner population. Prisoners are supported to maintain positive relationships with family and friends in the community. Prisoners have the opportunity to participate in recreational, sporting, religious and cultural activities. Prisoners’ sentences are managed appropriately to prepare them for returning to their community. Overall Rating: Generally Acceptable In this standard, three quality indicators were rated as good performance, four were rated as satisfactory performance and seven were rated as generally acceptable performance, giving an overall rating of generally acceptable. There was one example of good practice and eight recommendations for improvement. The prison offered an appropriate and sufficient range of high quality employment opportunities to prisoners. Prisoners engaged well in their work parties including the enhanced work parties which supported a commercial contract. Some work parties were cancelled frequently as staff were required for operational duties. As a result of COVID-19 restrictions there had been no new registrations for vocational qualifications in the past year. All prisoners were made aware of the system for paid work as part of their induction process. The Shotts Employability Board (SEB) met weekly to review applications and allocated prisoners to work parties. All prisoners were happy with the system for applying for and changing their work placements. The SEB did not keep eligible applicants on a waiting list for future opportunities. Prisoners were required to reapply every Monday if they were still interested in a work party opportunity. The Learning Centre provided a welcoming, bright and comfortable environment for prisoners to engage in learning. Prisoners and staff worked well together and prisoners valued their positive relationships with staff. Learning and teaching was of a high quality and purposeful. Induction was not compulsory and with no follow up was a missed opportunity to welcome prisoners to education and to highlight all that the Learning Centre had to offer. Staff did not always take prisoners previous qualifications, knowledge and experiences or barriers to learning into account when discussing their future learning. The prison offered a sufficient range of physical and health education opportunities, and these were available to all prison populations. The Physical Training Instructors (PTIs) were proactive in responding to the individual needs of prisoners who accessed the gym. The range of provision was limited and did not engage all prisoners. Due to COVID-19 restrictions no prisoners had gained sports and fitness accreditation.
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65 All prisoners had access to a well-stocked library, which took account of cultural and religious backgrounds. The librarian and passman were skilled, knowledgeable and proactive in promoting the library. Feedback on the library rules, stock, service and environment were captured, displayed and responded to. Nominated by the prisoners, the library assistant received recognition as the staff member of the year in the Fife College 2022 awards. A number of prisoners participated in a range of self-help and peer support opportunities. Prisoners produced the STIR magazine, a high quality art publication with contributions from all prisons. Prisoners who participated in art classes produced high quality work culminating in a number of successes at the Koestler Awards. All prisoners had access to a range of events prior to the pandemic. Over the past two years, these were limited but plans were in place to resume them in the near future. HMP Shotts were offering prisoners the opportunity to attend fresh air for a minimum of one hour per day, including those on isolation due to COVID-19 and the SRU. Access to fresh air was on a rotational basis offering different times across the week. Due to the poor turnout on the morning sessions a recommendation has been made to encourage participation by providing afternoon sessions every day. Although pastoral care was not available daily, requests and referrals were being dealt with in good time. The visitors centre had a welcoming feel to it, staffed by a FCO and Getting Better Together Shotts (GBTS) with an information loop on the TV and literature available for visitors. Interaction between staff and visitors was positive. During the visit sessions staff were not intrusive, whilst adhering to their security responsibilities. Access to normal visits consisted of five, 45 minute visits sessions available to book monthly. Uptake for morning and afternoon sessions was low. The father and child visits appeared particularly popular with a variety of toys and game activities available. However there were some complaints that father and child visits could be difficult to access. It was pleasing to report that HMP Shotts had recently increased the session from 12 to 18 prisoners; however even with the increase in spaces the evening sessions were fully booked. Accordingly although the overall number of visit opportunities seemed to meet the needs of the population, some sessions were poorly utilised and others over-subscribed. There were plans to introduce the video visit facility into the residential areas which could improve uptake. Those on restricted visits (closed) were managed appropriately with regular reviews in place. HMP Shotts provided a range of therapeutic treatments and cognitive development, as well as social and relational skills training activities, to all those at HMP Shotts as well as accommodating those on the national waiting lists. However there was some criticism voiced by prisoners that the lack of accessibility to courses prior to their critical dates ‘window’ was delaying their opportunity to gain progression or parole at the earliest time possible. During the inspection there were 100 ICM cases outstanding. The ICM co-ordinators were prioritising those individuals who required a pre-release or pre-parole case conference. The ICM co-ordinators were very enthusiastic and knowledgeable and were motivated to increase their own
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66 throughput and eradicate the backlog. It was reported that in some cases the ICM coordinators would complete Personal officer paperwork to meet ICM deadlines. Personal Officer lists were found in every residential area, which were linked to a master list held on the HMP Shotts SharePoint site. Some areas had the list posted on the prisoners notice boards, but in other areas these were only on the noticeboard in staff offices. HMP Shotts should ensure that Personal Officer lists are clearly posted where all prisoners can see them. The process for managing those on an Order for Lifelong Restrictions (OLR) and the Multi-Agency Public Protection Arrangements (MAPPA) worked well with good communication between partner agencies. In terms of the PANEL principles for this Standard: Participation: Prisoners were given the opportunity of work through a SEB on a one to one basis. Although there were some good examples of prisoners receiving individual support and mentoring to enable them to participate in work parties, there was also evidence where previous qualifications, knowledge and experiences or barriers to learning of prisoners were not taken into account. Prisoners who did not attend induction missed the opportunity to understand what was on offer as there was no follow-up communication later. Almost all prisoners who met with Inspectors highlighted the positive impact on their mental health and wellbeing as a result of participation in gym activities. Any prisoner who requires an annual case conference although not approaching their critical dates is asked if they wished a case conference. If they do, then an ICM is arranged. Accountability: The education department took into account the prison regime to minimise timetable clashes. Staff monitored the Library footfall, using the focus group findings to increase usage. Although HMP Shotts had a Family Strategy plan, this was now requiring a review due to being more than five years old. Regular case reviews of OLRs are carried by the Psychology department along with the personal officer, ensuring any new information is captured and is recorded in the national data base. Any new risks can then be identified to the Parole co-ordinator/Life Liaison Officer and a case conferences for referral is made to the RMT or MAPPA. Non-discrimination and equality: Educational opportunities were provided for all prisoner regardless of classification. There were some restrictions on protection prisoners attending enhanced work parties. Cultural events were vastly reduced due to COVID-19 but with the commencement of the Equality and Diversity Group in March 2022, plans were in place to return to the pre-pandemic timetable. The new Kiosk system was now in operation throughout the prison, with a range of languages on it, however not all prisoners were aware of this function. Prisoners were able to access a range of worship opportunities for different faiths including Muslim and Buddhist services however staff shortages did impact on these services. Only those visitors deemed as a risk were placed on closed visit, all other visitors were allowed open visits with prisoners, allowing prisoners children to see their father during child/father visits.
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67 Empowerment: Generally, most prisoners understood their rights for employment and the opportunities for education. Education focus groups allowed prisoners to suggest changes to timetables and subjects on offer and also ran focus groups twice yearly to understand the needs of their clients. Unfortunately, there was no evidence that the same process was in place for physical activity. Although there had been a Children’s Visits Activity Plan in place, this had now ended. HMP Shotts recognises the value of involving prisoners and their families in developing a new plan by arranging focus groups, however this had not yet taken place. Legality: Although the prison rules (82) state that all prisoners should work, this is not compulsory at HMP Shotts. During the Inspection, both residential halls offered all prisoners at least 60 mins of time in the fresh air to all prisoners. All prisoners managed under closed restrictions were done so in accordance with the Prison Rules. Encouraging observations Good examples of prisoners who were ‘not yet ready’ to participate in work parties being identified and supported well by their Personal Officer to work towards being able to participate. Almost all prisoners who met with Inspectors highlighted the positive impact on their mental health and wellbeing as a result of participation in gym activities Emerging concerns The number of work parties cancelled as staff were required for alternative prison duties Those not attending Education Induction should be followed up COVID--19 restrictions had prevented prisoners gaining sports and fitness accreditation. Registration for vocational qualifications had stalled There were no processes in place to consult with prisoners to take account of individual interests and needs to inform future programmes. For example, for those older adults and those with additional needs. The high number of outstanding ICM case conferences Prisoner perceptions of delays in progression or parole caused by limited access to offending behaviours programmes
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68 Quality Indicators 6.1 There is an appropriate and sufficient range of good quality employment and training opportunities available to prisoners. Prisoners are consulted in the planning of activities offered and their engagement is encouraged. Rating: Generally Acceptable The prison offered an appropriate and sufficient range of high quality employment opportunities to prisoners. These included work parties for gardens, laundry, catering, wood assembly, wood machine, engineers, bike shed, occupational, textiles, recycling and charity. The prison also provided employment for pass men in the residential halls, the education centre and gymnasium. Prisoners engaged well in their work parties including the enhanced work parties that supported a commercial contract. The prison had previously offered an extensive range of vocational training opportunities prior to COVID-19 restrictions. All prisoners were made aware of the available work parties at induction and all eligible prisoners were encouraged to attend a work party although employment is not compulsory. All eligible prisoners were given the opportunity to discuss their employment opportunities on a one to one basis by attending the SEB who met weekly to review and allocate available positions in work parties. There were good examples of prisoners receiving individual support and mentoring to enable them to participate in work parties. The scheduling of employment and training opportunities had not been reviewed since the start of COVID-19 restrictions. The SEB took no account of prisoner’s suggestions for future work parties. The prison regime had changed as a result of dealing with high levels of staff absenteeism. Some work parties were cancelled frequently as staff were required for prison security duties. As a result of COVID-19 restrictions there had been no new registrations for vocational qualifications in the past year. Recommendation 28: Registration for vocational qualifications should recommence 6.2 Prisoners participate in the system by which paid work is applied for and allocated. The system reflects the individual needs of the prisoner and matches the systems used in the employment market, where possible. Rating: Generally Acceptable All prisoners were made aware of the system for paid work as part of their induction process. The Shotts Prisoner Employment Policy supported the system for the allocation of paid work. The SEB met weekly to review applications and allocate
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69 prisoners to work parties. Almost all prisoners understood the rationale of selection for paid work, although some categories of prisoners were not eligible to apply for enhanced work parties. All eligible prisoners were able to apply for employment, or request a change of employment through the SEB. Prisoners were able to attend the SEB to discuss their application and to receive feedback. All prisoners were happy with the system for applying for and changing their work placements. There were good examples of prisoners who were ‘not yet ready’ to participate in work parties being identified and supported well by their Personal Officer to work towards being able to participate. Information regarding the availability of work parties was advertised in the accommodation halls, although the prison did not systematically advertise vacancies in work parties and relied on word-of-mouth. When a prisoner’s application for a work party was unsuccessful, the SEB did not keep eligible applicants on a waiting list for future opportunities. Prisoners were required to reapply every Monday if they were still interested in a work party opportunity. 6.3 There is an appropriate and sufficient range of good quality educational activities available to the prisoners. Prisoners are consulted in the planning of activities offered and their engagement is encouraged. Rating: Generally Acceptable The Learning Centre provided a welcoming, bright and comfortable environment for prisoners to engage in learning. The centre was fit for purpose and well equipped with a range of resources including the library. Prisoners and staff worked well together and prisoners valued their positive relationships with staff. Learning and teaching was of a high quality and purposeful. Staff adapted their learning and teaching approaches effectively to meet the needs of learners who were motivated and engaged in learning. A few prisoners were making good use of resources to support self-directed study. Prisoners participated in a wide range of subjects and qualifications at Scottish Credit and Qualifications Framework levels 3-6 across 12 subject areas including Communications, ICT, and Numeracy. There were a total of 13 prisoners participating in Open University courses with five continuing and eight who had recently applied. The Learning Centre Manager (LCM) held focus groups with prisoners to gather suggestions about changes to timetables and subjects on offer. Education opportunities were promoted within the halls and on the PIC. The LCM liaised informally with other areas within the prison and took account of their timetables when scheduling classes in order to minimise timetable clashes. The prison encouraged prisoners to participate in education and they received the
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70 appropriate wage from their work party whilst they attended the learning centre. Educational opportunities were provided for all categories of prisoner with timetabled provision for prisoners on protection regimes. All prisoners were informed that they had been scheduled for an induction session to education shortly after they arrived in the prison. If they didn’t attend at this time, there was no follow-up communication. This was a missed opportunity to welcome prisoners to education and to highlight all that the Learning Centre had to offer. During induction, Learning Centre staff made prisoners aware of the range of educational opportunities available within the prison. This provided an opportunity for staff to identify and support any prisoner requiring additional learning support. However, staff did not always take prisoners previous qualifications, knowledge and experiences or barriers to learning into account when discussing their future learning. 6.4 There is an appropriate and sufficient range of physical and health educational activities available to the prisoners and they are afforded access to participate in sporting or fitness activities relevant to a wide range of interests, needs and abilities. Prisoners are consulted in the planning of activities offered and their engagement is encouraged. Rating: Generally Acceptable The prison offered a sufficient range of physical and health educational opportunities and these were available to all prison populations. A change in regime due to the impact of COVID-19 has resulted in each residential level having individual access to the gym on a daily basis. As a result, attendance has increased to approximately 100 prisoners per day. The available space was used well to facilitate the increased numbers. For example, cardio equipment was in one area and weights were in the main hall area. The PTIs were proactive in responding to the individual needs of the prisoners who accessed the gym. This included an assessment using the physical activity readiness questionnaire and induction with a PTI before accessing physical activity. Personal training plans and health and nutrition advice and information was also provided on request. Relationships between the PTIs and prisoners were strong and their experience and support was valued. Almost all prisoners who met with Inspectors highlighted the positive impact on their mental health and wellbeing as a result of participation in gym activities. Prior to the pandemic, in partnership with Fife College, a few prisoners achieved accreditation in recognition of their achievements. The satellite gyms, which mainly consisted of cardio equipment in each of the residential halls were well used. In the NIC, weights equipment was also available, used well and prisoners were supported by a prison officer. There were a few examples where PTIs have provided individual programmes for use in these areas and promotional materials for the gym were on display in all residential halls.
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71 The range of provision was limited and did not engage all prisoners. Due to COVID--19 restrictions no prisoners had gained sports and fitness accreditation. There were no processes in place to consult with prisoners to take account of individual interests and needs to inform future programmes. For example, for those older adults and those with additional needs. Recommendation 29: Sports and fitness accreditation should be recommenced. 6.5 Prisoners are afforded access to a library which is well-stocked with materials that take account of the cultural and religious backgrounds of the prisoner population. Rating: Good All prisoners had access to a well-stocked library, which took account of cultural and religious backgrounds. This included books, audio material, DVDs and electronic games. An easy read section was also in place to support those with lower level reading ability. Coloured overlays were also available to support those with dyslexia. A smaller library resource was also located in the SRU. Regular donations from prisoners, the public and West Lothian Council library service also helped to expand the library content. The use of the Dewey decimal classification system to arrange books via subject aligned well with the library systems used in communities. Library resources were accessed by attending the library or through the well- established request service. The librarian and passman were skilled, knowledgeable and proactive in promoting the library. They supported prisoners to make best use of the resources and developed new initiatives to respond to identified needs. This included the partnership with NHS to develop a self-help service in response to a growing need for support with mental health. Self-help resources were displayed well and were widely accessible, including a confidential request service where information was delivered to residential areas. Requests for resources had increased and feedback was positive, including informal feedback across the wider prison population. The library assistant had completed first aid in mental health training, which had strengthened her knowledge in this area. The library assistant regularly visited halls to distribute information leaflets and promote the library. In cell reading materials were shared and goal setting and achievements were discussed regularly with prisoners. The library assistant, with good support from the passman developed and delivered a number of other programmes or activities. For example, monthly book groups and a regular podcast took place with all content identified by the prisoners. This included, music, book reviews, information sharing and inputs from partners. Partners, such as psychological services welcomed the opportunity to share information and demystify their profession. The Friday morning ‘Minds Matters’ sessions facilitated access to advice and information in response to an increase in mental health issues. Topics included mental health, suicide prevention, addiction, trauma, meditation and regular visits from a therapet, which was very popular.
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72 Library staff recorded footfall in the library on an ongoing basis and consulted with prisoners twice yearly. This showed that footfall was increasing. Feedback on the library rules, stock, service and environment were captured, displayed and responded to. Nominated by the prisoners, the library assistant received recognition as the staff member of the year in the Fife College 2022 awards. 6.6 Prisoners have access to a variety of cultural, recreational, self-help or peer support activities that are relevant to a wide range of interests and abilities. Prisoners are consulted on the range of activities and their participation is encouraged. Rating: Generally Acceptable All prisoners had access to a range of events prior to the pandemic. Over the past two years these have been limited but plans were in place to resume these in the near future. The Equality and Diversity Group held its first meeting in March 2022 and there were plans to build on the work of this group to design a varied programme of events for all prisoners. The Kiosk system that operates throughout the prison was available in a range of languages, however, not all prisoners were aware of this function. Prisoners who participated in art classes produced high quality work culminating in a number of successes at the Koestler Awards. Sixty-four pieces of art work were entered in 2022 with a further 15 entries in relation to graphic design, poetry and creative writing. In previous years, a few prisoners successfully gained gold and platinum Koestler Awards. Prisoners produced the STIR magazine, a high quality publication with contributions from all prisons. The content, with its focus on creativity and self-expression such as body art, was relevant to the prison population. The Editorial Group, consisted of four long-term prisoners who oversaw the production of the magazine. Supported by Fife College and distributed to 13 prisons across Scotland this provided an opportunity for prisoners to achieve individual goals. Similarly, the Snapshot monthly magazine written and designed by HMP Shotts prisoners was of good quality with content relevant to their context. A number of prisoners participated in a range of self-help and peer support opportunities, including a listener service, although these were limited. A systematic and planned approach to encourage participation would have benefitted the prison population. 6.7 All prisoners have the opportunity to take exercise for at least one hour in the open air every day. All reasonable steps are taken to ensure provision is made during inclement weather. Rating: Satisfactory During the Inspection, both residential halls were found to be operating time in the fresh air to all prisoners for a minimum of one hour per day. The four periods were
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73 for set times, but this was on a rotational basis ensuring each area had access at different times across the week. The timetable for accessing time in the fresh air was found on all hall notice boards. In every area a provision of outdoor weatherproof clothing was present, which appeared to be sufficient to accommodate everyone wishing to use it. The two periods in the morning were poorly attended from both of the residential halls. Attendance at afternoon sessions appeared much more popular with the prisoner groups. Staff advised that prior to COVID-19 only two sessions operated which meant grouping areas appropriately; such as Allenton levels 1 and 2 which both house protection prisoners. During the observation of an afternoon session a number of prisoners requested access back into the hall prior to the hour ending (referred to as ‘half-time’) which staff accommodated, the remaining prisoners enjoyed their full hour. This appeared to be a common practice, and the flexibility of staff to facilitate this ensured that prisoner’s needs or preferences were accommodated. One area reported having two individuals who were isolating due to COVID-19, both of whom were consistently offered their hour in the fresh air separate from other prisoners. The SRU was also found to consistently offering a daily hour in the fresh air to all prisoners. During the inspection period, all prisoners located in one specific area were restricted from having their opportunity of an hour in the fresh air due to on-going security concerns. These restrictions were applied appropriately and in full compliance with the Prison Rules. Recommendation 30: HMP Shotts should review the exercise timetable to appropriately group areas and consider scope to provide afternoon access to all prisoners every day. 6.8 Prisoners are assisted in their religious observances. Rating: Satisfactory The timetable for the various religious services was published and on display in all residential areas. The faith centre was bright and welcoming, with good décor and suitable to arrange for a wide variety of services or requirements. The pastoral team were awaiting the arrival of a new member of staff, due around the end of May. Currently, not all days had a member of the team on duty, but all requests and referrals were being dealt with in good time. There had also been some issues with the attendance of an Imam, but this had been resolved.
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74 Unfortunately, with reduced staffing the ability to deliver additional faith studies had been impacted. Previously up to four varying study groups were facilitated annually. It was hoped that after May, staffing would allow for the recommencement of a range of faith studies. The care of the pastoral team was evident through their willingness to provide, what they describe as ‘softer’ services, not directly linked to or based on one’s faith. Their willingness not just to attend to the ‘needs’ relating to faith but, trying to ensure any ‘needs’ of any prisoner were addressed is to be commended. 6.9 The prison maximises the opportunities for prisoners to meet and interact with their families and friends. Additionally, opportunities for prisoners to interact with family members in a variety of parental and other roles are provided. The prison facilitates a free flow of communication between prisoners and their families to sustain ties. Rating: Generally acceptable The Visits Centre was a welcoming venue, staffed by an FCO and Getting Better Together Shotts (GBTS). There was an information loop on screen and literature to assist families through their interaction with the prison and wider support groups. HMP Shotts provided a Family Strategy, however the five-year plan had expired in March of this year. The plan appeared to have been last updated in October 2019, and although a number of actions were completed there remained some which were on-going. Indeed, the plan appears not to have been reviewed and updated during the COVID-19 pandemic which was surprising. The FCO provided the Children’s Visits Activity Plan which showed activities across approximately 10 weeks for health, fitness, learning or general fun for children and families. This plan had ended with no replacement but inspectors were advised that families and prisoners were being consulted for the creation of a new Activity Plan. This was confirmed by managers who stated that user voices were important and that a survey was imminent for prisoner and families to shape services in the visits. The father and child visits appeared very popular with both prisoners and families. Staff positioned themselves well to maintain appropriate observations, but did so in a manner which was not intrusive nor impacted on the fun that the children present appeared to be having. A wide variety of toys and game activities were brought into the visit room which appeared to generate greater interactions between the fathers and their children. A stark contrast to the normal family visits where paper and colouring pencils were the only activity offered. Due to the pandemic, capacity of the visits required a reconfiguration of the layout, and part of this included the removal of the soft play area facilities (at the time of the inspection this area was still being used to store excess tables and chairs). Refreshment for all visits could be purchased from a number of vending machines which appeared well stocked. There previously was a tea-bar facility but this closed prior to the pandemic and had not yet been reopened.
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75 Prisoners were entitled to book five 45-minute visits sessions per month, inclusive of one evening and one weekend session per week. However, several prisoners commented that it could be difficult to access the Father and Child visits. Indeed, normal family visits in the evening or over the weekend appeared to be prime time with session often fully booked, and some prisoners reported that if these sessions were full then they would be without a visit that week. Conversely, morning and afternoon sessions appeared to be very poorly attended with numbers extremely low. In one instance HMIPS found a session where only three visits were booked and no visitors actually attended. During the inspection restrictions on capacity were lessened, increasing the session from 12 to 18 prisoners but even with additional places the evening sessions were fully booked. Recommendation 31: HMP Shotts should prioritise creating a new Family Strategy to plan improvements going forward and complete consultations with families around development of a new Children’s Visits Activity Plan. HMP Shotts should re-instate the soft play area as soon as possible and review what activities can be provided for children during normal family visits. Recommendations 32: HMP Shotts should review availability of visit sessions and maximise places in evening and weekends which best suit prisoners and families. 6.10 Arrangements for admitting family members and friends into the prison are welcoming and offer appropriate support. The atmosphere in the Visit Room is friendly, and while effective measures are adopted to maintain security, supervision is unobtrusive. Rating: Satisfactory practice A number of observations of admitting visitors to the prison and visits sessions were carried out. At all times, staff were found to be professional, they were courteous to visitors on arrival and helpful during visits sessions. Staff were observed dealing with a visitor who had mobility restrictions and their actions ensured that during necessary security checks no discomfort was placed on the individual. Visitors for one prisoner arrived when a visit had not been booked. Staff reviewed this appropriately and accommodated the visit, which was appreciated by the visitors. During visits sessions staff were observed to position themselves appropriately to maintain good overall security supervision, but not in a manner which would appear intrusive to either prisoners or visitors. Throughout all observations, the atmosphere in the visits room was relaxed and calm with all attendees appearing to interact freely without feeling scrutinised. GBTS staff the Visits Centre, however current provision only extends to week days and Saturday mornings. Inspectors were advised that GBTS were seeking to increase funding and provide staff across all visits sessions, and HMP Shotts should support them with this. The Centre was welcoming and well provisioned to support visitors, especially those with younger children. Whilst the GBTS staff were present there was a wide variety of activities for children as well as refreshments and information for families.
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76 6.11 Where it is not possible for families to use the normal arrangements for visits, the prison is proactive in taking alternative steps to assist prisoners in sustaining family relationships. Rating: Good Within the main visits area, HMP Shotts had five video conference units which could be booked through the normal visits process by submitting a visits request. Inspectors were advised that planning was underway to move this facility into the residential halls. This would potentially increase the capacity for the visits room for those seeking in person family contact, as well as, give potentially greater accessibility and flexibility to those wishing to undertake video visits. A video conference unit was also available within the SRU. Logistically, this benefited the whole establishment without creating the necessity to alter the regime when prisoners held within the SRU booked a video visit. This also ensured minimal disruption to regular family visits where additional staff would have been deployed within the visit room specifically for security of the individual from the SRU. This was considered good practice. The video visits that were observed appeared to run without issue but again were poorly utilised, with often only one or two prisoners and there was capacity for five. One potential issue was that although the prisoner had headphones, some appeared distracted by what was happening around them in the visits room. This possible distraction could be compared to having a call in a busy workplace or crowded room. Quieter surroundings may improve uptake and enjoyment of this facility. The prisoner induction included an offer of a family/friends induction on the facilities, support and range of opportunities available in the prison, in order that families can better understand what life in the prison is actually like. Good Practice 9: Video visits for prisoners in the SRU were facilitated within the SRU, which prevented any potential disruption to the main visit area. 6.12 Any restrictions placed on the conditions under which prisoners may meet with their families or friends take account of the importance placed on the maintenance of good family and social relationships throughout their sentence. Rating: Good During the inspection, only four prisoners were listed as being under restrictions for family visits and all were reviewed at minimum monthly by committee. All prisoners who were currently being managed under closed restrictions were done so in accordance with the Prison Rules. A review of these individuals and discussions with staff evidenced that each case was assessed on its own merits and decisions were tailored to the individual and the circumstances. One such individual, previously on the closed list, was reviewed and the restrictions were removed. They are now able to enjoy open visits with the majority of their
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77 family and friends. However, one of their visitors remained a risk and was therefore banned from entering the establishment. The prisoner was offered virtual visits with this individual. This was good use of the virtual facilities to maintain the family contact. 6.13 There is an appropriate and sufficient range of therapeutic treatment and cognitive development opportunities as well as an appropriate and sufficient range of social and relational skills training activities available to prisoners. Rating: Satisfactory HMP Shotts provided an appropriate range of therapeutic treatments and cognitive development, as well as social and relational skills training activities. A number of prisoners had transferred into HMP Shotts specifically to complete a course when the national waiting list triggered their attendance. Access to all courses was available to both mainstream prisoners and those in the protection regime. The Programmes Team delivered Constructs, Self-change Programme, Discovery and Pathways. As with all Prisons in Scotland, HMP Shotts adhered to the national waiting lists for prisoner attendance on the course identified for their specific needs. HMP Shotts was one of the few prisons offering some of these courses, which created logistical challenges but also other concerns. The lists provided showed that some prisoners may have to wait a considerable time in order to access and benefit from this opportunity. A number of prisoners voiced their concerns with regards to accessing programmes. It was felt by both indeterminate and determinate sentenced prisoners that the inability to access courses prior to their critical dates ‘window’ was delaying their opportunity to gain progression or parole at the earliest time possible. A number stated that this was the “SPS’ fault” and not theirs. Additionally, there was a concern regarding the approach to implementing the national waiting list which appeared to take no cognisance of the individual out with calculated critical dates. As such, prisoners who had served extremely long periods within HMP Shotts were informed that the next available space on a course meant they required to transfer to another establishment. Some prisoner had built friendships and a peer group who supported them, it may also place further hardship on their family if they decide to transfer for a course. The same could be the position for those prisoners who require to transfer to HMP Shotts for a programme. This is not a person-centred approach. Recommendation 33: SPS HQ should review the policy for implementing a national waiting list for access to programmes and its capacity for delivering programmes against demand to ensure there is no detrimental effect on the care of individuals in custody or their ability to progress.
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78 6.14 The prison operates an individualised approach to effective prisoner case management, which takes account of critical dates for progression and release on parole or licence. Prisoners participate in decision making and procedures provide for family involvement where appropriate. Rating: Generally acceptable At the time of the inspection, it was found that approximately 100 ICM case conferences were outstanding. Currently, the ICM co-ordinators were prioritising those individuals who required a pre-release or pre-parole case conference. Those individuals who required an annual case conference, where they were not approaching any critical dates, were written to asking if they wished a case conference at this time. Where the individual requested it the ICM co-ordinators would always oblige. Where appropriate the ICM co-ordinator would seek family involvement. However, although most pandemic restrictions had been removed, approximately only one in four family members who were invited to attend actually did so. The ICM co-ordinators were very enthusiastic and knowledgeable. There was a keen motivation to increase their own throughput and eradicate the backlog. In some instances, for those approaching critical dates, the ICM co-ordinators would complete missed Personal Officer interviews to ensure that the case conference could proceed without further delay. Personal Officer lists were found in every residential area, which were linked to a master list held on the HMP Shotts SharePoint site. All prisoners were listed with a named officer identified. Some areas had the list posted on the prisoners notice boards, but in other areas these were only on the noticeboard in staff offices. HMP Shotts should ensure that Personal Officer lists are clearly posted where all prisoners can see them. Recommendation 34: HMP Shotts should ensure that, whenever possible, it is always the Personal Officer that completes the required interview and documentation for the ICM process. Recommendation 35: HMP Shotts should continue to support ICM staff to address the backlog and bring all case conferences up to date. 6.15 Systems and procedures used to identify prisoners for release or periods of leave are implemented fairly and effectively, observing the implementation of risk management measures such as Orders for Lifelong Restriction (OLR) and Multi-Agency Public Protection Arrangements (MAPPA). Rating: Good The connectivity between internal departments evidenced a good level of communication relating to those prisoners identified for progression or potential release. The ICM co-ordinators knowledge and experience had promoted effective
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79 relationships and information sharing with all partners, whether managing individuals through MAPPA or those on an Order for Lifelong Restrictions (OLR). All OLR prisoners were managed nationally by the Head of Psychology, with regular case reviews led by the Psychologist within HMP Shotts. This included meeting with the Personal Officer to discuss the individual and any potential new information and the national database recorded monthly meetings. The ICM co-ordinators liaised with the Parole co-ordinator/Life Liaison Officer where potential risks were identified through case conferences for referral to RMT or MAPPA.
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80 STANDARD 7 - TRANSITIONS FROM CUSTODY TO LIFE IN THE COMMUNITY Prisoners are prepared for their successful return to the community. The prison is active in supporting prisoners for returning successfully to their community at the conclusion of their sentence. The prison works with agencies in the community to ensure that resettlement plans are prepared, including specific plans for employment, training, education, healthcare, housing and financial management. Inspection Findings Overall rating: Generally Acceptable Performance In this standard, two quality indicators were rated as satisfactory and three were rated as generally acceptable, giving an overall rating of generally acceptable. There were two examples of good practice and five recommendations for improvement. Relevant Information for this standard HMP Shotts is the only establishment in Scotland that is categorised as a long-term prison however during the inspection there were 15 prisoners serving under four years, including recalls. The following findings therefore need to be read in the context of the following information: Most prisoners are not liberated from HMP Shotts, but progress to other prisons to prepare for release. HMP Shotts does not have the same role as other establishments in terms of preparing prisoners for their successful return to the community. The prison liberates between 60 and 100 prisoners each year, with almost all released on non-parole licence, and not subject to statutory supervision by community-based social work services. The prison has a key role in supporting and approving progression of prisoners to National Top End (NTE) establishments and the open estate. Therefore, the prison has a responsibility for preparing individuals appropriately for these important transitions. In terms of the PANEL principles: Participation: Prisoners in HMP Shotts had good opportunities to get involved in key planning processes. ICM meetings were appropriately focussed on the individual prisoner. The prisoners were encouraged to share their views about the support they may require and access to services for helping them prepare for release or progression to less secure conditions. Prisoners were encouraged to become fully involved in the completion of reports by prison staff and prison based social workers. Families were provided with relevant information on the key planning processes and were encouraged to take part in ICM meetings where appropriate, although the numbers attending were low.
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81 Accountability: The delivery of accredited programmes at HMP Shotts reflected the needs of the population. There were clear attempts to be flexible to meet individual needs and examples of innovation to further develop these programmes. There was an outstanding need to review the broader delivery of interventions with a particular focus on meeting the support needs of a prison population affected by addictions, trauma and loss. The pre-release ICM meeting was key to identifying any concerns about plans for transition. These meetings ensured that all relevant support services were aware of the individual’s circumstances and the supports needed. Non-discrimination and equality: The importance of initial case conferences as part of the ICM processes was understood by key staff and every effort was made to ensure that these meetings had all the information they needed for identifying any vulnerabilities. Accessibility issues were discussed within the Programme Case Management Board (PCMB) and solutions developed to ensure that barriers to attending programmes delivered in the establishment were removed. Empowerment: Prisoners were placed at the centre of the ICM meetings. Preparatory discussions sought to ensure they understood the process of these meetings and were enabled to contribute. The format of these meetings ensured that prisoners had an opportunity to comment or ask questions regarding sentence plans. Care was taken to ensure that prisoners understood what was being said as well as any decision and outcomes from the meeting. There was a mixed understanding among prisoners about the range of services available to them. There were also examples of variability in the quality of communication with prisoners about decision making related to their progression. As a result, some prisoners felt ill informed about plans for progression and eventual release. There was some uncertainty about what may be in place for them in terms of future community supports. Legality: There was an appropriate emphasis on meeting legal obligations and the role of community-based services in meeting the needs of individuals making the transition from custody to life in the community. Community-based social work services played a key role in ensuring that services in the community were in place to enhance the likelihood of a successful future integration. Despite this, some prisoners were unclear about plans for release and were not confident that they would have access to the support they needed, including access to appropriate housing. Encouraging observations The co-location of interventions, psychology and prison based social work (PBSW) teams enabled opportunities for case discussion and reflection. In turn this promoted understanding of each other’s role. HMP Shotts prioritised the resumption of programme delivery following the lockdown. As a result, the programme delivery team was able to progress innovations to improve the content of existing programmes.
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82 Emerging concerns HMP Shotts should explore potential partnerships to offer independent advice in relation to the issues likely to concern all prisoners due for release from HMP Shotts, e.g. financial, housing, employment. This will help to ensure that prisoners have the access they need to advice relevant for making successful plans for release. HMP Shotts should improve consistency in the role played by personal officers (POs) in supporting individuals, including attendance at pre-release ICM meetings and ongoing time with prisoners prior to release. This will promote the confidence of prisoners in the plans for their release. HMP Shotts should explore opportunities to gather evidence on the progress and outcomes for individuals liberated from the prison to inform service delivery and support continuous improvement. This will help to ensure that prisoners benefit from evidence-based approaches to the successful return of individuals from custody to the community. To help to prepare prisoners for the significant transition from custody, HMP Shotts should promote the delivery of a formal ‘life skills’ learning opportunity.
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83 Quality Indicators 7.1 Government agencies, private and third sector services are facilitated to work together to prepare a jointly agreed release plan and ensure continuity of support to meet the community integration needs of each prisoner. Rating: Generally acceptable Collaboration between agencies based within the prison was effective. Appropriate efforts were made to identify services to support individual prisoners’ sentence plans and eventual community integration needs. The pre-release ICM meeting was a key step in the process. Efficient preparations ensured the right people were involved in ICM meetings, including family and community-based services. The meetings were focussed on the individual and their plan for progression and eventual release. This included identifying support needs and how they were to be met. The Link Centre had a limited resource. Efforts concentrated on addressing potential logistical barriers to progression and eventual reintegration, including access to a bank account and accepted identification documents. This was undoubtedly a valuable service. There were few external or community-based agencies with a regular presence in the prison. There was an emphasis on, and expectation of, community-based social workers (CBSW) to engage and involve services in planning for release. Access to independent general advice such as on benefits, financial matters or housing was not available to prisoners. Recommendation 36: HMP Shotts should explore potential partnerships to offer independent advice in relation to the issues likely to concern all prisoners due for release. This will help to ensure that prisoners have the access they need to advice relevant for making successful plans for release. 7.2 Where there is a statutory duty on any agency to supervise a prisoner after release, all reasonable steps are taken to ensure this happens in accordance with relevant legislation and guidance. Rating: Satisfactory The ICM process was well established and there was a consistent approach to the efficient coordination of these meetings. There was consistent attendance from PBSW and CBSW who were both involved in the preparation of assessments to inform sentence planning and the formulation of pre-release plans. Knowledge of the ICM process among prisoners and staff was satisfactory. The involvement of POs in meetings and the overall quality of reports was mixed. POs reported that it would be beneficial for ICMs to be arranged when they were on shift. New residential officers (direct entrants) made comment that there should be more emphasis placed on PO work while they were at the SPS college for initial training, and they felt unprepared when returning to their establishment.
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84 Collaboration between PBSW and CBSW from various parts of the country was challenging. However, the experienced PBSW Team worked hard to ensure that communication was effective. PBSW staff consistently fulfilled their responsibilities in the preparation of assessments and reports to assist decision making. The social work contribution was valued. Social workers were core members of the RMT, and alongside colleagues from psychology provided relevant expertise and knowledge to support and inform defensible decision making in relation to sentence progression and access to the open estate. Assessments and reports prepared by PBSW and psychologists benefitted from the relationships staff had developed with long term prisoners. As a result, assessments and reports reflected cooperative inter-disciplinary working and were informed by the views and experiences of prisoners. Good practice 10: The co-location of Interventions, Psychology and PBSW teams enabled opportunities for case discussion and reflection which in turn ensured that there was a good understanding of each other’s roles. Recommendation 37: SPS HQ should consider whether there should be more emphasis placed on Personal Officer work during officers initial training at the SPS college. 7.3 Where prisoners have been engaged in development or treatment programmes during their sentence, the prison takes appropriate action to enable them to continue or reinforce the programme on their return to the community. Rating: Satisfactory General Programme Assessments (GPAs) continued to be undertaken by psychology staff throughout the pandemic to determine access to the most appropriate programmes. Where specialised assessments were identified as appropriate, for example domestic abuse convictions, these were completed. There was recognition by the programmes team and prison-based social work of limited capacity to complete level of service/case management inventory (LS/CMI) assessments to inform the PCMB. Staff were ambitious for the further development of a broader range of interventions. Building on what existed to address addictions and increasing the availability and accessibility of counselling for loss and experience of trauma. The programme delivery team were also piloting a programme which included a focus on addressing domestic abuse. These were encouraging developments. Prisoners were not confident about the continuity of access to programmes when returning to the community. Prisoners were frustrated by the waiting list to access national programmes and the detrimental impact this lack of access had on progression. The programmes team were proactively seeking solutions to this issue.
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85 Good Practice 11: HMP Shotts prioritised the resumption of programme delivery following the lockdown and the programme delivery team was innovating to improve the content of existing programmes. 7.4 All prisoners have the opportunity to contribute to a co-ordinated plan which prepares them for release and addresses their specific community integration needs and requirements. Rating: Generally acceptable The ICM system was well established with a clear focus on identifying and meeting the needs of individual prisoners. Staff responsible for the operation of ICMs made effective arrangements to promote the involvement of all prisoners and, where appropriate, family members, although the attendance by family members was low. The central focus of the ICM on the prisoner, meant they were encouraged and supported to voice their views. While there is an expectation that prisoners are supported by POs, this was not always happening. There were challenges due to rostering and in the timely completion of reports and updates to Community integration plans (CIPs). The regime, whereby most prisoners were locked up after tea time, did allow for PO work to be carried out but a lack of training is a concern. New POs rely on more experienced POs to learn from which is not always the most effective way of learning. Information sharing between PBSW and CBSW was effective in co-ordinating plans for release. Given the prison accommodated prisoners from all over the country, there was an emphasis on the role of CBSW in identifying and arranging appropriate community supports and involving them in planning where relevant. There was a concerted effort to provide access to drug and alcohol interventions within the prison. Appropriate oversight was provided by a group of multi-agency statutory partners. Some prisoners due for release from the prison lacked confidence about important parts of their integration plans, especially housing options and access to mental health support. None had been given any formal opportunity to develop key life skills as part of preparation for release during their sentence. Recommendation 38: HMP Shotts should improve consistency in the role played by POs supporting individuals, including attendance at pre-release ICM meetings and ongoing time with prisoners prior to release. This will promote the confidence of prisoners in the plans for their release. Recommendation 39: HMP Shotts should explore the delivery of a formal ‘life skills’ learning opportunity to help to prepare prisoners for the significant transition from custody to the community.
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86 7.5 Where the prison offers any services to prisoners after their release, those services are well planned and effectively supervised. Rating: Generally acceptable The prison did not offer any services to prisoners after their release. No information was being gathered on progress and outcomes after release to inform any future developments. Prior to release efforts were made to help prisoners engage with services to support transition to the community on release. This was usually coordinated by CBSW and link centre staff based on needs identified in the pre-release ICM meeting. Other external agencies attended these meetings where relevant, including representatives from housing or accommodation providers. Link centre staff responded directly to the needs of prisoners on an individual basis, including in relation to finances and welfare rights issues. There were limited examples of external agencies looking to establish a routine presence in the prison to build relationships with prisoners to support the transition from custody to the community. Recommendation 40: HMP Shotts should explore opportunities to gather evidence on the progress and outcomes for individuals liberated from the prison to inform service delivery and support continuous improvement. This will help to ensure that prisoners benefit from evidence-based approaches to the successful return of individuals from custody to the community.
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87 STANDARD 8 - ORGANISATIONAL EFFECTIVENESS The prison’s priorities are consistent with the achievement of these Standards and are clearly communicated to all staff. There is a shared commitment by all people working in the prison to co-operate constructively to deliver these priorities. Staff understand how their work contributes directly to the achievement of the prison’s priorities. The prison management team shows leadership in deploying its resources effectively to achieve improved performance. It ensures that staff have the skills necessary to perform their roles well. All staff work well with others in the prison and with agencies which provide services to prisoners. The prison works collaboratively and professionally with other prisons and other criminal justice organisations. Inspection Findings Overall Rating: Generally acceptable Performance In this standard, four quality indicators were rated as satisfactory performance, three were rated as generally acceptable performance, and one was rated as poor performance giving an overall rating of generally acceptable. There were three recommendations for improvement. With only one exception, performance against the quality indicators in this standard was either fully satisfactory or generally acceptable with sufficient evidence of competence against some elements of the quality indicator to not cause concern. For example, there was clear evidence of appropriate action in response to our previous recommendations and sound business planning processes. Staff were clear on their roles and what was expected of them and planning to deal with vacancies and staff absences was robust, whilst still being compassionate. Compliance with core competency training requirements had suffered significantly as a result of the pandemic, but the issue was being gripped effectively by the new Learning and Development Manager. The main concern was the lack of a structured plan for assessing how the prison operated in relation to its Equality and Diversity (E&D) obligations. The prison would also benefit from more detailed statistical monitoring to safeguard against unintentional bias in the operation of systems affecting employment and educational opportunities or responses to complaints and prisoner indiscipline. While the GIC had helpfully begun a process of engagement with unit managers and some of the people who reported to them, we encourage further efforts to consolidate communication and engagement with front line staff. There is also a need to ensure managers give greater priority to the completion of staff appraisals. In terms of the PANEL principles for this Standard: Participation. The suspension of PIACs during the majority of the pandemic was disappointing as it significantly restricted the ability of prisoners to contribute to any discussion or decision making about the running of the prison
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88 regime. While the need to comply with COVID-19 related guidance around social distancing, etc., is fully recognised, there were parts of the prison where PIACs could have been held in line with Public Health Scotland guidance. Accountability. To their credit, the prison had unquestionably taken decisive action to address the areas of poor performance identified in the previous HMIPS inspection report. Understandably staff training to support their roles within the prison and maintain core competency had been significantly impacted by the pandemic. The prison estimated it would take a year to achieve full compliance again with core training which was a concern, particularly in relation to control and restraint procedures, but the prison had a clear plan for addressing that. Non-discrimination and equality. While the prison spoke eloquently of what it had done before the pandemic to promote Equality and Diversity, the lack of any up to date structured plan to assess and promote E&D at the time of our inspection was a major concern. It is imperative that the whole agenda around E&D is swiftly re-energised. Empowerment. While staff-prisoner relationships were witnessed by inspectors as positive and respectful throughout the prison, the length of the gap in the running of any PIAC during the pandemic left a concern about the commitment to empower prisoners to participate and claim their entitlements. Without an effective system of PIACs and focus groups it is difficult to see how prisoners can feel that their voice matters. Nevertheless, at the time of our inspection PIACs had begun to be re-established. Legality. There were no issues in relation to this standard regarding upholding the legal rights of prisoners as set out in domestic and international laws. Encouraging observations Respectful staff – prisoner relationships, with motivated committed staff. The swift and effective response by management to investigating and responding to some issues raised by inspectors during the inspection and clear evidence of action to address previous inspection recommendations. Emerging concerns The lack of a structured plan for assessing the extent to which the prison currently meets its E&D obligations and where improvements are necessary. Difficulties achieving core training competency levels due to operational restrictions posed by the pandemic. The loss of opportunities for prisoners to inform or influence decision making during the pandemic when PIACs were suspended. The need to improve communication and engagement with front line staff, building on recent helpful initiatives by the GIC. Poor completion rates for staff appraisals in 2020-21. Recent tensions between the trade union side and the management team, although relationships appeared to be improving at the time of our inspection
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89 The Senior Management Team (SMT) and a number of management posts below that had been occupied on a temporary promotion basis for over two years.
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90 Quality Indicators 8.1 The prison’s Equality and Diversity Strategy meets the legal requirements of all groups of prisoners, including those with protected characteristics. Staff understand and play an active role in implementing the Strategy. Rating: Poor COVID-19 and a reorganisation within the management team as a result of a medical retirement had impacted on efforts to promote and safeguard Equality and Diversity (E&D). The prison was able to talk about constructive partnership working developed in the past with Alzheimers Scotland, previous themed events in the prison and local training previously delivered on E&D, but action had paused completely during the pandemic and the prison was only just starting to re-engage with the agenda. At the time of the inspection the first meeting of a new operational E&D group had taken place, but no local E&D Strategy or Action Plan had been developed. Monthly meetings of the operational E&D group were planned, along with quarterly meetings with the Governor with a more strategic focus on E&D. The E&D Manager was only covering the role on a temporary basis resulting in the lack of a dedicated resource with appropriate specific training or experience around Equality & Diversity. The prison would benefit from conducting more systematic monitoring of data around opportunities for those with protected characteristics, and their involvement in disciplinary processes, relative to other prisoner groups to ensure no unintentional discrimination was occurring. Recommendation 41: HMP Shotts should prioritise re-energising the E&D agenda, including regular meetings of the E&D committee with prisoner representation, development of an E&D action plan, more systematic monitoring of data to avoid unintentional bias with employment, education and discipline, etc., and provide comprehensive training for the E&D Manager. 8.2 Appropriate action has been taken in response to recommendations of oversight and scrutiny authorities that have reported on the performance of the prison. Rating: Satisfactory The SPS and NHS prison healthcare teams were clear on the areas where performance improvements had to be prioritised after the previous HMIPS 2017 inspection report, and good progress had been made in several areas. Inspectors were pleased to see significant improvements had been achieved in relation to the range of educational opportunities and activities and development of the library. Inspectors also welcomed a notable improvement in mental health support since the last inspection.
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91 The prison conducted PRL audits on a systematic basis and there was also evidence of the prison responding to audit and assurance exercises carried out by SPS HQ. The reliability of some of the findings in these PRL audits might be questioned, however, as the one on E&D had provided substantial assurance, which did not tally with our own inspection. 8.3 The prison successfully implements plans to improve performance against these Standards, and the management team make regular and effective use of information to do so. Management give clear leadership and communicate the prison’s priorities effectively. Rating: Satisfactory The prison had a clear business plan based around five core themes of development, engagement, impact, standards and collaboration. Progress against the plan was carefully tracked and recorded, with clarity around which tasks had been completed and where slippage against the original envisaged timetable had occurred. Monthly business planning meetings provided a forum for discussing progress. Staff had been given the opportunity to input into the 2019/20 business planning process, but the pandemic had interfered with that process for systematic engagement. The prison intended to reinstate the engagement process for the next round of business planning. The GIC had recently started a series of engagement sessions with Unit Managers, who were encouraged to bring in some of their own direct reports for an open discussion on where and how improvement could be made. There was also a weekly meeting of FLMs every Monday and roster meetings every Wednesday. A brief was also emailed to all staff every month which provided an update on action in response to issues raised by staff. Despite these forums for engagement and communication, front line staff often criticised a lack of communication from management or what they perceived as late communication. Although this seemed to relate partly to changes in guidance around COVID-19 from Public Health Scotland, which the management team were obliged to implement without delay, there was evidence of the value of further strengthening communication with front line staff. We were concerned, however, that the Senior Management Team (SMT) and a number of management posts below that, had been occupied on a temporary promotion basis for over two years; this was not conducive to stability and longer term planning so we urge the SPS to secure some more permanent arrangements as soon as possible. Recommendation 42: The GIC should build on recent efforts to improve communications and engagement with staff, particularly with front line staff. Face-to-face discussions with larger groups of staff would be helpful.
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92 8.4 Staff are clear about the contribution they are expected to make to the priorities of the prison, and are trained to fulfil the requirements of their role. Succession and development training plans are in place. Rating: Generally acceptable Staff were clear about their roles and the contribution they were expected to make to the prison’s priorities, but regimes staff in particular found it hard having to cover for the absence of residential staff as it was more difficult for them to answer prisoners’ queries. Despite frustrations for some staff around being pulled away from their specialised functions, most staff expressed a strong commitment and motivation to their roles within the prison. Contingency plans for a range of potential issues were in place within the prison and there was regular and robust monitoring of anticipated vacancies and those expected to return to work to inform planned recruitment needs. Management also understood the issues they faced in managing succession issues within the prison. They were acutely aware, for instance, of the number of staff who were moving towards retirement age in the next few years and of the high number of individuals acting up at different levels within the organisation. They had plans in place to bring longer term stability to the staffing structure, but their planning was to some extent dependent on decisions elsewhere or national recruitment by SPS HQ. The prison had an overall record of 78% compliance for core competency training, with significantly lower compliance rates around Personal Protection Training, C&R, Fire Response Procedures and Emergency Response. Although still new to the post, the prison’s new Learning and Development Manager had a strong grip on these training priorities such as the need to focus on C&R training. COVID-19 restrictions during the pandemic had necessitated a lengthy pause in C&R training, and the prison estimated that it would take a year to recover due to limitations posed by the Training Variable and the challenges in securing staff availability. This was a concern, particularly in relation to the limited number of staff still in competency to conduct planned removals and other C&R processes. More positively the Learning and Development Manager was committed to embedding control and monitoring of training around the MyLo system, with the aim of ensuring that the principal responsibility for meeting training requirements rested more clearly with individuals and their line managers. Awareness raising and informal mentoring and shadowing opportunities to support those seeking promotion were in place, but a more structured approach might be beneficial. 8.5 Staff at all levels and in each functional staff group understand and respect the value of work undertaken by others. Rating: Generally acceptable The staffing challenges posed by COVID-19 related absences often required regimes staff to temporarily suspend their work parties and help their residential staff
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93 colleagues. Although it was difficult for regimes staff to fill in for residential staff, they accepted the need to do so and this helped facilitate recognition of respective roles and challenges. Front line SPS and NHS staff were required to work effectively together on a daily basis and again there was generally a respectful recognition of respective roles and shared challenges. The GIC and Deputy Governor took opportunities to rotate individuals into different roles to widen experience and support respect for the work of others. However, before the inspection there had been significant tensions in the relationship between the GIC and the local trade union representatives over a number of important issues which had clearly been difficult for all involved and which had contributed to some significant instability prior to our inspection. It was encouraging therefore to hear both the GIC and the trade union representatives suggest that relationships had started to improve, and we hope that continues. 8.6 Good performance at work is recognised by the prison in ways that are valued by staff. Effective steps are taken to remedy inappropriate behaviour or poor performance. Rating: Generally acceptable The prison had a robust but caring approach to managing staff absences, implementing return to work interviews and monitoring absences effectively. The total number of staff absences had reduced from 93 at Christmas 2021 to 27 at the time of our inspection, which was encouraging. The Staff Recognition Committee chaired by the HR Manager with representation from across the prison encouraged and discussed nominations for Governor awards. Individuals chosen by the Governor to receive such an award were given the choice on whether they wished to be presented with the award in front of their peers or preferred to receive the award in private. It was pleasing to see the Staff Recognition noticeboard refreshed with more recent photographs during the course of our inspection. A medal was presented to all staff reaching 20 years’ service and inspectors welcomed the establishment of an Achievement Tree with the names of those staff with 25 years’ service engraved on metal leaves. However, even recognising the exceptional additional challenges posed for the prison by the pandemic, it was disappointing to see that the completion rate for staff appraisals for 2020-21 was only 46%, despite evidence of reminders being sent. Inspectors hope that with COVID pressures now receding, management at all levels will now give the completion of staff appraisals the priority it deserves. Recommendation 43: HMP Shotts should give greater priority to the completion of staff appraisals, ensuring improved completion rates for 2021-22 and future years.
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94 8.7 The prison is effective in fostering supportive working relationships with other parts of the prison service and the wider justice system, including organisations working in partnership to support prisoners and provide services during custody or on release. Rating: Satisfactory The GIC contributed to the Criminal Justice Partnerships for North and South Lanarkshire and West Lothian, but Shotts acts as a national facility with prisoners often returning to a local prison prior to liberation; it simply wouldn’t be possible for the GIC to attend all community justice partnerships across the country. However, the prison worked alongside Police Scotland and MAPPA colleagues as required around public protection issues. It also supported the work of the Addictions Drugs Partnership for Lanarkshire, contributing specifically around drug related deaths and consideration of what more could be done within the prison and local community to reduce risks. At the time of the inspection the prison was exploring a range of initiatives to provide for those in their care such as Street Soccer and Street Cones. The prison hoped to bring the Metro Big Band to HMP Shotts, when they appeared at the Edinburgh Fringe, and to renew their previously successful partnership with Alzheimers Scotland to build on the work that had been suspended during COVID-19. A lot of these initiatives were at a very early stage at the time of our inspection, but it was encouraging to hear discussion of them as part of the planned recovery from COVID-19. 8.8 The prison is effective in communicating its work to the public and in maintaining constructive relationships with local and national media. Rating: Satisfactory As with other prisons, most media issues were dealt with by the national communications team within SPS HQ. However, the GIC had taken part in a recently aired BBC Scotland TV programme “My Kind of Town” partly to explain the importance of the prison within the local community. A local community group GBTS operated within the HMP Shotts Visitor Centre, and the prison management team appreciated the contribution they made to family visits and the successful running of themed events for prisoners and families.
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95 STANDARD 9 - HEALTH AND WELLBEING The prison takes all reasonable steps to ensure the health and wellbeing of all prisoners. All prisoners receive care and treatment which takes account of all relevant NHS standards, guidelines and evidence-based treatments. Healthcare professionals play an effective role in preventing harm associated with prison life and in promoting the health and wellbeing of all prisoners. Inspection Findings Overall rating: Poor In this standard, five quality indicators were rated as satisfactory, six were rated as generally acceptable and five were rated as poor, giving an overall rating of poor. This grading is reflective of the significant and sustained pressures on staff and the detrimental impact on patients receiving care. This is not a reflection of the considerable efforts made by staff within HMP Shotts or the North Lanarkshire Health and Social Care Partnership (HSCP) to support the healthcare needs of patients in HMP Shotts. There were 12 examples of good practice and 22 recommendations for improvement. The Healthcare Team had experienced significant and sustained staff shortages across all disciplines. Continued staff shortages had impacted on the team’s ability to provide adequate staffing and maintain a safe skill mix on some occasions. As described in the escalation below and in QI 9.2 and QI 9.6, there was no GP cover after 1.30pm. As a direct result of absences within the Senior Leadership team, staff reported they were not receiving one to one support or clinical supervision in any consistent pattern. Staff morale was low and staff were reporting fatigue. The fragility in the workforce was a significant concern and was escalated during the inspection. Senior managers were aware of the ongoing challenges for staff in HMP Shotts. Inspectors were provided with evidence of the service model review commissioned by senior management from North Lanarkshire HSCP. The lack of medical cover was impacting on the ability to provide long-term condition management of patients. All patients’ records are kept in the electronic Vision patient record system. It was not clear how staff were using the full function of this system effectively to collect data for patients with long-term health conditions. These factors have led to a systematic failure to deliver long-term condition reviews and oversight. The clinical pharmacy role was not patient facing and was not shown to be accessible for the population of HMP Shotts to discuss their medications with a member of the Pharmacy Team. This was not equitable to what is provided within the community in NHS Lanarkshire and is a concern. North Lanarkshire’s HSCP must action the recommendations made in their service review regarding pharmacy provision and support as a matter of priority. It was not clear how the Pharmacy
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96 Team links to the NHS Lanarkshire Pharmacy Service for professional support and development. Our clinical partner’s discussion with the pharmacy adviser identified challenges with building effective working relationships with GPs to improve prescribing practices and the potential to develop multi-disciplinary team (MDT) working to improve patient outcomes. Registered nurses had the responsibility of reviewing complaints. There was no evidence as to whether staff had received training on how to review, respond and escalate complaints. Whilst staff had the opportunity to have informal discussions between themselves about complaints, there was no formal process in place to share learning from complaints. Inspectors were told that staff meetings were not taking place at the time of our inspection due to staffing shortages Inspectors were told that secondary care appointments were being sent by post because of issues with the IT systems in HMP Shotts, which presented a significant data risk. Inspectors were informed, during the inspection, that practice had changed and all referrals to secondary care were being managed electronically, directly to the NHS board, and postal referrals would be stopped. Inspectors will follow this up as part of their revisit. Escalation During the inspection, gaps were identified in senior clinical staffing resource during periods of the day, with no GP cover provided between 1:30 pm and 6pm. GP cover was provided in the health centre in the mornings and after 6pm, on-call GP facilities were available. This was highlighted during the previous inspection in 2017. Further to this, there were only two Band 5 Registered General Nurses (RGNs) on shift from 3:30pm until 6pm to undertake clinical duties, such as medication rounds and attend emergency calls (code red/code blue). Emerging concerns: The prison is open to activities during 3:30pm until 6pm and therefore there is an increased risk of incidents. There is no clear mechanism for the Band 5 RGNs to discuss concerns, or get support around clinical decision making for deteriorating patients during this period of time. Contacting the Scottish Ambulance Service for emergency response is the default position, as there is no other way to obtain measurable clinical advice. It was important to note that following a restructure and changes in both leadership and responsibility of prisoner healthcare. In response to North Lanarkshire’s HSCP identifying underlying challenges in healthcare delivery, a service model review of HMP Shotts was carried out in March 2022 and an action plan was developed. Inspectors reviewed both the service review and action plan provided and were encouraged to see many of the issues identified throughout the inspection and planned improvements. These had been assigned senior leadership, however were yet to have identified timelines. At the time of the inspection, we were not fully assured that all risks were being safely managed. Interim measures were needed to reduce potential risks, support staff and maintain the safety of the patients.
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97 We asked the Partnership to urgently review the service provision between 1.30pm and 6pm; identifying what clinical services and support is required to ensure the health needs of the prison population is equable with the community. We have escalated the above concerns internally within Healthcare Improvement Scotland and with the Clinical Service Manager for HMP Shotts and advised that we would be formally escalating these concerns to the North Lanarkshire Health & Social Care Partnership, NHS Chief Executive and SPS Chief Executive. These are outlined in QI 9.2, QI 9.6, QI 9.8 and QI 9.16. Primary care Patients could self-refer to healthcare services within the prison using a confidential self-referral system. Referral forms were available in the residential areas, with some in picture format. Self-referral forms were collected daily from a locked box by healthcare staff and then triaged to the appropriate service. GPs were available each day until 1:30pm in HMP Shotts. However, no medical cover was provided from 1.30pm to 6pm until the out of hours’ service became available at 6pm. The absence of medical cover during these times is a significant risk for patients and staff. Healthcare staffing was also reduced from 3:30pm. The variable levels of GP cover within the establishment was raised as a concern and were escalated during the inspection. Inspectors were told that patients would be seen by a GP within two weeks, or by a nurse within two days, depending on the medical need. After a patient was reviewed by nursing staff, inspectors observed the nurse record notes in the Vision system. Inspectors saw that a standard Situation background assessment recommendation (SBAR) approach to record keeping was generally used. However, the level of detail that was included varied. Mental Health There were processes in place on transfer to prison to identify patients requiring access to mental health services A referral system was open to all staff and self- referrals. Patients were triaged daily and followed up based on the level of urgency. At the time of inspection patients were waiting up to 6 weeks, urgent referrals could be seen within 72 hours if required. A multi-disciplinary meeting took place weekly between the Mental Health and Addictions Team discussing number of areas including; patients currently on Talk to Me, hospital referrals, upcoming liberations (including follow up arrangements), Care Programme Approach (CPA) plans for patients returning from hospital and waiting times for each discipline. There was evidence of liaison with Community Mental Health Teams (CMHT) pre-liberation and attendance at prisons suicide prevention strategy Talk to Me (TTM) case conferences. This was shared with primary care outside of mental health nursing hours. Psychiatry clinics took place regularly and urgent requests for consultations were responded to. Improvements were evident, since the last inspection, based on the introduction of standardised assessment tools which was not previously in place. However, North Lanarkshire HSCP should introduce an electronic system to record and update
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98 documents to keep documents live and ensure the most up to date information is accessible. There was no process in place for accessing specialist support in intellectual disabilities, autistic spectrum disorder, neuropsychiatric disorders and cognitive impairment. Substance misuse Individuals requiring support with drug and alcohol dependence were identified during their initial health assessment on transfer to the prison. A process was in place for patients who were receiving Opiate Substitution Therapy (OST) to continue their treatment upon transfer. Psychological support was available to patients in several forms. There was evidence of collaborative working and clear communication between SPS and the Addictions Team. This was through the multidisciplinary Substance Misuse Group which gave opportunities to discuss prisoners who may benefit from support from the Addictions Team. There was a discharge planning process in place to ensure continuity of care for those patients preparing for liberation. Harm reduction sessions were available to patients due to be liberated covering CPR training, overdose prevention and use of injectable naloxone. Person centred care plans are in place with evidence of patient involvement. However, there were some limitations in regards to patient choice of OST due to the HSCP awaiting allocation of funding. Senior management were following this up at the time of the inspection. Long-term conditions, palliative and end of life care Inspectors saw that admission screening identifies patients with long-term health conditions. However, it was not clear what follow up of long-term health conditions was in place or how this informed care planning. This is a significant concern. No long-term condition clinics or annual reviews were taking place at the time of inspection in HMP Shotts. A standardised national assessment tool, Supportive and Palliative Care Indicators Tool (SPICT) was in place in HMP Shotts to assess both palliative and end of life care needs. Palliative care, when required, was delivered in conjunction with both NHS and SPS. Development of Anticipatory Care Plans (ACPs) had been compromised by the pandemic and competing staffing priorities. However, continued work with St Andrews Hospice was identified as a priority for healthcare staff in HMP Shotts to continue to develop the work around ACPs and attendance at the Macmillan Palliative Care Team in custody group. All patients assessed on admission who had an identified life-limiting illness were added to the palliative care register and Anticipatory Care Plans (ACPs) were put in place. The electronically available ACPs were reviewed on an ongoing basis and were owned by the patient. Inspectors saw evidence of these for some patients with long-term conditions during the inspection.
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99 Infection, prevention and control All areas, where healthcare was delivered, were in a good state of repair and were clean and ready for use. During the inspection, inspectors found the clinical equipment was clean and ready for use and completed cleaning schedules were available for review. Inspectors saw evidence of a rolling programme of audits in place. Staff were knowledgeable regarding standard infection control precautions and had adequate supplies of PPE. The cleaning resource provided was sufficient and cleanliness was of a good standard. Encouraging observations Patients receive information at admission identifying services that are available to them regarding healthcare and how to refer to these services. Where secondary care appointments were missed, the GP triaged these appointments so that the most clinically urgent were prioritised to be rescheduled. Healthcare and SPS staff worked collaboratively to provide transport for these clinically urgent appointments with GEOAmey to support this. Prisoner information channel used to share health promotion notices including a podcast with information on oral health, mental health support and a mindfulness group which was run by psychology. Links with education department delivering heart health course and mental health stigma workshop. An emotional resource group facilitated by psychology was piloted within the prison with positive feedback received. The group focussed on supporting prisoners to improve their awareness, recognition and regulation of difficult emotions. At the request of SPS, psychology recently started facilitating drop in support sessions following adverse events within the prison. The sessions focus on psychoeducation and signposting to services to provide support to those who may have witnessed a traumatic incident or be emotionally impacted by an adverse event. A multidisciplinary substance misuse group has recently been restarted; the Addictions Team and SPS staff meet monthly to discuss any prisoners who may benefit from input from the Addictions Team. Anti-bacterial hand sanitisers were available and a system in place to decontaminate the boxes used for personal belongings at security for visitors to HMP Shotts. A newsletter is produced from the daily huddles which would include any changes to guidance to be shared with staff. The daily huddle was used as a mechanism to RAG rate staffing insufficiencies and seek solutions amongst other patient centred discussions. In response to identification of underlying challenges in healthcare delivery a Service Model Review of HMP Shotts was carried out in March 2022 and an action plan was developed. HIS inspectors will look for evidence of implementation of this action plan in future inspections.
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100 Emerging concerns North Lanarkshire HSCP must ensure that all prisoners transferred to HMP Shotts are reviewed by a nurse before being admitted into the prison. North Lanarkshire HSCP must develop a pathway to ensure patients receive psychiatry follow up when transferred. National co-ordination and discussion with partner agencies (such as Police Scotland, Scottish Courts, GEOAmey and SPS) is required to ensure that people arrive at the prison during the prison’s core opening times or when nursing resource is available. North Lanarkshire HSCP must provide a room that is clean and clutter free at reception. North Lanarkshire HSCP must revise without delay, the process in place when identifying long term health conditions and provide assurance that patients are reviewed in line with what is equitable in the community to address health inequalities. North Lanarkshire HSCP must implement a system for secondary care referrals that ensures patient confidentiality is protected. North Lanarkshire HSCP must ensure that all eligible patients who wish to be involved in national screening programmes are supported to do so and that this is clearly documented in the patients VISON record. North Lanarkshire HSCP must ensure that checks on emergency equipment are carried out within the agreed timeframe and that these checks are clearly recorded. North Lanarkshire HSCP as a matter of urgency must review the medical cover available in the afternoons to - (i) ensure the risk to patients is reduced. (ii) support nursing staff in dealing with emergency situations. North Lanarkshire HSCP must ensure that patients are able to access national screening programmes in line with community provision and keep accurate records of attendance. North Lanarkshire HSCP must introduce an electronic system to record and update documents to keep documents live and ensure the most up to date information is accessible. North Lanarkshire HSCP must develop a pathway for accessing specialist support in intellectual disabilities, autistic spectrum disorder, neuropsychiatric disorders and cognitive impairment. North Lanarkshire HSCP must ensure that person centred care plans and appropriate risk assessments are in place for all patients with long-term conditions and that these are reviewed regularly. As a priority North Lanarkshire’s HSCP must action the recommendations made in their service review regarding pharmacy provision and support to provide a service equitable with the community. NHS Lanarkshire’s pharmacy service must provide structured and regular support to staff involved in supporting pharmacy services within HMP Shotts. North Lanarkshire HSCP and SPS must seek solutions to assist staff to administer medication at a suitable and therapeutic time. NHS Lanarkshire HSCP should consider the reintroduction of the oral health educator role to support the dental service.
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101 NHS Lanarkshire HSCP and SPS must ensure complaints forms are available in alternative formats and languages to ensure all patients can provide feedback, raise concerns and complain. NHS Lanarkshire HSCP must ensure that all staff managing complaints receive training to ensure that all complaints are correctly managed. NHS Lanarkshire HSCP should develop a process to discuss complaints to share learning and identify any themes or required improvements. NHS Lanarkshire HSCP must ensure that alternative and consistent IT solutions are provided to support clinical staff as referrals by post is a significant data breach. North Lanarkshire HSCP must demonstrate implementation of recommendations from service review and provide clear pathways to support staff on site in HMP Shotts in the absence of senior staff.
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102 Quality Indicators 9.1 An assessment of the individual’s immediate health and wellbeing is undertaken as part of the admission process to inform care planning. Rating: Generally acceptable performance HMP Shotts receives prisoners who are transferred from other prisons. All prisoners should receive a healthcare assessment by a nurse prior to being admitted into the prison. However, inspectors were told that some prisoners were not assessed until the following day due to staffing and workload pressures. During the inspection, inspectors observed the admission process. The immediate health and wellbeing needs of patients were identified on arrival by a registered nurse. Nursing staff used a standard health screening tool to carry out the process. Staff were observed to ensure the patient’s dignity and confidentiality was maintained throughout their health screening. Good systems and processes were in place to ensure that all the patient’s healthcare needs were identified during the screening assessment. These were documented in the Vision patient record system and shared with the appropriate Healthcare Teams. Inspectors were made aware that not all patients requiring psychiatry support intervention had been followed up. This is a concern. Inspectors were told work was being undertaken to develop a pathway to ensure early identification of patients requiring follow up. Inspectors will review the progress of this work. Patients receive information at admission identifying services that are available to them regarding healthcare and how to refer to these services. This is good practice. Patients identified as requiring to see the GP are reviewed the following day. Medicines reconciliation takes place the following day by the GP and all drugs are prescribed onto the patient’s medication administration record (Kardex). Anyone identified as being at risk of self-harm or suicide is managed in line with the prison’s suicide prevention strategy; TTM. People coming into prison should be assessed for risk of self-harm. However, this system does not work when prisoners are transferred into HMP Shotts after 6pm. This is a significant concern for prisoners as there was no nursing cover provided after this time. During the inspection, inspectors were provided with details of the number of prisoners who had been admitted after 6pm during the period from May 2021 to May 2022. All prisoner transfers were facilitated by GEOAmey. While the room used for screening provided a confidential space, it was cluttered and had been identified in previous reports as being unfit for purpose. HMP Shotts must provide a room that is clean and clutter free to enable access to the hand washing facilities.
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103 Inspectors saw that systems and processes were in place to identify any patient unfit to be detained in prison, and appropriate actions were taken to maintain the safety of these patients. Recommendation 44: North Lanarkshire HSCP must ensure that all prisoners transferred to HMP Shotts are reviewed by a nurse before being admitted into the prison. Recommendation 45: North Lanarkshire HSCP must develop a pathway to ensure patients receive psychiatry follow up when transferred. Recommendation 46: National co-ordination and discussion with partner agencies (such as Police Scotland, Scottish Courts, GEOAmey and SPS) is required to ensure that people arrive at the prison during the prison’s core opening times or when nursing resource is available. Recommendation 47: North Lanarkshire HSCP must provide a room that is clean and clutter free at reception. Good practice 12: Patients receive information at admission identifying services that are available to them regarding healthcare and how to refer to these services. 9.2 The individual’s healthcare needs are assessed and addressed throughout the individual’s stay in prison. Rating: Generally acceptable performance Following their initial health screening assessment, the patient’s medical history and prescribed medication was reviewed by a GP. The outcome of the assessment was recorded onto the patient’s Vision care record. Inspectors were told that, as part of the admission process, prisoners were provided with a pack that contained information about healthcare services available at HMP Shotts. Healthcare information was also displayed in the residential areas. Patients could self-refer to healthcare using a confidential self-referral system. Referral forms were available in the residential areas, with some in picture format. Self-referral forms were collected from a locked box by healthcare staff and then triaged to the appropriate service. Patients not seen in the residential areas that day, after having their referrals triaged, were given letters to let them know their appointment time. Inspectors were told that patients would be seen by a GP within two weeks, or by a nurse within two days, depending on the medical need. After a patient was reviewed by nursing staff, inspectors observed the nurse recorded notes in Vision. Inspectors saw that a standard SBAR approach to record keeping was generally used. However, the level of detail that was included varied. Inspectors saw that admission screening identifies patients with long-term health conditions. However, it was not clear what follow up of long-term health conditions was in place or how this informed care planning. This is a significant concern, as
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104 there was no process in place to provide follow up or review of long term health conditions in line with community provision. Near Me (a video calling system that allows patients to attend appointments remotely) was in place for secondary care appointments. Patients going out of prison to attend any external appointments were supported by GEOAmey. Where secondary care appointments were missed, the GP triaged these so that the most clinically urgent appointments were prioritised to be rescheduled. This is good practice. Inspectors were told that healthcare and SPS staff worked collaboratively to provide transport for these clinically urgent appointments with GEOAmey to support this. This is good practice. Patients who missed their secondary care appointments were issued with a letter from the health centre to confirm the appointment would be rescheduled. Referrals to secondary care were in paper format and posted to the appropriate specialist service. This is a significant concern. Inspectors discussed the risks to patient confidentiality with this process with healthcare staff. During the inspection, the staff implemented a temporary process so that referrals will now be emailed securely and told inspectors that they will continue to look for more permanent solution. Inspectors were told that patients eligible for national screening programmes like bowel and abdominal aortic aneurysm screening would be supported to participate in these. However, inspectors could not find clear evidence in a patient’s Vision care record that this had happened. Patients who required social care to support them with their personal care needs, were provided access to this through an external care company. SPS can refer to this service and it was reported to be working well. There was also a clear process for healthcare staff to refer patients to occupational therapy, where assistive equipment was required to help support their care needs. Emergency equipment was in place and was found to be well maintained and organised. Emergency medication was found to be in date. Emergency equipment should be checked weekly. However, inspectors found that although equipment checks were being regularly carried out, this was not consistently recorded. Inspectors discussed this with staff to ensure that equipment checks are recorded consistently and evidence compliance with this. GPs were available each day until 1.30pm in HMP Shotts, however, no medical cover was provided from 1.30pm to 6pm until the out of hours’ service became available at 6pm. The absence of medical cover during these times is a significant risk for patients and staff. Healthcare staffing is also reduced from 3:30pm. Nursing staff told inspectors that this made them feel vulnerable and unsupported. The lack of medical cover in the afternoons was escalated at the time of the inspection to the Clinical Service Manager for HMP Shotts and advised that we would be formally escalating these concerns to the North Lanarkshire Health & Social Care Partnership, NHS Chief Executive and SPS Chief Executive.
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105 Recommendation 48: North Lanarkshire HSCP must revise without delay, the process in place when identifying long term health conditions and provide assurance that patients are reviewed in line with what is equitable in the community to address health inequalities. Recommendation 49: North Lanarkshire HSCP must implement a system for secondary care referrals that ensures patient confidentiality is protected Recommendation 50: North Lanarkshire HSCP must ensure that all eligible patients who wish to be involved in national screening programmes are supported to do so and that this is clearly documented in the patients VISON record. Recommendation 51: North Lanarkshire HSCP must ensure that checks on emergency equipment are carried out within the agreed timeframe and that these checks are clearly recorded. Recommendation 52: North Lanarkshire HSCP as a matter of urgency must review the medical cover available in the afternoons to: (iii) ensure the risk to patients is reduced. (iv) support nursing staff in dealing with emergency situations. Good Practice 13: Where secondary care appointments were missed, the GP triaged these appointments so that the most clinically urgent were prioritised to be rescheduled. Good Practice 14: Healthcare and SPS staff worked collaboratively to provide transport for these clinically urgent appointments with GEOAmey to support this. 9.3 Health improvement, health prevention and health promotion information and activities are available for everyone. Rating: Generally acceptable performance An opt-out Blood borne virus (BBV) screening programme was in place as part of the health screening process at the prison. Where patients had not received this screening at reception, they were able to opt-in to be screened through the healthcare self-referral form. Health promotion activity was in place in relation to infectious disease prevention. This included health education and health promotion programmes. However, it was not clear during the inspection what process was in place to ensure delivery of all national and local age appropriate health screening. Inspectors were told that screening appointment invitations were sent direct to patients but this could not be evidenced in a patient’s Vision care record. This was a concern. In the absence of a clear recording process, inspectors cannot be assured that patients are getting access to national screening and surveillance programmes.
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106 A wide variety of health education and health promotion information was available and displayed in patient areas, including the halls, health centre waiting room and visitors centre. Development work was in progress to ensure the leaflets and posters were available in a variety of formats making them accessible to a wide range of people. The information displayed included how to make informed decisions about health; including sexual health information and risks associated with drug use. Healthcare and prison staff worked together to deliver a programme of health promotion activities based on; health improvement, making better decisions and understanding the risks of behaviours and choices. The prisoner information channel was used to share health promotion notices including a podcast with information on oral health, mental health support and a mindfulness group which was run by psychology. This is good practice. The health improvement staff worked with the education department to deliver an 8-week heart health course and a mental health stigma workshop. This is good practice. Peer support was available through cocaine and alcoholics anonymous meetings. Details on how to attend these mutual aid meetings were displayed in the halls and patients would be signposted if they were engaged with the Addictions Team. All prisons in Scotland are non-smoking establishments. Vapes were made available to all prisoners in HMP Shotts. Information and support was also available on nicotine withdrawals and how to reduce or stop vaping. Those wanting to access sexual health services in the prison could do so by completing the healthcare self-referral form. Recommendation 53: North Lanarkshire HSCP must ensure that patients are able to access national screening programmes in line with community provision and keep accurate records of attendance. Good Practice 15: Prisoner information channel used to share health promotion notices including a podcast with information on oral health, mental health support and a mindfulness group which was run by psychology. Good Practice 16: Links with education department delivering heart health course and mental health stigma workshop. 9.4 All stakeholders demonstrate commitment to addressing the health inequalities of prisoners. Rating: Satisfactory performance Healthcare staff described an understanding of health inequalities and were knowledgeable about the potential barriers to accessing care. Staff demonstrated a respectful and professional approach to all patients whilst maintaining confidentiality. They were supportive and gave explanations of care to be given whilst gaining consent. For example, at medication rounds staff took opportunities to support patients raising other healthcare concerns.
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107 We saw evidence that staff are directed to NHS Lanarkshire’s electronic learning platform where modules on equality and diversity are available. Staff spoken with were aware of the Equality Act 2010 and could sign post to where up to date policies were available on the staff intranet. Barriers to accessing care were identified at admission and staff facilitated any requirement to utilise interpreter services. 9.5 Everyone with a mental health condition has access to treatment equitable to that available in the community, and is supported with their wellbeing throughout their stay in prison, on transfer and on release. Rating: Satisfactory performance A validated assessment tool was used to assess people referred to the Mental Health Team. This included an assessment of the patient's mental health, history, psychosocial factors, identification of risks, formulation of presenting problem and recommendation for care intervention. A risk assessment was completed for all patients at time of assessment and this was routinely updated every six months or in line with any significant changes in risk. Whilst the service used standardised tools for assessments and care plans, there was no electronic system in place. Having an electronic system would enable staff to record and update documents to keep them live and ensure the most up-to-date information was accessible. Patients were fully involved in their assessment, and had the opportunity to discuss the purpose and outcome of this assessment. The risks and benefits of any treatment or intervention offered were discussed with patients to allow them to make informed choices about their care. Individual person-centred outcome focussed care plans were written with the patient which reflected their goals. Patients had regular reviews where they were able to discuss and review their care. The multidisciplinary Mental Health Team consisted of health and social care professionals, including mental health nurses, psychologists and a consultant psychiatrist. There are challenges that NHS Lanarkshire are aware of and identified in the service review regarding the gaps in workforce. Due to the staffing pressures in the workforce, mainly in primary care, it meant that mental health nursing staff supported the wider healthcare team when required. Whilst psychology provided neuropsychological assessments there was no process in place to access specialists in intellectual disabilities, autistic spectrum disorder, neuropsychiatric disorders and cognitive impairment. The clinical lead for the team was a consultant psychiatrist, who chaired the weekly meetings where updates from each discipline were provided. Discussions took place about a number of areas including; patients currently on Talk to Me, hospital referrals, upcoming liberations (including follow up arrangements), Care Programme Approach (CPA) plans for patients returning from hospital and waiting times for each discipline. A wide range of therapies and treatments, appropriate for the patient population, were provided within the prison. The Mental Health Team’s operational guidelines
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108 details the procedure in place for working in partnership with services including; GP and physical health team, addiction service, social work, advocacy, chaplaincy, listener/peer support service and forensic psychology. The treatments and interventions offered to patients within the prison are equitable to those available in the community. The waiting times at the time of the inspection were acceptable and no longer than the national waiting times for these services. An emotional resource group, facilitated by psychology, had been piloted within the prison with positive feedback received. The group focussed on supporting prisoners to improve their awareness, recognition and regulation of difficult emotions. This is good practice. At the request of SPS, psychology have recently started facilitating drop in support sessions following adverse events within the prison. The sessions focussed on psychoeducation and signposting to services to provide support to those who may have witnessed a traumatic incident, or be emotionally impacted by an adverse event. This is good practice. Systems and processes were in place to ensure that any patient requiring inpatient mental health care is assessed and transferred to hospital under the Mental Health Care and Treatment (Scotland) Act 2003. Robust systems and processes were in place to ensure that patients requiring community follow-up on release from prison were referred to relevant services. This also included the provision of detailed discharge summaries. Recommendation 54: North Lanarkshire HSCP must introduce an electronic system to record and update documents to keep documents live and ensure the most up to date information is accessible. Recommendation 55: North Lanarkshire HSCP must develop a pathway for accessing specialist support in intellectual disabilities, autistic spectrum disorder, neuropsychiatric disorders and cognitive impairment. Good practice 17: An emotional resource group facilitated by psychology was piloted within the prison with positive feedback received. The group focussed on supporting prisoners to improve their awareness, recognition and regulation of difficult emotions. Good Practice 18: At the request of SPS, psychology recently started facilitating drop in support sessions following adverse events within the prison. The sessions focus on psychoeducation and signposting to services to provide support to those who may have witnessed a traumatic incident or be emotionally impacted by an adverse event.
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109 9.6 Everyone with a long-term health condition has access to treatment equitable to that available in the community, and is supported with their wellbeing throughout their stay in prison, on transfer and on release. Rating: Poor performance Inspectors were told that patients with a long-term condition were identified at their health screening during admission, through nurse triage or at medicine reconciliation. However, there was no formal process to ensure that patients were appointed for ongoing regular reviews. No long-term condition clinics or annual reviews were taking place in HMP Shotts at the time of inspection. Care plans were observed to be in place for some patients with associated risk assessments. However, the care plans were not person centred or outcome focussed and there was an inconsistent approach in regard to the implementation and review of the plans and risk assessments. Do not attempt cardiopulmonary resuscitation (DNACPR) forms were seen to be in place for two patients and these were generally well completed including the discussion with the patient. Inspectors were told of continued challenges with nursing staff resources and capacity this was observed during the inspection, as described in the escalation. The lack of medical cover was impacting on the ability to provide long term condition management of patients. All patient healthcare records are held in the Vision computer system. It was not clear how staff were using the full function of this system effectively to collect data for patients with long-term health conditions. These factors have led to a systematic failure to deliver long-term condition reviews and oversight. Nursing staff described links with community services for support and advice. For example, the tissue viability service and Diabetes service. This was working well to support patients. Recommendation 56: North Lanarkshire HSCP must ensure that person centred care plans and appropriate risk assessments are in place for all patients with long-term conditions and that these are reviewed regularly. 9.7 Everyone who is dependent on drugs and/or alcohol receives treatment equitable to that available in the community, and is supported with their wellbeing throughout their stay in prison, on transfer and on release. Rating: Satisfactory performance Patients requiring support with drug and/or alcohol dependence were identified at health screening on transfer to the prison or as part of their health assessment appointments, using a validated screening tool. The outcome was documented in the patient care record. Patients were also sent a letter signposting them to support services available within the Addictions Team. As highlighted in QI 9.5 it is a concern that patient assessments are recorded on paper and scanned. The service should review IT options for patient assessments to be stored electronically allowing live documents (see recommendation in Q.I. 9.5).
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110 Systems and processes were in place to confirm prescriptions of those patients transferred to the prison. A copy of the Kardex was brought to HMP Shotts from the transferring prison for patient’s prescribed OST. Individual support needs for patients referred to addiction services were identified through an assessment process. Individual person-centred outcome-focussed care plans which reflected the support needs required, were in place for all patients. There was evidence of patient involvement in the writing of their care plans which were regularly reviewed, monitored and updated by the patient and their nurse or caseworker. Funding was due to be allocated for increasing the number of patients able to access Buvidal (long acting buprenorphine injections). Therefore, there were some limitations in terms of promoting patient choice for OST in line with the MAT standards at the time of the inspection. Senior managers were aware and liaising with the board to follow up the allocation of funding. Patients were provided with evidence-based pharmacological, harm reduction and psychological interventions. These interventions include psychosocial clinical interventions, relapse management and Cognitive Behaviour Therapy based psychoeducational work. A mindfulness group was available to prisoners, facilitated by an addictions caseworker delivering breath work, mindfulness and meditation. Systems and processes were in place to ensure that copies of patients’ medication prescription accompanied patients who were transferred to other prisons. This system was designed to ensure that there was no delay in continuing treatment once they arrived at the receiving prison. A standardised discharge planning tool was in place and ensured that patients were referred to community services and information was passed to these services for continuity of care. This included the early identification of community prescribers and pharmacies. All prisoners preparing for liberation were offered a harm reduction session that covered CPR training, overdose prevention and use of injectable naloxone use. The Addictions Team consisted of a range of multidisciplinary professionals including addictions nurses, case workers and a lead medical practitioner for addictions. The team worked closely with the Mental Health Team to allow for a range of treatments and therapies to be offered to patients. A multidisciplinary team meeting took place each week to discuss the allocation of referrals, and the assessments and reviews of patients. A medical practitioner for addictions is the clinical lead for the team. Written systems, protocols and procedures were in place to describe the joint working with mental health and primary care services for patients with co-morbidities. These included regular meetings with mental health nurses and/or primary care nurses according to the needs of the patients with co-morbidities. A multidisciplinary Substance Misuse Group has recently been restarted; the Addictions Team and SPS staff meet monthly to discuss any prisoners who may benefit from input from the Addictions Team. This is good practice.
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111 Good Practice 19: A multidisciplinary substance misuse group has recently been restarted; the Addictions Team and SPS staff meet monthly to discuss any prisoners who may benefit from input from the Addictions Team. 9.8 There is a comprehensive medical and pharmacy service delivered by the service. Rating: Poor performance The Clinical Pharmacy Service delivered within HMP was provided by the national contract supplied by Lloyds Pharmacy. The current clinical pharmacy role involves the regular review of patient Kardexes and providing advice to other members of the multidisciplinary team. It also involves regular controlled drug checks (as part of the contract) but does not form part of a Clinical Pharmacy Service. The role was not patient facing and was not shown to be accessible for the population of HMP Shotts to discuss their medications with a member of the Pharmacy Team. This was not equitable to what is provided within the community in NHS Lanarkshire and is a concern. North Lanarkshire’s HSCP shared their service review as part of their evidence which contained specific recommendations about a Pharmacy Service. The service must action the recommendations regarding pharmacy provision and support as a matter of priority. NHS Lanarkshire provides HMP Shotts with pharmacy support for six hours per week to manage the Lloyds contract. During the discussions in relation to pharmacy, it was evident that pharmacy had not been part of the self-evaluation process. They described a lack of ability to influence within the service. Since the pandemic, they had been unable to attend the establishment due to a lack of available space. There was a lack of evidence to support multidisciplinary working in relation to medicines and the Pharmacy Service. The pharmacist described Standard Operating Procedures in place, which pharmacy had been involved in approving as part of the Home Office License Application. There was an up-to-date Home Office Licence in place at the time of our inspection. The pharmacist described the Prescribing Advisory Group (PAG) which prior to COVID-19 was well established, with a standing agenda and monitored prescribing as part of a multidisciplinary discussion. This was described to be in line with the current work within primary care which was positive. There are strong links with the National Prison Pharmacist Group and the pharmacist representing NHS Lanarkshire advised that there is regular communication with the service. This included updates on outcomes of these meetings via email, telephone calls and updates through the PAG (when this was operational). As the PAG has not been in existence since prior to the COVID-19 pandemic, it was unclear how the prescribing of medicines and the reviews of these have been managed during the pandemic. Inspectors spoke to staff providing Pharmacy Support Services and management was being provided by the Primary Healthcare Team. It was not clear of the wider
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112 links to the NHS Lanarkshire Pharmacy Service for professional support and development. The variable levels of GP cover within the establishment was raised as a concern and were escalated during the inspection. Discussions with pharmacy staff also identified challenges with building effective working relationships with GPs to improve prescribing practices and the potential to develop multi-disciplinary team working to improve patient outcomes. For example, the inspectors identified some inconsistencies and follow up when patients were on high dose antipsychotic medication. Inspectors were provided with the service review and acknowledged the recommendations in relation to medicine cover. During our inspection, inspectors reviewed the timings of medication administration. Some patients had supervised administration as not all patients are suitable for in possession medication. Inspectors saw that with the limitations in place due to the SPS regime, some patients were receiving their sedative medication early, between 3pm to 5pm. This was not therapeutic and was a significant concern. SPS must seek solutions to assist staff to administer medication at a suitable and therapeutic time. Nursing staff were observed administering medication and inspectors saw this was carried out safely. Paperwork in relation to medication administration was generally well completed. Concerns regarding nursing staff wearing radio earpieces during medication administration and the risk of medication errors was discussed with SPS staff during the inspection. This practice was changed during the inspection and staff were being accommodated to turn their radio’s off during medicine administration times. Recommendation 57: As a priority North Lanarkshire’s HSCP must action the recommendations made in their service review regarding pharmacy provision and support to provide a service equitable with the community. Recommendation 58: NHS Lanarkshire’s pharmacy service must provide structured and regular support to staff involved in supporting pharmacy services within HMP Shotts. Recommendation 59: North Lanarkshire HSCP and SPS must seek solutions to assist staff to administer medication at a suitable and therapeutic time 9.9 Support and advice is provided to maintain and maximise individuals’ oral health. Rating: Generally acceptable performance Dental care was delivered in a clean and well-maintained environment. Dental procedures and management were carried out in line with national and NHS Lanarkshire guidelines.
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113 Patients were able to self-refer to the dental service and were given a letter to inform them of the date and time of their appointment or that they were on the waiting list. The dentist was available four days per week and managed their own waiting list, with a dental hygienist being available one day per week. Daily dental lists were managed to allow emergency treatments such as patients with pain to be seen as quickly as possible, usually the next day. The waiting time for other dental emergencies such as broken tooth was approximately two weeks. The waiting time for routine examinations was much longer. Inspectors were told that patients who required emergency dental care, or who were on treatment plans took priority over those requesting a routine examination. Inspectors saw the current waiting list that had 120 patients, the longest wait was from October 2020. Inspectors were told that the waiting list may not be completely accurate as some patients on it may have been seen more quickly, as an emergency or may have been released from prison. Inspectors were told that oversight and management of the dental waiting list was the responsibility of the Dental Team. The dental staff told inspectors that prior to the COVID-19 pandemic there were oral health educators who worked in the prison, who they considered a good resource. The oral health educators provided support directly to prisoners and could also be another source for the referral of patients to the dental service. Staff told inspectors that the reintroduction of oral health educators may reduce the number of patients on the waiting list. Clean and used dental instruments were stored appropriately, used and contaminated instruments were taken off site for decontamination. Recommendation 60: NHS Lanarkshire HSCP should consider the reintroduction of the oral health educator role to support the dental service. 9.10 All pregnant women, and those caring for babies and young children, receive care and support equitable to that available in the community, and are supported with their wellbeing throughout their stay in prison, on transfer and on release. Rating: Not applicable There were no female prisoners in HMP Shotts at the time of the inspection. 9.11 Everyone with palliative care or end of life care needs can access treatment and support equitable to that in the community, and is supported throughout their stay in prison, on transfer and on release. Rating: Generally acceptable A standardised national assessment tool, (SPICT) was in place in HMP Shotts to assess both palliative and end of life care needs. Palliative care when required was delivered in conjunction with both NHS and SPS. Development of ACPs had been compromised by the pandemic and competing staffing priorities. However, continued work with St Andrews Hospice was identified as a priority for healthcare
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114 staff in HMP Shotts to continue to develop the work around ACPs and attendance at the Macmillan Palliative Care Team in custody group. Staff described how to access all necessary services, facilities and equipment services to deliver safe, effective, person-centred palliative or end of life care. There was evidence of a positive team-working relationship between the Prison Healthcare Team, NHS board palliative care service and community service. There was also strong links identified with Macmillan Palliative Care Team. Community Occupational Therapy services were accessed through the Community Rehab Team at University Hospital Wishaw if there was a requirement to assess patients for aids and adaptation. Staff described a prompt response. The accessible cells in HMP Shotts were of a good standard, they were spacious and well maintained. Prior to the pandemic any patients receiving palliative or end of life care were discussed by both SPS and NHS at a multidisciplinary meeting monthly. Staff were keen to reinstate this as a priority. 9.12 Everyone at risk of self-harm or suicide receives safe, effective and person centred treatment, and support with their wellbeing throughout their stay in prison, on transfer and on release. Rating: Satisfactory performance On transfer to the prison, every patient at risk of self-harm or suicide was assessed using a standardised and validated health screening tool, if the transfer took place before 6pm. As referenced in QI 9.1 there was no healthcare staff on duty from 6pm to complete risk assessments and follow the talk to me process. Any patient identified as being at risk of self-harm or suicide during their admission to prison or during their stay in prison were immediately commenced onto TTM. Inspectors reviewed several completed care plans and found them to be comprehensive and demonstrated patient involvement. This included the types of treatment being offered and were regularly reviewed. TTM case conferences were attended by the SPS and where possible a mental health nurse who was involved in the patients ongoing care. Mental health nursing cover was available Monday to Friday 8:30am to 3:30pm. Any case conferences taking place outside these times were attended by a primary care nurse. The Healthcare Team was aware of the importance of a registered mental health nurse (RMN) attending who knows the patient therefore tried to plan TTM around this. Patients were also encouraged and supported to participate in their own case conference. If a translator was required to support the patient this was booked in advance. All members of the wider Primary Care Nursing Team, involved in caring for patients had undergone TTM training. Evidence of a good multi-disciplinary Mental Health Team (MHT) was in place as discussed in QI 9.5. The clinical MDT discussed all patients who were in the SRU
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115 and being managed under Rule 41 (which relates to accommodation in specific conditions). There was a suicide prevention meeting with representatives from SPS and mental health nurses. Staff were able to arrange an urgent same day appointment with a mental health nurse for any patient who appeared to be at immediate risk of self-harm or suicide. Each stage of TTM process was clearly documented in the patient record on Vision. 9.13 All feedback, comments and complaints are managed in line with the respective local NHS Board policy. All complaints are recorded and responded to in a timely manner. Rating: Poor performance All complaints, comments and feedback were managed in line with the local NHS complaints policy. There was a clear governance structure in place for reporting and responding to complaints and feedback. Information posters describing the process were displayed in patient areas, including the halls and health centre waiting room. Feedback and comments forms and complaints forms were available in the halls, the patient waiting area in the health centre and on request from healthcare staff. These forms were clear and easy to understand in English however, the forms were not available in alternative formats and languages. Systems and processes were in place to record all complaints received in the health centre along with the date of receipt to ensure they were processed and responded to within set timescales. Systems and processes were in place to ensure that those making complaints would be acted on without negative consequences to current and future care or support. Registered nurses had the responsibility of reviewing complaints. There was no evidence if staff had received training on how to review, respond and escalate complaints. Whilst staff had the opportunity to have informal discussions about complaints there was no formal process in place to share learning from complaints. Inspectors were told that staff meetings were currently not taking place due to staffing shortages. It would be useful to hold weekly team meetings where learning from complaints can be disseminated with the wider Healthcare Team. Information was provided at the end of each complaint response informing patients of their right to contact the Scottish Public Services Ombudsman if they were not satisfied with the outcome or response to their complaint. Information about how to do this was also included.
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116 Recommendation 61: NHS Lanarkshire HSCP and SPS must ensure complaints forms are available in alternative formats and languages to ensure all patients can provide feedback, raise concerns and complain. Recommendation 62: NHS Lanarkshire HSCP must ensure that all staff managing complaints receive training to ensure that all complaints are correctly managed. Recommendation 63: NHS Lanarkshire HSCP should develop a process to discuss complaints to share learning and identify any themes or required improvements. 9.14 All NHS staff demonstrate an understanding of the ethical, safety and procedural responsibilities involved in delivering healthcare in a prison setting. Rating: Poor performance Staff had a clear understanding of their roles and responsibilities in reporting any situations which could result in physical or psychological harm to those in prison. Healthcare staff indicated that any issues requiring to be raised as a priority were recorded on a SPS intelligence report. All registered staff were aware of their legal obligations for confidentiality and keeping accurate and prompt records, as part of maintaining their registration and commitment to the Nursing and Midwifery Council (NMC) code. All staff had their own access to the electronic record keeping system Vision clinical system. As part of prison healthcare staff induction, staff were informed how to report any concerns. Inspectors were told that secondary care appointments were being sent by post because of issues with the IT systems in HMP Shotts, this is a significant data risk. Inspectors were made aware during the inspection that practice had changed and all referrals to secondary care were being managed electronically directly to the NHS board and postal referrals would be stopped. Inspectors will follow this up as part of their revisit. Recommendation 64: NHS Lanarkshire HSCP must ensure that alternative and consistent IT solutions are provided to support clinical staff as referrals by post is a significant data breach. 9.15 The prison implements national standards and guidance, and local NHS Board policies for infection prevention and control. Rating: Satisfactory performance Inspectors observed good infection control precautions in place at HMP Shotts. PPE was available with hand sanitiser and both clinical and domestic waste bins were available for disposal. Visitors were sign posted to use masks on arrival and to dispose of when leaving. At reception, visitors were prompted sanitising the boxes used for personal belongings, this is good practice.
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117 The healthcare centre facility and clinical rooms within HMP Shotts were of a good standard and were visibly fresh and clean, the fabric was intact and could be effectively decontaminated. Inspectors saw areas in the halls where healthcare staff administer medicines and triage, these were of a good standard and were clean and ready for use. Inspectors saw evidence of daily cleaning schedules with senior nurse oversight and sign off. HMP Shotts used an electronic system to upload audits including standard infection control audits. These were reviewed for compliance by senior staff and results were shared through staff safety briefs for any non-compliance actions plans to be completed. These were also shared at the North Hygiene meetings represented by senior management. Healthcare staff had standard infection audit programme in place which included other aspects of healthcare delivery and compliance. Cleaning resource was provided by a private contractor supplied by SPS. The cleaning was of a good standard and staff reported no concerns with provision. Trained pass men were responsible for cleaning in residential areas and were visible throughout the inspection. The standard of cleanliness in HMP Shotts was high. The health centre is also externally audited by NHS Lanarkshire. Inspectors observed the most recent audit carried out. This had identified some areas for improvement that staff had acted upon. Equipment was clean and ready for use and staff were knowledgeable about standard infection control precautions (SICPs). Inspectors observed good hand hygiene practice from staff. Healthcare staff could sign post inspectors to the National Infection Prevention and Control Manual (NIPCM) through NHS Lanarkshire intranet platform. Inspectors saw infection prevention control was part of staff mandatory training requirements. Staff had been fitted for FFP3 masks during the pandemic, these were available in emergency bags. PPE was readily available in clinical areas and staff were wearing masks. Inspectors saw some variable compliance with mask wearing from SPS officers, this was raised at the time of the inspection. Changes to guidance was discussed at the morning adult services huddle. A newsletter was produced from these meetings which would include any changes to guidance to be shared with staff. This is good practice. Good Practice 20: Anti-bacterial hand sanitisers were available and a system in place to decontaminate the boxes used for personal belongings at security for visitors to HMP Shotts. Good Practice 21: A newsletter is produced from the daily huddles which would include any changes to guidance to be shared with staff.
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118 9.16 The prison healthcare leadership team is proactive in workforce planning and management. Staff feel supported to deliver safe, effective, and person-centred care. Rating: Poor performance HMP Shotts Healthcare team had experienced significant and sustained staff shortages across all disciplines. Continued staff shortages had impacted on the team ability to provide adequate staffing and maintain a safe skill mix on some occasions. During the inspection there were further absences in the Senior Leadership team for both primary care and mental health services. Nursing staff numbers were further reduced to 2 primary care nurses at 3.30pm when other members of the multidisciplinary team shift ended. From 3.30pm to 6pm their role was to provide healthcare delivery which included responding to emergencies, admitting prisoners being transferred from other prisons and delivering medications. As described in the escalation and in QI 9.2 there was no GP cover after 1.30pm. As a direct result of absences within the Senior Leadership team, staff reported they were not receiving one to one support or clinical supervision in any consistent pattern. Staff morale was low and staff were reporting fatigue. The fragility in the workforce was a significant concern and was escalated during the inspection. There was no consistent senior leadership structure in place to support staff in the absence of medical cover. Inspectors found all staff to be open and honest about the challenges in HMP Shotts. Senior managers were aware of the ongoing challenges for staff in HMP Shotts. Inspectors were provided with evidence of the service model review commissioned by senior management from North Lanarkshire HSCP. In response to the identified challenges during a change in leadership accountability for HMP Shotts prior to the inspection including a workforce review. This had identified key areas of improvement and actions which illustrated the significant concerns raised by inspectors however inspectors raised concerns regarding the staffing provision both nursing and GP’s, the impact on staff and the impact on patients because of the lack of provision. There was a commitment to review workforce and seek solutions to provide additional staff and senior oversight in HMP Shotts with a continued recruitment. This would allow a re-introduction of clinical supervision and one to one support for staff. Inspectors will follow up the progress of this work with HMP Shotts following the escalation response and will return to HMP Shotts to review progress. There was a mandatory training programme in place which was overseen by senior management. All staff in HMP Shotts had received an induction programme. Inspectors participated in the daily huddle which was used as a mechanism to RAG rate staffing insufficiencies and seek solutions amongst other patient centred discussion. This is good practice. Recommendation 65: North Lanarkshire HSCP must demonstrate implementation of recommendations from service review and provide clear pathways to support staff on site in HMP Shotts in the absence of senior staff.
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119 Good Practice 22: The daily huddle was used as a mechanism to RAG rate staffing insufficiencies and seek solutions amongst other patient centred discussions. 9.17 There is a commitment from the NHS Board to the delivery of safe, effective and person-centred care which ensures a culture of continuous improvement. Rating: Generally acceptable performance HMP Shotts Prisoner Healthcare Team was managed by the Adult Health Services Unit (AHSU) within North Lanarkshire Health & Social Care Partnership (HSCP). A restructure of the North Lanarkshire HCSP took place over a year ago resulting in changes in both leadership and responsibility of Prisoner Healthcare Team. In response to identification of underlying challenges in healthcare delivery a service model review of HMP Shotts was carried out in March 2022 and an action plan was developed, this is good practice. Inspectors reviewed both the service review and action plan provided and were encouraged to see identification of many planned improvements. These had been assigned senior leadership and yet to have identified timelines. Inspectors will follow up and review the progress of this work. Operational healthcare staff within the prison were aware of the HSCP Leadership structure and their roles and responsibilities for the ongoing service delivery of healthcare within the prison. There had been changes in leadership in this structure in the last year. Nursing staff could describe the leadership structure but were not familiar with some of the senior management that were present during the inspection. Senior managers from the North Lanarkshire HSCP were visible in the health centre during the inspection but did not routinely base themselves in HMP Shotts. Inspectors were provided with evidence that prisoner healthcare is represented at all appropriate NHS Lanarkshire primary care forums. There was leadership and representation of prisoner healthcare services across the Operational, Governance and Professional Senior Manager Team forums. Where patients had concerns about healthcare delivery, they were encouraged to report these using the complaints forms available in the residential areas. The service review had also highlighted plans to improve service delivery by conducting surveys and questionnaires for patients led by health improvement colleagues. Prison healthcare uses the DATIX system to report any adverse events in NHS Lanarkshire. Reports from this were visible to managers within the HSCP and were discussed at clinical governance committee meetings. Inspectors were provided with minutes of this meeting and saw DATIX relating to prisoner healthcare being discussed. Staff told inspectors there was inconsistency in reporting due to staff shortages. Any learning from DATIX incidents was shared with staff verbally as well as by email.
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120 Good Practice 23: In response to identification of underlying challenges in healthcare delivery a Service Model Review of HMP Shotts was carried out in March 2022 and an action plan was developed. HIS inspectors will look for evidence of implementation of this action plan in future inspections.
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121 Annex A Summary of Recommendations To be updated after matters of fact stage
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122 Annex B Summary of Good Practice To be updated after matters of fact stage
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123 Annex C SUMMARY OF RATINGS Standard/QI Standard rating/QI rating Standard 1 – Lawful and Transparent Custody Satisfactory QI 1.1 Satisfactory QI 1.2 Satisfactory QI 1.3 Satisfactory QI 1.4 Satisfactory QI 1.5 Satisfactory QI 1.6 N/A QI 1.7 Satisfactory QI 1.8 Generally acceptable QI 1.9 Satisfactory Standard 2 – Decency Generally acceptable QI 2.1 Satisfactory QI 2.2 Satisfactory QI 2.3 Generally acceptable QI 2.4 Satisfactory QI 2.5 Satisfactory QI 2.6 Poor Standard 3 – Personal Safety Generally acceptable QI 3.1 Generally acceptable QI 3.2 Good QI 3.3 Generally acceptable QI 3.4 Generally acceptable QI 3.5 Satisfactory QI 3.6 Generally acceptable QI 3.7 Satisfactory Standard 4 – Effective, Courteous and Humane Exercise of Authority Satisfactory QI 4.1 Generally acceptable QI 4.2 Generally acceptable QI 4.3 Satisfactory QI 4.4 Satisfactory QI 4.5 Generally acceptable QI 4.6 Satisfactory QI 4.7 Satisfactory QI 4.8 Satisfactory QI 4.9 Satisfactory QI 4.10 Good
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124 Standard 5 – Respect, Autonomy and Satisfactory Protection Against Mistreatment QI 5.1 Satisfactory QI 5.2 Satisfactory QI 5.3 Good QI 5.4 Satisfactory QI 5.5 Satisfactory QI 5.6 Satisfactory QI 5.7 Satisfactory QI 5.8 Satisfactory Standard 6 – Purposeful Activity Generally acceptable QI 6.1 Generally acceptable QI 6.2 Generally acceptable QI 6.3 Generally acceptable QI 6.4 Generally acceptable QI 6.5 Good QI 6.6 Generally acceptable QI 6.7 Satisfactory QI 6.8 Satisfactory QI 6.9 Generally acceptable QI 6.10 Satisfactory QI 6.11 Good QI 6.12 Good QI 6.13 Satisfactory QI 6.14 Generally acceptable QI 6.15 Good Standard 7 – Transitions from Custody into the Community Generally acceptable QI 7.1 Generally acceptable QI 7.2 Satisfactory QI 7.3 Satisfactory QI 7.4 Generally acceptable QI 7.5 Generally acceptable Standard 8 – Organisational Effectiveness Generally acceptable QI 8.1 Poor QI 8.2 Satisfactory QI 8.3 Satisfactory QI 8.4 Generally acceptable QI 8.5 Generally acceptable QI 8.6 Generally acceptable QI 8.7 Satisfactory QI 8.8 Satisfactory Standard 9 – Health and Wellbeing Poor QI 9.1 Generally acceptable QI 9.2 Generally acceptable QI 9.3 Generally acceptable
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125 QI 9.4 Satisfactory QI 9.5 Satisfactory QI 9.6 Poor QI 9.7 Satisfactory QI 9.8 Poor QI 9.9 Generally acceptable QI 9.10 N/A QI 9.11 Generally acceptable QI 9.12 Satisfactory QI 9.13 Poor QI 9.14 Poor QI 9.15 Satisfactory QI 9.16 Poor QI 9.17 Generally acceptable
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126 Annex D Prison Population Profile on [ADD DATE]
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127 Annex E Inspection Team Wendy Sinclair-Gieben, HMIPS Stephen Sandham, HMIPS Calum McCarthy, HMIPS Kerry Love, HMIPS Sam Gluckstein, HMIPS Billy Menzies, Serco Paul Durning, SPS John Shanks, Scottish Prison Service Margaret Rose Livingstone, Education Scotland Ann Kivlin, Education Scotland Sheila Brown, Education Scotland Neil Gentleman, Care Inspectorate James Black, Care Inspectorate Catherine Haley, HIS Lindsay Macphee, HIS Jamie Thomson, HIS Sophie Moss, HIS
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128 Annex F Acronyms used in this Report ABS Anti-Bullying Strategy ACP Anticipatory Care Plan AHSU Adult Health Services Unit BBV Blood Borne Virus BICS British Institute of Cleaning Science BSL British sign language CAST Custody Adjustment Support and Transition CBSW Community Based Social Workers CIP Community Integration Plan CMHT Community Mental Health Team C&R Control and Restraint CCTV Closed Circuit Television COPFS Crown Office and Procurator Fiscal Service COVID-19 Corona Virus Disease 2019 CPA Care Programme Approach CPR Cardiopulmonary resuscitation CPT European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment DATIX NHS electronic incident reporting system DNACPR Do not attempt cardiopulmonary resuscitation ECR Electronic Control Room ECHR European Convention of Human Rights E&D Equality and Diversity EDF Equality and Diversity Form ESOL English to Speakers of Other Languages FCO Family Contact Officer FLM First Line Manager GBTS Getting Better Together Shotts GIC Governor in Charge GPAs General Programme Assessments H&S Health and Safety
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129 HIS Healthcare Improvement Scotland HMCIPS Her Majesty’s Chief Inspector of Prisons for Scotland HMIPS Her Majesty’s Inspectorate of Prisons for Scotland HMP Her Majesty’s Prison HQ Headquarters HSCP Health and Social Care Partnership ICC Internal Complaints Committee ICM Integrated Case Management IMU Intelligence Management Unit IPM Independent Prison Monitor LCM Learning Centre Manager LIM Local Incident Management LS/CMI Level of Service/Case Management Inventory LTPs Long Term Prisoners MAPPA Multi-Agency Public Protection Arrangements MDT Multi-Disciplinary Team MHT Mental Health Team MORS Management of an Offender at Risk from Any Substance NIC National Induction Centre NIP National Induction Presentation NIPCM National Infection Prevention and Control Manual NMC Nursing Midwifery Council NOC Notification of Concern NPM National Preventive Mechanism NTE National Top End OPCAT UN Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment OLR Order of Lifelong Restriction OST Opiate Substitution Therapy PAG Prescribing Advisory Group PANEL Participation, Accountability, Non Discrimination and Equality, Empowerment, Legality PBSW Prison Based Social Work PCF Prisoner Complaint Form
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130 PCF1 Prisoner Complaint Form 1 PCF2 Prisoner Complaint Form 2 PCMB Programme Case Management Board PEI Physical Education Instructor PEEP Personal Emergency Evacuation Plans PER Prisoner Escort Record PIAC Prisoner Information Action Committee PIC Prisoner Information Channel PMAG Prison Monitoring and Assurance Group POs Personal Officers PPE Personal Protective Equipment PPT Personal Protection Training PR2 SPS Prison Records System (version 2) PRL Prison Resource Library PTI Personal Training Instructor RAG Red, Amber, Green RGNs Registered General Nurses RMN Registered Mental Health Nurse RMT Risk Management Team RRA Reception Risk Assessment SBAR Situation Background Assessment Recommendation SBR Suspected Bullying Report SEB Shotts Employability Board SICP Standard infection control precaution SMT Senior Management Team SOP Standard Operating Procedure SPICT Supportive and Palliative Care Indicators Tool SPS Scottish Prison Service SPSO Scottish Public Service Ombudsman SRU Separation and Reintegration Unit SSM Special Security Measure SSOW Safe Systems of Work TTCG Tactical Tasking and Co-Ordination Group TTM Talk To Me
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131 UOF Use of Force VIR Violent Incident Review VRG Violence Reduction Group
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Total Recommendations ‐ 22 Total Open Actions ‐ 16 Priority Open Actions – 6 Closed Actions – 6 Appendix 1‐ HIS Review Recommendations Update 17th May 2023 HIS Priority Actions RAG Update Recommendation 44: North Lanarkshire HSCP and the SPS should work jointly to ensure that transfer arrangements for incoming prisoners are such that they enable a nurse to review/TTM assess all prisoners before they are admitted to a prison A Discussions have taken place with SPS Senior Management on site with an agreement where possible to arrange transfers of prisoners into the establishment prior to the completion of healthcare staff shifts. This is being monitored, and any deviation (i.e. where a prisoner arrives after healthcare staff have finished) will be managed as agreed with the Governor in Charge (GIC). Prisoner assessed by SPS staff and placed on observation until Healthcare staff can assess. Clinical Manager/Team Lead will continuously review compliance with requirement for admissions Healthcare screening, and any deviation will be escalated via the Datix system and highlighted on safety brief, with immediate action to assess prisoner as soon as is possible CNM review current process for admissions to ensure this is completed for all prisoners on transfer into to HMP Shotts. Data Collection started 1st May – daily number of transfers/time of transfer/daily number assessed by Primary Care Team (PCT) /daily number not assessed on the day. NB: There have been no prisoner transfers since 1st May 2023 Recommendation 48: North Lanarkshire HSCP must revise without delay, the process in place when identifying long term health conditions and provide assurance that patients are reviewed in line with what is equitable in the community to address health inequalities A Team Meeting held to discuss staff development and responsibility for chronic disease management. CNM delegated with assigning specialist areas to staff and researching training opportunities. Review current process to identify long term conditions for all prisoners on admission to the prison as well as any changes in their condition that may develop. Process to be devised to ensure prisoners with long term conditions are reviewed in line with community guidance and this is clearly documented within patients notes. All prisoners with a long term condition will have a person centred care plan and appropriate risk assessment completed. These should be reviewed and updated regularly.
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Recommendation 52: North Lanarkshire HSCP as a matter of urgency must review the medical cover available in the afternoons to: (i) ensure the risk to patients is reduced (ii) support nursing staff in dealing with emergency situations A The mechanism in place (staff contact the Flow Navigation Centre in afternoon hours with concerns about patients) was reviewed, updated and re‐circulated to staff following the inspection. Consultant connect is available as an integral part of this but has seldom been used or required. The Local Enhanced Service (LES) specification has been developed with invitations to tender being sent to all GPs in NHSL. 1 practice responded and met with the General Manager, Associate Medical Director and Clinical Director. 1 GP is currently shadowing for greater contextual understanding of the role. Associate Medical Director, Clinical Director and General Manager are also working on a contingency if this option does not result in an approved LES. Recommendation 57: As a priority North Lanarkshire’s HSCP must action the recommendations made in their service review regarding pharmacy provision and support to provide a service equitable with the community. A Prescribing processes and checks have been reviewed and checks are made regularly for accuracy and safe prescribing. Review of Pharmacy admin staff roles will form part of a wider workforce review. The existing staff who work in the pharmacy roles are supported by a senior Pharmacy Advisor from NHS Lanarkshire who visits regularly and is integrated into appropriate forums etc. in the delivery of service. The National Pharmacy Contract also provided senior pharmacist support on a weekly basis in the form of a site based day. The implementation of the new national pharmacy contract has been agreed. Lloyds will cease their contract on 30th June 2023. MD Green have been awarded the new contract. Weekly national meetings are in place to project plan the changeover. ECOR is being progressed to recruit to pharmacy vacancy. Recommendation 61: NHS Lanarkshire HSCP and SPS must ensure complaints forms are available in alternative formats and languages to ensure all patients can provide feedback, raise concerns and complain G The 12 most utilised languages complaint forms have been developed. Discussions to take place with SPS Head of Offender Outcomes to ascertain and agree the process for implementing these to prisoners as and when required. Meeting arranged 17th May 2023. Recommendation 65: North Lanarkshire HSCP must demonstrate implementation of recommendations from service review and provide clear pathways to support staff on site in HMP Shotts in the absence of senior staff A There has been prolific senior management presence onsite since November 2022. Recruitment of the CNM for PCT has been successful with a start date of 3rd July. Senior management support continues to be provided until the CNM starts. The Improvement Manager has been in post since the 3rd April, is onsite most days and has well integrated links to the senior management team.
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HIS Non Priority Actions RAG Update Recommendation 46: National co‐ordination and discussion with partner agencies (such as Police Scotland, Scottish Courts, GEOAmey and SPS) is required to ensure that people arrive at prison during the prisons core opening times or when nursing resource is available A Discussion has taken place with SPS Senior Management on site, with an agreement where possible to arrange transfers of prisoners into the establishment prior to the completion of healthcare staff shifts. This is being monitored, and any deviation (i.e. where a prisoner arrives after healthcare staff have finished) will be managed as agreed with the GIC ‐ Prisoner assessed by SPS staff and placed on observation until Healthcare staff can assess. CNM will continuously review compliance with requirement for admissions Healthcare screening and any deviation will be escalated via the Datix system and highlighted on safety brief, with immediate action to assess the prisoner as soon as is possible. Compliance monitoring and data collection has begun since 1st May now the IM has started post however there have been no prisoner transfers since 1st May 2023 due to issues with GEOAmey Recommendation 56: North Lanarkshire HSCP must ensure that person centred care plans and appropriate risk assessments are in place for all patients with long term conditions (LTC) and that these are reviewed regularly A A structure to identify and review patients with LTC has been developed and thereafter medical reviews will occur as result of this structure with a recall system in place on VISION. Frequency of reviews will be decided by medical staff based on need and any relevant guidelines. When staffing allows; allocation of responsibility for chronic disease management will be conducted based on individual staff member’s skills, experiences and development needs. Senior Nurse will via staff PDP identify these responsibilities and assess issues such as training opportunities required
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HIS Non Priority Actions RAG Update Recommendation 45: North Lanarkshire HSCP must develop a pathway to ensure patients receive psychiatry follow up when transferred, G Link with the head/lead forensic psychiatrists Scottish Prisons and Community at all health boards to devise a simple pathway to share that says a transfer letter from previous prison must be sent to SHOTTS pre admission to allow appropriate follow up appointment to be booked with psychiatrist. To mitigate in the short term, the mental health secretary will check vison/docman for every new prisoner transfer to ascertain if psychiatry follow‐up is required for them. If it is the patient will be booked to our psychiatrist as per instructions of their last psychiatric letter. Recommendation 54: North Lanarkshire HSCP must introduce an electronic system to record and update documents to keep documents live and ensure the most up‐to‐date information is accessible. A On an ongoing basis, there will be scoping of whether North HSCP can introduce an electronic system to record and update documents to keep documents live and ensure the most up to date information is accessible. Discussion has been ongoing regarding the potential introduction of the MORSE system At present a national, (and older) version of Vision is the main system in use across all HMPs in Scotland Recommendation 55: North Lanarkshire HSCP must develop a pathway for accessing specialist support in intellectual disabilities, autistic spectrum disorder, neuropsychiatric disorders and cognitive impairment. A The service has no bespoke internal functionality for these disorders based at the prison, but any individual with such presenting needs would be referred to the existing Lanarkshire services. This entails prisoner patients having to wait an equitable period of time as the general public for assessment and any interventions that such a referral may produce. Newly established ‘Lanarkshire’ pathways are in situ for ADHD and Cognitive Impairment. There has been change in personnel in relation to the Senior Nursing position for Mental Health & LD. New staff are establishing themselves now and will support with the further development of access for prisoner patients to appropriate services. Recommendation 58: NHS Lanarkshire's pharmacy service must provide structured and regular support to staff involved in supporting pharmacy services within HMP Shotts A Review of Pharmacy admin staff roles will form part of a wider workforce review when the newly appointed Project/Improvement Manager is in post. However, the existing staff who work in the pharmacy roles are supported by a senior Pharmacy Advisor from NHS Lanarkshire who visits regularly and is integrated into appropriate forums etc. in the delivery of service. The implementation of the new national pharmacy contract has been agreed. Lloyds will cease their contract on 30th June 2023. MD Green have been awarded the new contract. Weekly national meetings are in place to project plan the changeover. ECOR is being progressed to recruit to pharmacy vacancy.
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HIS Non Priority Actions RAG Update Recommendation 59: North Lanarkshire HSCP and SPS must seek solutions to assist staff to administer medication at a suitable and therapeutic time A Existing practices are made as safe as possible (SOP’s in place) by working in conjunction with SPS. Development is planned between both organisations to change the administration of “Weekly” medication as and when healthcare staffing enables this. Recommendation 50: North Lanarkshire HSCP must ensure that all eligible patients who wish to be involved in national screening programmes are supported to do so and that this is clearly documented in patients VISION record A The service will ensure on an ongoing basis that prisoners are able to be included in national screening programmes for Bowel cancer and AAA (If in the appropriate age groups). Currently prisoners receive their own screening appointment letters directly (not via healthcare department). This is reliant on their whereabouts being known. A National solution is required for this and NHS Lanarkshire will keenly participate. If this process is required to be evidenced/audited, a system must be developed to ensure that all appropriate patients have accessed screening by direct correspondence and that this is documented on Vision. This will require prisoners to share these details. Recommendation 53: North Lanarkshire HSCP must ensure that patients are able to access national screening programmes in line with community provision and keep accurate records of attendance A As above Recommendation 60: NHS Lanarkshire HSCP should consider the re‐introduction of the oral health educator role to support the dental service G Oral health care team are updating PPT training with SPS on 22nd February 23 and will commence monthly education visits once training completed in March. Service lead anticipates more frequent visits in future plans. IM is meeting senior health improvement manager 17th May to discuss position and move forward
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HIS Closed Actions RAG Update Recommendation 47: HMP Shotts must provide a room that is clean and clutter‐free at reception G Interview/Assessment room in Reception area has been reviewed, has been cleared, is regularly cleaned and is now fit for purpose. Recommendation 49: North Lanarkshire HSCP must implement a system for secondary care referrals that ensures patient confidentiality is protected G Immediately after the inspection a solution was found with use of secure e mail over surface mail as SCI Gateway option was still being explored. SCI gateway infrastructure is now in place and went live on 11th May 2023. Recommendation 51: North Lanarkshire HSCP must ensure that checks on emergency equipment are carried out within the agreed timeframe and that these checks are clearly recorded. G Emergency equipment is checked regularly and documentation is signed to evidence this by healthcare staff. CNM will complete random audits of documentation to ensure compliance. Recommendation 62: NHS Lanarkshire HSCP must ensure that all staff managing complaints receive training to ensure that all complaints are correctly managed. G The senior management team have reviewed all processes which now ensures the CNM onsite manages all Stage 1 complaints. Full training has been issued. Anything Stage 2 and above is escalated and managed via the organisational process (Patient Affairs & General Manager). Recommendation 63: NHS Lanarkshire HSCP should develop a process to discuss complaints to share learning and identify any themes or required improvements. G CNM has reintroduce monthly team meetings. CNM to chair with attendance from SM/SN to provide additional info and communication from strategy group and operational issues. Standing Agenda items are agreed with opportunity to add additional items. Items to include Infection Prevention & Control, Briefing Notes, Datix's, Actions Plans & shared Learnings. Discussion, Action points and updates to be recorded in R Drive. Recommendation 64: NHS Lanarkshire HSCP must ensure that alternative and consistent IT G Immediately after the inspection a solution was found with use of secure e mail over surface mail as SCI Gateway option was still being explored. SCI gateway infrastructure is now in place and went live on 11th May 2023.
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solutions are provided to support clinical staff as referrals by post is a significant data breach
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Total Recommendations ‐ 32 Total Open Actions – 10 Total Closed Actions ‐ 22 Appendix 2 ‐Service Model Review Update 17th May 2023 Service Model Review Actions RAG Update Recruitment and retention of staff A Ongoing Open Day's planned 6‐8 monthly with SPS. Held on 2 occasions (Oct 2022 & Feb 2023). Shadow shift project to engage with Lanarkshire Staffbank staff and promote experience in Shotts and allow for training of temporary staff. Rolling adverts for Primary Care staff via national SHOW vacancy website. Attendance by Practice Education Facilitators to Open Day and regular communication to facilitate Student/Mentorship in prison setting once vacancy backfill allows for clinical supervision of students. Recruitment is on‐going. Application made to STAC for Secure Environment Allowance for staff. Awaiting decision. Clearly define roles and responsibilities for each grade of staff and identify development opportunities A Newly appointed seconded Team Leader/Clinical Nurse Manager (CNM) in post April 23 ‐ gaining access to systems presently. 2nd CNM appointed with a start date of July 23. Develop monthly service development meetings with the MDT G Improvement manager will set up monthly improvement group meetings with the senior team and teams within the HC. The first meeting is set for 24th May within the HC. A staff experience questionnaire has been sent to all staff for completion. Results will be presented at the meeting. Student Feedback A Practice Education Facilitator for Shotts has changed early 2023 and we are engaged with team to facilitate training for current and future Primary Care team staff to bring suitable students into the learning environment. Currently we need more registrants in the team to support student plans. Completion of Mandatory and Compulsory Training for all staff G Rolling programme of training and education affected by turnover of staff and current vacancy level. All staff aware of personal responsibility for skill and training requirement. Seconded CNM gaining access to TURAS and EESS platforms. Skills Bus has been delayed from Nov/Dec 2022 however team has been contacted again to provide dates.
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Develop an electronic staffing roster on MS Teams G All staff will have visibility to this for transparency, any amendments made are audited allowing staff to trace/track all changes. Await the new PCT CNM to commence post in July then discuss and agree on the roster format. Review of addictions pathway for released prisoners G Addictions Charge Nurse invited to share current pathway with Drug Death Task Forum. This group is due to meet on 23rd July 2023 Water outlet not been utilised G Outlets have been removed and room is ready for preparation to store room facility. Seconded CNM is reviewing requirements to push work forward. Patient Feedback A Health Improvement advisor based at prison has confirmed the restart of Satisfaction Questionnaires from April 2023. Dates for focus groups yet to be confirmed. Health Improvement advisor left post in April ‐ eCOR to be raised to backfill and continue this work. Training in relation to End of Life Care G Anticipatory Care Planning (ACP) training/refresher for staff to be arranged •Staff to complete Lanarkshire ACP training module on learn pro. Confirmation of death training to be arranged for all appropriate staff. Clinic team to develop a pack containing appropriate and relevant resources that can be shared with bereaved families.
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Service Model Review Closed Actions RAG Update Robust process for monthly NMC Registration checks for Registered nurse to be established G Robust monthly process implemented by Senior Nurse, and undertaken by CNM as routine monthly task. Proactive approach to reminding staff that Registration fees are due for renewal. Proactive approach to ensure staff undertake Revalidation exercise timeously and in advance of due date for sign off. Introduction of Daily Safety Brief G Template for safety brief updated, agreed and implemented. Morning safety brief being completed by Primary Care Team at beginning of shift and electronic copy saved in R‐drive. Introduction of 2pm verbal briefing started 8th May 2023 by CNM, includes MDT representation.6pm Safety handover completed by PCT Nurse on duty at end of working day. Emailed to colleagues and Senior management team for info Introduction of a Monthly Health Centre Team/Service meeting G CNM re‐commenced these meetings in April 2023 Staff Health & Well Being G Discussion with SPS staff at Strategy group ‐ unable to provide alternative rest area but staff can utilise facilities at main reception for breaks, this also includes use of Gym facilities. Staff breaks extended to include time to walk to main reception if staff wish to utilise this area. Weekly staff email bulletin includes up to date information for all staff re how to access staff health and wellbeing facilities. Radio chatter distraction to staff G Discussed at Strategy Group, and agreed clinical staff should remove ear piece when issuing medication. Communicated this to staff. Health & Safety G Control Book reviewed end of November 22 with Action Plan issued. CNMs tasked with completion and/or delegation of tasks. Control book reviewed and on continuous review and update as risk assessments are required. Psychological Safety G iMatters survey due reviewed July 2023 as annual plan. Psychological survey carried out with staff for anonymous feedback ‐ will be repeated at regular intervals in the calendar year. Develop guidelines in relation to SPS purchased social care services G Senior professional & operational management have raised concerns to SPS at joint NHSL/SPS strategy forum. SPS did not share concerns expressed, but agreed to further investigate individual episode of alleged suboptimal care. NHSL will continue to raise concerns if required using appropriate medium. Individual investigation was investigated and concluded to NHSL satisfaction.
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Competent witness training G Register of all staff completing Competent witness training now being completed and CNM responsible for ensuring this is kept up to date. PDD to be contacted by SN to request review of training pack. Discussion completed with Practice Development. Review of kardex's G Process in place with regular review and re writing of medication kardex (Prescription sheet). Missing kardex’s within pharmacy G Test of changed developed and instated by way of sign in and out tracer card within pharmacy to reduce time wasted searching for kardexes when they are not in their allocated folder or with the GP. Completion of hand Hygiene learn pro module annually by all staff G Learn pro hand hygiene module records are held in this database and are being updated by CNM monthly. CNM is completing 10 hand hygiene audits each month with team and submitting on Monthly Highlight report for North hygiene group. Request to CNM for all completed audits to be recorded monthly on LanQIP ‐now completed onto LanQIP system Ensure all staff are fully aware of appropriate use of Personal Protective Equipment (PPE) G Winter Respiratory guidance and posters shared with CNM by SN. Request to share with team as well as posters to be displayed in all clinical areas. SN re‐shared Winter Respiratory guidance with all staff, including Respiratory questions and Quick Reference pathway which fully outlines appropriate use of PPE. Above guidance now added to admissions paperwork and staff now complete the questionnaire for all prisoners transferred into HMP Shotts during the admission process Prompt added to Daily Safety Brief as well as discussion at Morning safety handover to ensure all staff were fully aware of update. SN ensured posters were visible in relation to this guidance in health centre area for staff reference Ensure all staff fully aware of local guidance re cleaning and decontamination of environment and equipment G A‐Z Decontamination checklist shared by Senior Nurse (SN) to CNM and request for this to be completed as applicable. SN shared laminated posters with staff with instructions on use of appropriate cleaning agents‐ request for these to be displayed in Health centre area for staff reference. Cleaning schedules are available in all clinical rooms and staff are aware re completion of these at end of each room use.
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Completion of monthly SICP's audits as per SICPs Monitoring Audit Programme G Monthly SICP'S audits are completed by CNM, reported and submitted on Highlight report for collation by SN. SN shared annual SICP'S Monitoring audit programme with CNM. Request to CNM that all SICP'S audits are recorded on LanQIP when complete‐ this is now being actioned. Scottish Infection Control Education Pathway added to staff learn pro training scorecards for completion by all appropriate staff and record of completion will then be available for CNM to review. CNM will ensure staff complete. Poor compliance by all patients with PPE guidance and physical distancing G This advice continues to be reinforced for all patients attending Health centre area. Ensure all staff fully aware of national and local guidance in relation to infection prevention and control G Winter Respiratory guidance and posters shared with CNM by SN, Request to share with team as well as posters to be displayed in all clinical areas. SN re‐shared Winter Respiratory guidance with all staff. This included Respiratory questions and Quick Reference pathway which fully outlines appropriate use of PPE SN shared IPC team contact details as well as email link to IPC guidance for staff use by email as well as laminated posters displayed in health centre area for staff reference when required. Ensure all sharps bins are temporarily closed G CNM has discussed this with staff and is ensuring all staff are fully aware of how to temporarily close Sharps bins and correct labelling of bins. SN shared appropriate signage re Temporary closure of sharps bins with staff and request to display these in all appropriate clinical areas where sharps bins are used.
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Cancellation of patient transport G Database is being completed and updated daily to record any Geo‐amey cancellations. CNM is ensuring all cancelled appointments are reviewed daily to prioritise need for re‐appointment for individual prisoners. All cancellations appointments are reviewed by clinical staff and prioritised when requesting re‐appointments. Review of joint NHS Scotland and SPS MORS Policy G Discussed at local strategic meeting with SPS Staff and agreement that SPS staff should always action request from NHS staff to commence MORS Policy. NHS staff should escalate to Governor/Deputy Governor if any SPS staff refuse to commence MORS policy when requested. National review of MORs policy on‐going. SPS and Healthcare work in collaboration to review safety of patients. Ongoing national discussions regarding MORS. Appropriate use of ACP G SN shared updated copy of ACP booklet as well as the ACP Guidance for Health Professionals. CNM to share and discuss appropriate use of this with team. Staff to consider use of ACP booklet when indicated for individual patient completion. Review current escalation process for deteriorating patients G Training completed in 2022 for staff however change of staff will mean more training later this year. Closing as this will be a rolling programme of education.
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1 REPORT Item No: 11 SUBJECT: North Lanarkshire ADP – Self-Assessment TO: Performance, Finance & Audit Committee Lead Officer for Report: Morag Dendy Head of Planning, Performance and Quality Assurance Author(s) of Report John Holleran – Strategic Lead, North Lanarkshire ADP DATE: 21 June 2023 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: ☐
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2 3. RECOMMENDATIONS 3.1 The IJB is asked to: (1) Note the content of the report; (2) Note the content of the Annual Reporting Survey to the Scottish Government that requires approval by the IJB. This is due to be submitted via the ADP by 27th June 2023. The survey is designed to collect information on a range of aspects relating to the delivery of the Nation Mission, to deliver on the priorities in line with additional investment; (3) Note the arrangements in place across each priority area; Prevention, Early Intervention and Education Residential Rehab Assertive Outreach and Crisis support Harm reduction – including Naloxone provision Whole Family Approach and Family Inclusive Practice Lived and Living Experience (4) Approve NLADP Annual report completion setting out the appropriate supports and governance is in place to deliver the National Mission priorities and The Partnership Delivery Framework objectives. 4. VARIATIONS TO DIRECTIONS? Yes ☐ No ☐ N/A ☒ 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 The NLADP Strategic Lead has been working closely with key partners through the five ADP sub-groups (below) to develop key actions and support in keeping with national evidence, regional scoping work and learning from commissioned services including the voices of lived experience. The ADP sub-groups oversee and support decision making on local investments linked to delivering on the National Mission priorities. 1. Prevention, Early Intervention, & Education 2. Treatment, Care & Recovery 3. Whole Family Approach 4. Public Health Approach to Justice 5. Reducing Alcohol Harms Group
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3 5.2 All thirty of Scotland ADPs are responsible for delivering on the National Mission Priorities. The aim of the National Mission is to improve and save the lives of people who use drugs and their loved ones. The purpose of the Annual Report Survey to give local ADPs a tool to engage and discuss opportunities and barriers to delivery. Strategic Planning follows a cycle of Assessing need Aligning resources Agreeing delivery plans and priorities Reporting and learning from outcomes 5.3 Annual Report Survey is designed to ensure key measures are in place and that the local system is supporting the work of the ADP. The Annual Report Survey should be agreed and signed off with the relevant Chief Officers and stakeholders 5.4 The Annual report survey sets out where the local ADP and relevant partners are in relation to the Partnership Delivery Framework: 1. Strategic planning 2. Financial arrangements 3. Quality improvement and Outcomes 4. Governance and Oversight 5. The relationship between the ADP and the Integration Authority 6. CONCLUSIONS 6.1 The Annual report survey sets out the range of work in place to scope strengths and challenges in current arrangements. NLADP place the experience of people with lived experience and families at the centre of developments and engagement with all stakeholders. This approach has significantly reshaped the commissioning intentions, created a robust response to the challenge of preventable drug deaths in North Lanarkshire and informed the ADP Investment Plans. 6.2 A detailed report with full commissioned services activity, governance processes and financial arrangements will follow at the next meeting. This will reflect progress made in 2022/23 towards the associated measures set out below. 7. IMPLICATIONS
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4 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 ☐ 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) • Medication Assisted Treatment (MAT) standards – 1-5 implemented and embedded by March 2024 (6-10 beyond) • Residential rehab – assessment and access for anyone who chooses/where appropriate as part of their care and treatment. Each ADP/Health Board should now publish rehab pathways online setting out how people can access residential rehab. • Harm reduction – consistent approaches and increase workforce confidence/capacity to deliver HR. Includes Naloxone provision, Blood-Bourne Virus testing and wound care. • Assertive Outreach – ADPs should define their approach for increased support with commissioning for effective assertive outreach/crisis support. • Treatment Targets – increase engagement by 9% (113) by 2024 • Whole Family Approach – increase/widen Family Inclusive Practice (FIP) across all treatment and care settings • Recovery – Lived and Living Experience (LLE) involved in design, delivery and evaluation of services. LLE Panels to be established. • Mental Health – Complex needs are fully considered and met via trauma informed workforce • Stigma – tackled at local level
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5 • Human Rights – are at the heart of how substance use services and wider supports are designed and offered. 7.3 FINANCIAL This paper has been reviewed by Finance: Yes ☐ No ☐ N/A ☒ 7.4 RISK ASSESSMENT/RISK MANAGEMENT Relevant Risk Register Details Current Risk Level Risk Owner Choose an item. 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 □ 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
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6 □ 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 EQIA Completed & Fairer Scotland Impact Assessment Form Completed and attached to report: Yes ☐ No ☐ N/A ☒ EQIA added to website: Yes / Date added ☐ No ☐ N/A ☒ 8. BACKGROUND PAPERS This report sets out the progress made by North Lanarkshire ADP on delivering on Rights, respect recovery, the national performance framework, National mission objectives linked to reducing harm from alcohol and drugs. This report forms the basis of the annual return to the Scottish Government setting out progress made from investments in 2022.
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7 9. APPENDICES Please include a glossary of terms if not already included. Appendix 1 ADP Annual Reporting Survey 2022-23 CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact the following; John Holleran on 01698 753651 john.holleran@lanarkshire.scot.nhs.uk
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8 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
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1 Appendix 1 Alcohol and Drug Partnership (ADP) Annual Reporting Survey: 2022/23 This survey is designed to collect information from all ADPs across Scotland on a range of aspects relating to the delivery of the National Mission during the financial year 2022/23. This will not reflect the totality of your work but will cover those areas where you do not already report progress nationally through other means. The survey is primarily composed of single option and multiple‐choice questions, but we want to emphasise that the options provided are for ease of completion and it is not expected that every ADP will have all of these in place. We have also included open text questions where you can share more detail. We do not expect you to go out to services in order to respond to questions relating to activities undertaken by them in your area. Where questions refer to service level activities, we are interested in the extent to which you are aware of these at an ADP level. We are aware of some element of duplication with regards to questions relating to MAT Standards and services for children and young people. To mitigate this, we’ve reviewed the relevant questions in this survey and determined the ones that absolutely need to be included in order to evidence progress against the national mission in the long‐term. While some of the data we are now asking for may appear to have been supplied through other means, this was not in a form that allows for consistently tracking change over time. The data collected will be used to better understand the challenges and opportunities at the local level and the findings will be used to help inform the following: The monitoring of the National Mission; The work of a number of national groups including the Whole Family Approach Group, the Public Health Surveillance Group and the Residential Rehabilitation Working Group, amongst others; and The priority areas of work for national organisations which support local delivery. The data will be analysed and findings will be published at an aggregate level as Official Statistics on the Scottish Government website. All data will be shared with Public Health Scotland to inform drug and alcohol policy monitoring and evaluation, and excerpts and/or summary data may be used in published reports. It should also be noted that the data provided will be available on request under freedom of information regulations and so we would encourage you to publish your return. The deadline for returns is Tuesday 27th June 2023. Your submission should be signed off by the ADP and the IJB, with confirmation of this required at the end of the questionnaire. We are aware that there is variation in the timings of IJB meetings so please let us know if this will be an issue. If you require clarification on any areas of the survey or would like any more information, please do not hesitate to get in touch by email at substanceuseanalyticalteam@gov.scot.
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2 Cross‐cutting priority: Surveillance and Data Informed Q1) Which Alcohol and Drug Partnership (ADP) do you represent? [single option, drop‐down menu] North Lanarkshire ADP Q2) Which groups or structures were in place at an ADP level to inform surveillance and monitoring of alcohol and drug harms or deaths? (select all that apply) [multiple choice] ☒ Alcohol harms group □ Alcohol death audits (work being supported by AFS) ☒ Drug death review group ☒ Drug trend monitoring group/Early Warning System □ None □ Other (please specify): Q3a) Do Chief Officers for Public Protection receive feedback from drug death reviews? (select only one) [single option] ☒ Yes □ No □ Don’t know Q3b) If no, please provide details on why this is not the case. [open text – maximum 255 characters] Q4a) As part of the structures in place for the monitoring and surveillance of alcohol and drugs harms or deaths, are there local processes to record lessons learnt and how these are implemented? (select only one) [single option] ☒ Yes □ No □ Don’t know Q4b) If no, please provide details. [open text – maximum 255 characters]
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3 Cross‐cutting priority: Resilient and Skilled Workforce Q5a) What is the whole‐time equivalent staffing resource routinely dedicated to your ADP Support Team as of 31st March 2023. [open text, decimal] Total current staff (whole‐time equivalent including fixed‐term and temporary staff, and those shared with other business areas) 7.00 Total vacancies (whole‐time equivalent) 1 Q5b) What type of roles/support (e.g. analytical support, project management support, etc.) do you think your ADP support team might need locally? Please indicate on what basis this support would be of benefit in terms of whole‐time equivalence. [open text – maximum 255 characters] Strategic Lead WTE Development officer x3 WTE Information Research Officer WTE Administrator WTE Clerical Officer WTE Q6a) Do you have access to data on alcohol and drug services workforce statistics in your ADP area? (select only one) [single option] ☒ Yes □ No (please specify who does): □ Don’t know 6b) If yes, please provide the whole‐time equivalent staffing resource for alcohol and drug services in your ADP area. [open text, decimal] Total current staff (whole‐time equivalent) 50.00 Total vacancies (whole‐time equivalent) 10.5 Q7) Which, if any, of the following activities are you aware of having been undertaken in your ADP area to improve and support workforce wellbeing (volunteers as well as salaried staff)? (select all that apply) [multiple choice] ☒ Coaching, supervision or reflective practice groups with a focus on staff wellbeing ☒ Flexible working arrangements ☒ Management of caseload demands ☒ Provision of support and well‐being resources to staff ☒ Psychological support and wellbeing services ☒ Staff recognitions schemes
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4 □ None □ Other (please specify):
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5 Cross cutting priorities: Lived and Living Experience Q8a) Do you have a formal mechanism at an ADP level for gathering feedback from people with lived/living experience using services you fund? (select all that apply) [multiple choice] ☒ Feedback/complaints process ☒ Questionnaire/survey □ No ☒ Other (please specify): Commisioned support from NCOs including Scottish Recovery Consortium and Scottish Drug Forum. In addition, local comissioned services gather feedback and report to the ADP on a 1/4ly basis. Q8b) How do you, as an ADP, use feedback received from people with lived/living experience and family members to improve service provision? (select all that apply) [multiple choice] Lived/living experience Family members Feedback used to inform service design ☒ ☒ Feedback used to inform service improvement ☒ ☒ Feedback used in assessment and appraisal processes for staff ☒ ☒ Feedback is presented at the ADP board level ☒ ☒ Feedback is integrated into strategy ☒ ☒ Other (please specify) Q9a) How are people with lived/living experience involved within the ADP structure? (select all that apply) [multiple choice] Planning (e.g. prioritisation and funding decisions) Implementation (e.g. commissioning process, service design) Scrutiny (e.g. monitoring and evaluation of services) Other (please specify) Board representation at ADP ☒ ☒ ☒ Focus group ☒ ☒ ☒ Lived experience panel/forum ☐ ☐ ☐ In development Questionnaire/ surveys ☒ ☒ ☒ Other (please specify)
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6 Q9b) How are family members involved within the ADP structure? (select all that apply) [matrix, multiple choice] Planning (e.g. prioritisation and funding decisions) Implementation (e.g. commissioning process, service design) Scrutiny (e.g. monitoring and evaluation of services) Other stage (please specify) Board representation at ADP ☒ ☒ ☒ Focus group ☒ ☒ ☒ Lived experience panel/forum ☐ ☐ ☐ In development Questionnaire/ surveys ☒ ☒ ☒ Other (please specify) Q9c) If any of the above are in development for either people with lived/living experience and/or family members, please provide details. [open text – maximum 2000 characters] The ADP is currently supported by Scottish Recovery Consortium and Scottish Drug Forum to establish our lived experience representatives panels. These will be led/supported by a dedicaed post within the ADP support team on a permanent basis. This is currently out to advert. Q10) What monitoring mechanisms are in place to ensure that services you fund are encouraged/supported to involve people with lived/living experience and/or family members in the different stages of service delivery (i.e. planning, implementation and scrutiny)? [open text – maximum 2000 characters] NLADP has a quarterly reporting process in place where all comissioned services are requried to set out what involvement those with lived and living experiecne have had in the design, delivery and evaluation of their services. Q11) Which of the following support is available to people with lived/living experience and/or family members to reduce barriers to involvement? (select that apply) [multiple choice] ☒ Advocacy ☒ Peer support □ Provision of technology/materials ☒ Training and development opportunities ☒ Travel expenses/compensation ☒ Wellbeing support □ None □ Other (please specify):
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7 Q12a) Which of the following volunteering and employment opportunities for people with lived/living experience are offered by services in your area? (select all that apply) [multiple choice] ☒ Community/recovery cafes ☒ Job skills support ☒ Naloxone distribution ☒ Peer support/mentoring ☒ Psychosocial counselling □ None □ Other (please specify): Q12b) What are the main barriers to providing volunteering and employment opportunities to people with lived/living experience within your area? [open text – maximum 2000 characters] This fully supported via the dedicated commsioned service (Individual Placement Support). This is currently delviered by SAMH across the whole of North Lanarkshire. Q13) Which organisations or groups are you working with to develop your approaches and support your work on meaningful inclusion? (select all that apply) [multiple choice] ☒ MAT Implementation Support Team (MIST) ☒ Scottish Drugs Forum (SDF) ☒ Scottish Families Affected by Drugs and Alcohol (SFAD) ☒ Scottish Recovery Consortium (SRC) □ None □ Other (please specify):
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8 Cross cutting priorities: Stigma Reduction Q14) Do you consider stigma reduction for people who use substances and/or their families in any of your written strategies or policies (e.g. Service Improvement Plan)? (select only one) [single option] ☒ Yes (please specify which): □ No □ Don’t know Q15) Please describe what work is underway to reduce stigma for people who use substance and/or their families in your ADP area. [open text – maximum 2000 characters] NLADP hosted a number of workshops this year with the support of Scotish Families affected by Alcohol and Drugs and the Scottish Recovery Consortium. The next phase is to establish local stigma steering group and a stigma action fund to support local atcitivies. we also work closely with Stigma Free Lanarkshire and community sector partners to shape our local reponse.
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9 Fewer people develop problem substance use Q16) How is information on local treatment and support services made available to different audiences at an ADP level (not at a service level)? (select all that apply) [multiple choice] Non‐native English speakers (English Second Language) People with hearing impairments People with learning disabilities and literacy difficulties People with visual impairments Other audience (please specify) In person (e.g. at events, workshops, etc) ☐ ☐ ☐ ☐ Leaflets/posters ☐ ☐ ☐ ☐ Online (e.g. websites, social media, apps, etc.) ☐ ☐ ☐ ☐ Other (please specify)
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10 Q17) Which of the following education or prevention activities were funded or supported by the ADP? (select all that apply) [multiple choice] 0‐4 (early years) 5‐12 (primary) 13‐15 (secondary S1‐4) 16‐24 (young people) 25+ (adults) Parents People in contact with the justice system Other audience (please specify) Counselling services ☐ ☒ ☒ ☒ ☐ ☒ ☐ Information services ☐ ☒ ☒ ☒ ☒ ☒ ☒ Physical health ☐ ☒ ☒ ☒ ☒ ☐ ☐ Mental health ☐ ☒ ☒ ☒ ☒ ☒ ☒ Naloxone ☐ ☐ ☐ ☒ ☒ ☒ ☒ Overdose awareness and prevention ☐ ☐ ☒ ☒ ☒ ☒ ☒ Parenting ☐ ☐ ☒ ☒ ☒ ☒ ☐ Peer‐led interventions ☐ ☐ ☒ ☒ ☒ ☒ ☒ Personal and social skills ☐ ☐ ☒ ☒ ☒ ☒ ☒ Planet Youth ☐ ☐ ☒ ☒ ☐ ☐ ☐ Pre‐ natal/pregnancy ☐ ☐ ☐ ☒ ☒ ☒ ☒ Reducing stigma ☐ ☐ ☒ ☒ ☒ ☒ ☒ Seasonal campaigns ☐ ☐ ☐ ☒ ☒ ☒ ☒ Sexual health ☐ ☐ ☒ ☒ ☐ ☐ ☐ Teaching materials for schools ☒ ☒ ☒ ☒ ☐ ☐ ☐ Wellbeing services ☐ ☒ ☒ ☒ ☒ ☒ ☒ Youth activities (e.g. sports, art) ☐ ☒ ☒ ☒ ☒ ☒ ☒ Youth worker materials/training ☐ ☒ ☒ ☒ ☒ ☒ ☒ Other (please specify)
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11 Risk is reduced for people who use substances Q18a) In which of the following settings is naloxone supplied in your ADP area? (select all that apply) [multiple choice] ☒ Accident & Emergency departments ☒ Community pharmacies ☒ Drug services (NHS, third sector, council) ☒ Family support services □ General practices ☒ Homelessness services ☒ Justice services ☒ Mental health services ☒ Mobile/outreach services ☒ Peer‐led initiatives ☒ Women support services □ None □ Other (please specify): Q18b) In which of the following settings is Hepatitis C testing delivered in your ADP area? (select all that apply) [multiple choice] ☒ Accident & Emergency departments □ Community pharmacies ☒ Drug services (NHS, third sector, council) □ Family support services □ General practices □ Homelessness services ☒ Justice services □ Mental health services ☒ Mobile/outreach services ☒ Peer‐led initiatives □ Women support services □ None □ Other (please specify):
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12 Q18c) In which of the following settings is the provision of injecting equipment delivered in your ADP area? (select all that apply) [multiple choice] ☒ Accident & Emergency departments ☒ Community pharmacies ☒ Drug services (NHS, third sector, council) □ Family support services □ General practices ☒ Homelessness services ☒ Justice services ☒ Mental health services ☒ Mobile/outreach services ☒ Peer‐led initiatives ☒ Women support services □ None □ Other (please specify): Q18d) In which of the following settings is wound care delivered in your ADP area? (select all that apply) [multiple choice] ☒ Accident & Emergency departments □ Community pharmacies ☒ Drug services (NHS, third sector, council) □ Family support services □ General practices ☒ Homelessness services ☒ Justice services ☒ Mental health services ☒ Mobile/outreach services ☒ Peer‐led initiatives ☒ Women support services □ None □ Other (please specify): Q19a) Are there protocols in place to ensure all prisoners identified as at risk are offered with naloxone upon leaving prison? (select only one) [single option] ☒ Yes □ No □ No prison in ADP area Q19b) If no, please provide details. [open text – maximum 255 characters]
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13 People most at risk have access to treatment and recovery Q20a) Are referral pathways in place in your ADP area to ensure people who experience a near‐fatal overdose (NFO) are identified and offered support? (select only one) [single option] ☒ Yes □ No □ Don’t know Q20b) If yes, have people who have experienced a near‐fatal overdose been successfully referred using this pathway? (select only one) [single option] ☒ Yes □ No □ Don’t know Q20c) If no, when do you intend to have this in place? [open text – maximum 255 characters] Q21) In what ways have you worked with justice partners? (select all that apply) [multiple choice] ☒ Contributed towards justice strategic plans (e.g. diversion from justice) ☒ Coordinating activities ☒ Information sharing ☒ Joint funding of activities ☒ Justice partners presented on the ADP ☒ Prisons represented on the ADP (if applicable) ☒ Providing advice/guidance □ None □ Other (please specify): Q22a) Do you have a prison in your ADP area? (select only one) [single option] ☒ Yes □ No
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14 Q22b) Which of the following activities did the ADP support or fund at the different stages of engagement with the justice system? (select all that apply) [multiple choice] Pre‐arrest In police custody Court Prison (if applicable) Upon release Community justice Advocacy ☐ ☒ ☒ ☒ ☒ ☐ Alcohol interventions ☐ ☒ ☐ ☒ ☒ ☒ Alcohol screening ☐ ☒ ☐ ☒ ☐ ☐ Buvidal provision ☒ ☐ ☐ ☒ ☒ ☐ Detoxification ☐ ☐ ☐ ☐ ☐ ☐ Drugs screening ☐ ☒ ☐ ☒ ☐ ☐ Psychological screening ☐ ☒ ☐ ☒ ☐ ☒ Harm reduction ☐ ☒ ☐ ☒ ☒ ☒ Health education ☐ ☐ ☐ ☐ ☐ ☐ “Life skills” support or training (e.g. personal/social skills, employability) ☐ ☐ ☐ ☐ ☒ ☒ Opioid Substitution Therapy (excluding Buvidal) ☐ ☐ ☐ ☒ ☒ ☒ Peer‐to‐peer naloxone ☐ ☒ ☐ ☒ ☒ ☒ Recovery cafe ☐ ☐ ☐ ☒ ☒ ☒ Recovery community ☐ ☐ ☐ ☐ ☐ ☐ Recovery wing ☐ ☐ ☐ ☐ ☐ ☐ Referrals to alcohol treatment services ☐ ☒ ☐ ☒ ☒ ☒ Referrals to drug treatment services ☐ ☒ ☐ ☒ ☒ ☒ Staff training ☐ ☐ ☐ ☐ ☐ ☐ Other (please specify)
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15 Q23a) How many recovery communities are you aware of in your ADP area? [open text, integer] 6 Q23b) How many recovery communities are you actively engaging with or providing support to? [open text, integer] 6 Q24a) Which of the following options are you using to engage with or provide support to recovery communities in your area? (select all that apply) [multiple choice] ☒ Funding ☒ Networking with other services ☒ Training □ None □ Other (please specify): Q24b) How are recovery communities involved within the ADP? (select all that apply) [multiple choice] ☒ Advisory role ☒ Consultation ☒ Informal feedback □ Representation on the ADP board □ Recovery communities are not involved within the ADP □ Other (please specify):
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16 People receive high quality treatment and recovery services Q25) What treatment or screening options are in place to address alcohol harms? (select all that apply) [multiple choice] ☒ Access to alcohol medication (Antabuse, Acamprase, etc.) ☒ Alcohol hospital liaison ☒ Alcohol related cognitive testing (e.g. for alcohol related brain damage) ☒ Arrangements for the delivery of alcohol brief interventions in all priority settings ☒ Arrangement of the delivery of alcohol brief interventions in non‐priority settings ☒ Community alcohol detox ☒ In‐patient alcohol detox ☒ Fibro scanning ☒ Psychosocial counselling □ None □ Other (please specify): Q26) Which, if any, of the following barriers to residential rehabilitation exist in your ADP area? (select all that apply) [multiple choice] □ Current models are not working □ Difficulty identifying all those who will benefit ☒ Further workforce training required □ Insufficient funds ☒ Lack of specialist providers □ Scope to further improve/refine your own pathways □ None □ Other (please specify): Q27) Have you made any revisions in your pathway to residential rehabilitation in the last year? (select only one) [single option] □ No revisions or updates made in 2022/23 ☒ Revised or updated in 2022/23 and this has been published □ Revised or updated in 2022/23 but not currently published Q28) Which, if any, of the following barriers to implementing MAT exist in your area? (select all that apply) [multiple choice] □ Difficulty identifying all those who will benefit ☒ Further workforce training is needed □ Insufficient funds □ Scope to further improve/refine your own pathways □ None □ Other (please specify):
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17 Q29a) Which of the following treatment and support services are in place specifically for children and young people aged between 13 and 24 using alcohol? (select all that apply) [multiple choice] 13‐15 (secondary S1‐4) 16‐24 (young people) Alcohol‐related medication (e.g. acamprosate, disulfiram, naltrexone, nalmefene) ☐ ☐ Diversionary activities ☒ ☒ Employability support ☒ ☒ Family support services ☒ ☒ Information services ☒ ☒ Justice services ☒ ☒ Mental health services ☒ ☒ Outreach/mobile ☐ ☒ Recovery communities ☐ ☒ School outreach ☒ ☒ Support/discussion groups ☒ ☒ Other (please specify) Q29b) Please describe what treatment and support is in place specifically for children aged 0‐4 (early years) and 5‐12 (primary) affected by alcohol. [open text – maximum 2000 characters] Barnardos offer direct support to CYP in North Lanarkshire ‐ this is commissioned directly via NLADP. Additional capacity withing CL&D has been resourced via the ADP to support moed towards the Planet Youth model. Q30a) Which of the following treatment and support services are in place specifically for children and young people aged between 13 and 24 using drugs? (select all that apply) [multiple choice] 13‐15 (secondary S1‐4) 16‐24 (young people) Diversionary activities ☒ ☒ Employability support ☒ ☒ Family support services ☒ ☒ Information services ☒ ☒ Justice services ☒ ☒ Mental health services ☒ ☒ Opioid Substitution Therapy ☐ ☐ Outreach/mobile ☐ ☒ Recovery communities ☐ ☒ School outreach ☒ ☒ Support/discussion groups ☒ ☒ Other (please specify)
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18
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19 Q30b) Please describe what treatment and support is in place specifically for children aged 0‐4 (early years) and 5‐12 (primary) affected by drugs. [open text – maximum 2000 characters] Barnardos offer direct support to CYP in North Lanarkshire ‐ this is commissioned directly via NLADP. Additional capacity withing CL&D has been resourced via the ADP to support moed towards the Planet Youth model. NLADP currently funds a test of change to understand more around contextual safeguarding for CYP at risk of entering the justice system as a result of drug related activites. In addition, the ADP funds a test of change to understand the needs of siblings impacted by drug use ‐ this is match funded by Corra funding with parental support in place alongside the ToC.
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20 Quality of life is improved by addressing multiple disadvantages Q31) Do you have specific treatment and support services in place for the following groups? (select all that apply) [multiple choice] Yes No Non‐native English speakers (English Second Language) ☐ ☒ People from minority ethnic groups ☐ ☒ People from religious groups ☐ ☒ People who are experiencing homelessness ☒ ☒ People who are LGBTQI+ ☒ ☐ People who are pregnant or peri‐natal ☒ ☐ People who engage in transactional sex ☒ ☐ People with hearing impairments ☐ ☐ People with learning disabilities and literacy difficulties ☒ ☐ People with visual impairments ☒ ☐ Veterans ☒ ☐ Women ☒ ☐ Other (please specify) Q32a) Are there formal joint working protocols in place to support people with co‐occurring substance use and mental health diagnoses to receive mental health care? (select only one) [single choice] □ Yes (please provide link here or attach file to email when submitting response): □ No Q32b) If no, please provide details. [open text – maximum 255 characters] Q33) Are there arrangements (in any stage of development) within your ADP area for people who present at substance use services with mental health concerns for which they do not have a diagnosis? [open text – maximum 2000 characters] Turning Point Scotland operated an overdose response service working with the Harm reduction service, Scottish Ambulance Service, housing and other key stakeholders and partners. NLAPD recently commisioned this longer‐term adding a crisis support element which draws on local need and key learning from the Drug Death Task Force funded pilot and local research/feedback. Q34) How are you, as an ADP, linked up with support service not directly linked to substance use (e.g. welfare advice, housing support, etc.)? [open text – maximum 2000 characters] NLADP have 5 sub‐groups with broad representation from welfare/housing and advocacy colleagues. These forums and stakeholders have actively shaped our commisioning
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21 priorities and service landscape over the past year leading to 5 new services being created to meet local needs.
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22 Q35) Which of the following activities are you aware of having been undertaken in local services to implement a trauma‐informed approach? (select all that apply) [multiple choice] ☒ Engaging with people with lived/living experience ☒ Engaging with third sector/community partners ☒ Recruiting staff ☒ Training existing workforce ☒ Working group □ None □ Other (please specify):
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23 Children, families and communities affected by substance use are supported Q36) Which of the following treatment and support services are in place for children and young people (under the age of 25) affected by a parent’s or carer’s substance use? (select all that apply) [multiple choice] 0‐4 (early years) 5‐12 (primary) 13‐15 (secondary S1‐4) 16‐24 (young people) Carer support ☐ ☒ ☒ ☒ Diversionary activities ☐ ☒ ☒ ☒ Employability support ☐ ☐ ☒ ☒ Family support services ☐ ☒ ☒ ☒ Information services ☐ ☒ ☒ ☒ Mental health services ☐ ☒ ☒ ☒ Outreach/mobile services ☐ ☐ ☒ ☒ Recovery communities ☐ ☐ ☐ ☒ School outreach ☐ ☒ ☒ ☒ Support/discussion groups ☐ ☒ ☒ ☒ Other (please specify) Q37a) Do you contribute toward the integrated children’s service plan? (select only one) [single option] ☒ Yes □ No □ Don’t know Q37b) If no, when do you plan to implement this? [open text – maximum 255 characters]
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24 Q38) Which of the following support services are in place for adults affected by another person’s substance use? (select all that apply) [multiple choice] ☒ Advocacy ☒ Commissioned services ☒ Counselling ☒ One to one support ☒ Mental health support ☒ Naloxone training ☒ Support groups ☒ Training □ None □ Other (please specify): Q39a): Do you have an agreed set of activities and priorities with local partners to implement the Holistic Whole Family Approach Framework in your ADP area? (select only one) [single option] ☒ Yes □ No □ Don’t know Q39b) Please provide details. [open text – maximum 255 characters] Barnardos and Phoenix Furtures lead this work locally alongside statutory and wider communty sector colleagues. There is a whole family approach sub‐group within the ADP as well as an early intervention and prevention group. Q40) Which of the following services supporting Family Inclusive Practice or a Whole Family Approach are in place? (select all that apply) [multiple choice] Family member in treatment Family member not in treatment Advice ☒ ☒ Advocacy ☒ ☒ Mentoring ☒ ☒ Peer support ☒ ☒ Personal development ☒ ☒ Social activities ☒ ☒ Support for victims of gender based violence ☒ ☒ Other (please specify)
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25 Confirmation of sign‐off Q41) Has your response been signed off at the following levels? [multiple choice] ☒ ADP ☒ IJB □ Not signed off by IJB (please specify date of the next meeting): Thank you for taking the time to complete this survey, your response is highly valued. The results will be published in the forthcoming ADP annual report, scheduled for publication in the autumn. Please do not hesitate to get in touch via email at substanceuseanalyticalteam@gov.scot should you have any questions. [End of survey]
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1 REPORT Item No: 12 SUBJECT: Equality Outcomes and Mainstreaming Report update TO: Performance, Finance & Audit Committee Lead Officer for Report: Ross McGuffie, Chief Officer NHSCP Author(s) of Report Maria Williamson (Acting) Head of Planning, Performance and Quality Assurance DATE: 21 June 2023 1. PURPOSE OF REPORT This paper is coming to the IJB to provide a progress update on the actions set out in the Equality Outcomes and Mainstreaming Report 2022-24 reported to IJB in June 2022. For approval ☐ For endorsement ☒ To note ☒ 2. ROUTE TO THE BOARD This paper has been: Prepared By: (Acting) Head of Planning, Performance and Quality Assurance ☒ Reviewed By: Chief Officer ☒ Endorsed By: Chief Officer ☒ 1
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2 3. RECOMMENDATIONS It is recommended that the IJB PFA Committee: (1) Note the progress update to the actions set out in the Equality Outcomes and Mainstreaming Report 2022-24. 4. VARIATIONS TO DIRECTIONS? 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 The Equality Act 2010 stipulates that all public bodies across Scotland are required to produce and deliver a set of equality outcomes to further one or more of the three needs of the Public Sector Equality Duty (PSED/also known as General Duty). 5.2 The Act provides specific protection to people who are discriminated against based on a defined set of nine “protected characteristics”. The nine protected characteristics are: Age Disability Gender reassignment Marriage and civil partnership Pregnancy and maternity Race Religion and belief Sex Sexual orientation 5.3 On 27th May 2012, the Equality Act (2010) (Specific Duties) (Scotland) Regulations 2012, came into force, to support public bodies in their performance of the general equality duty. This places a statutory duty on designated public bodies to: Report progress on mainstreaming the public sector equality duty Publish equality outcomes and report progress Assess and review policies and practices (impact assessment) Consider award criteria and conditions in relation to public procurement Publish in a manner that is accessible. Yes ☐ No ☒ N/A ☐ 2
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3 5.4 In April 2015 the Scottish Government added Integrated Joint Boards to Schedule 19 of the Equality Act 2010 and to The Equality Act 2010 (Specific Duties) (Scotland) Amendment Regulations 2015. 5.5 A mainstreaming report was submitted to IJB in June 22 (see appendix 1), with equality outcomes based on the commissioning intentions of the 2020-23 strategic commissioning plan. At that time participation and engagement work had already commencing around the next 2023-26 Strategic Commissioning Plan. 5.6 Progress against the equality outcomes and the action plan was agreed to be monitored via the Performance, Finance and Audit sub-committee. An update has been added to appendix two from the Mainstream report (see appendix 2) 5.7 North Lanarkshire Council has established an Equalities Delivery Board, with engagement from all council services including Adult Health & Social Care. The Equalities Delivery Board role is to: • enable collective ownership of the delivery of the Council’s Equalities Strategy and its associated objectives and outcomes • ensure the effective implementation of the Equalities Delivery Framework • provide a cross-service approach to the advancement of equality in the line with the ambitions set out in the Plan for North Lanarkshire • advise the Council on matters of compliance re the Public Sector Equality Duties (General and Specific) and any relevant implication for Council policy • support and champion the work of the Employee Equality Forum, and other corporate equalities campaigns and activities • engage across services to ensure equality is embedded and advanced via the development of individual service Equality Action Plans • Encourage improved equalities reporting amongst our employee base and provide ideas and input for ways in which we can directly engage residents and groups of staff. • Consider relevant religious, cultural and other Equalities related events, conferences and celebrations that the Council may wish to support and participate in e.g Pride Glasgow • develop a robust performance monitoring framework that will more effectively measure performance and impacts against our equality outcomes. 5.8 NHS Lanarkshire is integrating equality into the day-to-day working, taking equality into account in the way the organisation exercises their functions, ensuring equality is part of everything that the organisation does. The NHS Lanarkshire’s Equality Strategy 2021-2025 sets out a range of activities that enable the health board to meet their commitments to the equalities agenda 3
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4 as well as their legal equality duties. The NHS Lanarkshire Equality and Diversity Steering Group has a similar focus/objective to the North Lanarkshire Equalities Delivery Board and oversees the delivery of the Equality Strategy actions across NHS Lanarkshire and publishes progress reports to the following groups: • NHS Lanarkshire Board • Corporate Management Team • Staff Governance Committee • Population Health Primary & Community Services Governance Committee. In 2021, NHS Lanarkshire developed and published two Equality Outcomes (Near Me and Staff Equality Networks) and as part of the development of NHS Lanarkshire’s Quality Strategy 2021-25 two further Equality Outcomes are being published in 2023 (Healthcare needs assessment of resettled populations in Lanarkshire and Greenspace and biodiversity). 6. CONCLUSIONS 6.1 To ensure successful delivery of the 2023-26 Strategic Commissioning Plan, it is important to ensure the mainstreaming report is updated as our new commissioning intentions are progressed. 6.2 It remains vital that we are fully committed to the values and ethos of the Equality Act 2010, ensuring equality is mainstreamed and that everyone in North Lanarkshire has equal opportunities regardless of their age, ability, gender, sexual orientation, race, belief, childbearing. 6.3 Adult Health & Social Care is developing a service action plan which will feed into and form the basis of the council’s corporate equalities action plan, monitored through the Equalities Delivery Board. 6.4 The council is reviewing its EQIA arrangements and a revised and improved approach will be co-ordinated and progressed via the Equalities Delivery Board. The service has identified an Equalities lead (Senior Manager, Strategy & Performance), responsible for ensuring the effectiveness of EQIA use within the service. A revised programme of EQIA training is being developed to support the roll out of the new process. Working with the council’s Equalities Manager, the Equalities lead will develop a process for the periodical review of compliance. 6.5 NHS Lanarkshire continues to ensure the ongoing importance of embedding equalities into the organisation through the use of equality impact assessment, with the EQIA tool recently being adapted to incorporate socio- economic impact in line with the Fairer Scotland Duty and to give consideration to the articles of the United Nations on the Convention of the Rights of the Child (UNCRC). With the Equality and Diversity Steering Group continuing to provide Bi-annual reports on the delivery of Equality strategy actions. 4
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5 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 ☒ 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) 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 n/a Low 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 Yes ☐ No ☐ N/A ☒ 5
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6 ☒ Involve stakeholders in the development work aimed at achieving the national outcomes A range of engagement activities are in place across NL. Plans in place to strengthen our approach and ensure broader reach across all of our communities. ☒ 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 The planned refresh of our engagement and participation strategy and approach will support the development of participation guidelines. ☒ 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 EQIA Completed & Fairer Scotland Impact Assessment Form Completed and attached to report: EQIA added to website: Relevant EQIAs are published on the HSCP North Lanarkshire website. Yes ☐ No ☒ N/A ☐ Yes / Date added ☒ No ☐ N/A ☐ 6
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7 8. BACKGROUND PAPERS 8.1 HSCNL Mainstreaming Report June 22 https://mars.northlanarkshire.gov.uk/egenda/images/att98267.pdf 8.2 Delivering for Communities – Engagement and participation https://mars.northlanarkshire.gov.uk/egenda/images/att100738.pdf 9. APPENDICES 9.1 Equality Outcomes. 9.2 Keep Well flash report. 9.3 NHS Lanarkshire Mainstreaming Report 2023. CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact the following; Maria Williamson, Senior Manager, Quality Assurance. (Acting) Head of Planning, Performance and Quality Assurance WilliamsonM@northlan.gov.uk 7
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8 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 8
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Appendix 1 Equality Outcome Protected Characteristics Actions Lead Progress Update May 23 Inequalities in North Lanarkshire have been further exacerbated by the Covid-19 pandemic. Through targeted interventions, people with a protected characteristic(s) will be supported to maximise their health and wellbeing through the pandemic recovery. 1,2,3,4,5,6,7,8,9 Creation of Long Covid AHP Team to provide proactive supports to those with lasting effects from Covid. Development of anti-viral pathway to support those most at risk of complications from Covid. Head of Health Medical Director Head of Health Improvement NHS Lanarkshire is following evidence as adopted by Scottish Intercollegiate Guidelines Network and National Institute for Clinical Excellence. The Long Covid rehabilitation pathway is based on those guidelines with the support of a holistic multi professional team, that meets every 3 months. Learning from this pathway will inform how we develop our rehabilitation support for people with long term conditions. Long Covid rehabilitation pathway is led by South HSCP and has been in place since May 22. The anti-viral pathway has been in place since Dec 21 and sits operationally in the Flow Navigation Centre. Treatment is accessed through a single point. 9
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Targeted role out of Covid-19 vaccination programme, including proactive use of home visits and clinics supporting identified groups. Use of Keep Well to provide practical supports to key communities such as Gypsy Travellers and Homeless. Utilise Covid Community Champions group to proactively engage with seldom heard groups Complete 7 Priority groups supported through an outreach service. 72% of clinics held out with Health premises. Learn pro module developed to raise better awareness of Gypsy Traveller Communities. Proactively engaging with underrepresented groups forms part of our revised engagement. 10
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Through development of our first responses, we will make services and supports more accessible to meet the needs of people with a protected characteristic(s) to maximise independence and connectedness. 1,2,3,4,5,6,7,8,9 Development of Home Assessment Teams in each Locality to provide rapid response at home for those that require it and faster discharge from hospital. Development of CAPA model to support faster and effective access to mental health and wellbeing supports for children and young people. Development of Mental Health in Primary Care teams to create rapid access to appropriate level mental health and wellbeing supports for adults. Creation of Community Connectors in the third sector, providing proactive support to access a wide range of community-based supports, including mental health and wellbeing, for all ages in North Lanarkshire Head of Health Head of Adult SW Head of Planning HAT teams established in 2 of the 6 localities, with plans to expand across NL. Support delivered to over 700 people. We started using the CAPA model in April 23 and aim to have this fully embedded in CAMHS by Autumn 23. 10 Community Connector posts have been agreed and are progressing to recruitment. 11
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Equality Outcome Protected Characteristics Actions Lead Progress Update May 23 The HSCPs Engagement and Participation Strategy will ensure that we are able to actively engage with a much wider range of individuals in North Lanarkshire, including those from seldom heard groups, supporting people with a protected characteristic(s) to be engaged in the design and delivery of services 1,2,3,4,5,6,7,8,9 Develop Locality Profiles to fully understand the needs of each Locality area. Create a diverse range of engagement and participation opportunities to suit different needs. Provide support to enable stakeholder representatives to participate meaningfully. Development of Locality Planning Group structures to support proactive engagement at a local level. Expansion of the IJBs Strategic Planning Group to widen patient, service user and carer representation Head of Planning Manager Adults – Planning OD Manager Locality profiles have been updated. Plans to strengthen engagement and participation activity are underway and it is anticipated revised arrangements will be in place from Oct 23. Revised arrangements will facilitate a range of support to enable meaningful participation. Locality Planning Groups have been refreshed, with updated Terms of Reference. Group has been expanded to ensure wider representation. Planned mix of meeting in person and online to enable active participation. 12
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Through proactive engagement and Market Facilitation, the HSCP will support the Independent Sector to flourish, creating varied and person-centred supports for individuals including those with disabilities, long term conditions, or who are frail; supporting individuals to have greater choice and control over their care; and creating sustained employment opportunities within the North Lanarkshire area 1,2,3,4,5,6,7,8,9 Development of the partnership’s Market Facilitation Plan to reflect pandemic recovery. Creative use of independent sector sustainability payments to support local providers. Development of regular provider support calls for Care at Home and Care Homes, creating the opportunity for ongoing dialogue, peer support and collaboration Continued development of Self- Directed Support to ensure people, including those with physical or learning disabilities, long term conditions, mental health problems and frailty can exercise choice and control over their care. Head of Planning Head of Adult SW Manager Adults – QA Manager Adults – younger adults Engagement has been maintained across the sector to ensure capacity. Link with Scottish Care are established, and a recent recruitment event received positive feedback. Sustainaiblity payments to support local provider have been utilised to create capacity and support recruitment and retention. Regular provider support calls continued throughout Covid. These have progressed to quarterly in person sessions. Transformational programme in progress that considers a whole system approach. 13
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Through the development of Technology Enable Care, individuals including children and young people, those with disabilities, long term conditions, or who are frail 1,2,3,4,5,6,7,8,9 Sustained roll out and use of Near Me across community health and social care services to provide alternative means of engagement. Development of the TEC Flat in Allershaw Tower to support staff and service users/carers to see TEC in action and enable innovative solutions to retain independent living. Head of Health Head of Adult SW Head of Planning Remains an innovative project showcasing a mixture of NLC provided equipment and mainstream technology. Utilised regularly to educate staff across the partnership on the benefits of technology. Open invitation to provide solutions that can promote safety, enhance wellbeing and support choice and independence. Focus on finding technology-based solutions to enable people to remain independent and safe in their day to day lives. Launched Making Life Easier blog and quarterly newsletter to increase engagement. Disability Information Officer post now filled and launched Making Life Easier clinics operating within each locality area 14
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Equality Outcome Protected Characteristics Actions Lead Progress Update May 23 will have alternative methods to engage with services and more innovative solutions to remain living independently, connected in their own community. Continued expansion of the Making Life Easier website to support self-management, assessment and access to simple equipment. Roll out of a wide range of online Mental Health resources Planning for a dedicated Assistive Technology area and self-assessment on Making Life Easier. link established to technology flat video demonstrating TEC to public. Developed communication plan that includes training and promotion of Making Life Easier at local events, libraries, community centres. A wide range of online Mental Health resources have been rolled out, with plans to create a dedicated area for Mental Health on Making Life Easier. Phone Assessment training has been delivered to Access Social Work staff to reduce service user waiting lists. Making Life Easier content reviewed to ensure relevance and local focus of information. Plan in place to review existing assessments with the aim to streamline. 1. Age 2. Disability 3. Gender reassignment 4. Marriage and civil partnership 15
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5. Pregnancy and maternity 6. Race 7. Religion and belief 8. Sex 9. Sexual orientation 16
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Health Improvement Keep Well Flash Report 2022/2023 Keep Well is a Nurse led service with a pan Lanarkshire remit. The focus of KW is to engage and support the most vulnerable populations who do not readily access mainstream services. Keep Well assisted Organisational Development with a new Learn Pro Module to raise awareness of Gypsy Traveller Communities. This NHS Lanarkshire module has now been launched and is available via Learn Pro platform. We would like to take this opportunity to encourage our NHS colleagues to undertake this module. New Learn Pro Module Priority was given to the groups and communities the team were still to reengage with, following the Covid‐19 Pandemic. By March 2023, the team have made significant progress and have started to begin work with the last Priority Group. Working closely with partner services, the team provide an outreach service with most of the clinics delivered in community settings such as Restorative Justice premises, Places of Worship, Temporary Homeless Accommodation Units, Recovery Community premises for example. 72% clinics held during 2022 ‐23 were in non NHS premises. As with last year, 90% of referrals to Keep Well are from Addiction Support Services. The referrals from these partner services have increased by 71% compared with Pre Pandemic levels (April 22 – March 23). Keep Well Priority Groups 7 Priority Groups • Black, Asian and Minority Ethnic Groups (BAME) • Gypsy Traveller community, • those affected by Homelessness • those within community justice system, • those with problematic substance use • those from the Deaf Community • CarersGypsy Traveller Event Over 2 days in August, KW team attended an event in partnership with MECOPP Community Health Workers. The team were able to deliver 23 health checks to community members. This resulted in half of those patients seen requiring a referral to GP practice for review of abnormal clinical findings. The team were able to support an individual who lived out with the Lanarkshire area obtain vital repeat medication. 17 Appendix 2
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Health Improvement 69 participated in the online pilot FOR MORE INFORMATION PLEASE CONTACT ALANA MCGLYNN, HEALTH IMPROVEMENT PROGRAMME MANAGER ALANA.MCGLYNN@LANARKSHIRE.SCOT.NHS.UK OR KEEP WELL TEAM ON 01698 754260 keepwell.lanarkshire@nhs.scot Priority will be given to the recovery of the last remaining Priority Group and clinic dates have been secured for some of the partners within this group. Keep Well have agreed to support North ADP with locality events planned during 2023‐24. This will involve partnership working with commissioned services along with other 3rd sector and voluntary services. Support will also be provided by the team to assist NHS Lanarkshire to meet the ‘Hepatitis C elimination’ targets set by Scottish Government. The team look forward to welcoming back one of our nurses from maternity leave returning our capacity to 3 Registered Nurses and 1 Health Care Support Worker. Development for 23/24 • Delivered 177 clinics • Engaged with 438 patients • 69% of patients seen were case managed • 42% of attendees were found to have clinical risk that required further investigation by their GP practice. Some examples include elevated blood pressure, elevated blood cholesterol level, elevated blood glucose level, irregular pulse rate, raised assign score, poor mental health • There were 686 referrals made to other services to support health behaviour change. Some examples include NL Leisure, SL Leisure and Culture, Addiction Support Services, Quit Your Way, Harm Reduction Team, Health and Homeless team, Lanarkshire Weight Management Team, Financial Inclusion Services. • 32 Referrals made to Homeless, Sexual Health and Cancer Screening Project • 303 patients were case managed in this period • 105 people accepted testing for Blood Borne Virus detection • 139 Individual referrals were received from partner services Activity 2022/23 KW Team 2 Nurses 1 HSW Patient feedback“Thank you very much for taking the time to enquire about my health” “I’m so grateful and thankful you seen me. My GP sent me straight to hospital, as my blood pressure remained dangerously high, you saved my life” 18
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1 NHS Lanarkshire Equalities Progress Report 2021-23 Covering: Equality Mainstreaming Equality Outcomes Workforce Workforce Data 19 Appendix 3
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2 Accessibility If you would like this document in a language or format of your choice including large print, audio, braille, or if you have any questions or want to provide feedback please contact: Call Hina Sheikh - 01698 754294 E- Mail hina.sheikh@lanarkshire.scot.nhs.uk Languages Hina Sheikh - 01698 754294 Write to: Hina Sheikh Equality and Diversity Manager NHS Lanarkshire Law House Airdrie Road Carluke ML8 5ER 20
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3 CONTENTS Page 1. Introduction 4 2. Mainstreaming 4 3. About Us 5 4. NHS Lanarkshire’s Commitments 6 4.1 Strategy, Leadership and Governance 8 4.2 Community Engagement 12 4.3 Health Inequalities 18 4.4 Developing the Workforce 24 5. Equality Outcomes 31 5.1 Equality Outcomes 1 & 2: Update Reports April to December 2022 32 5.2 Equality Outcomes 3 & 4: 2023 – 2025 38 6. NHS Lanarkshire Board Diversity Data 44 7. Workforce Data 45 7.1 Workforce characteristics 46 7.2 Training 50 7.3 Leavers 53 7.4 Recruitment 55 7.5 Employee relations and 58 7.6 Occupational Segregation Information/Equal Pay Data 61 8. Procurement 62 9. Conclusion 63 21
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4 1. Introduction The Equalities agenda continues to be a significant area of on-going improvement and development for NHS Lanarkshire, post publication of a range of documentation in 2021, which set out our commitment and direction of work for the following four years. In this second year update report we highlight the progress being made to embed equalities throughout the organisation. Going beyond our legal requirements is a clear statement of our intent to deliver services that reflect and respond to the needs of all the communities we serve within NHS Lanarkshire. At this time of producing this report we are still responding to the Covid-19 pandemic and severe service pressures. The pandemic has had, and will continue to have, a significant influence on us all, but our experiences will vary as Covid-19 has exposed and amplified pre-existing levels of social and economic inequality. This means it is more important than ever for us to ensure that the Equalities agenda continues to be a significant area of on-going improvement and development for NHS Lanarkshire. It should be noted that the content of the report highlights progresses up to and including 31 December 2022 to allow for our internal governance processes prior to publication in April 2023. 2. Mainstreaming Mainstreaming is a specific requirement for public bodies in relation to implementing the Equality Duty 2010. In simple terms it means integrating equality into the day-to-day working of NHS Lanarkshire, taking equality into 22
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5 account in the way we exercise our functions. In other words, equality should be part of everything we do. On 5 April 2011 the Equality Act 2010 introduced a new public sector equality duty (also known as the General Equality Duty) which requires public authorities, in the exercise of their functions, to have due regard to the need to: 1. Eliminate unlawful discrimination, harassment and victimisation and any other conduct that is prohibited under this Act; 2. Advance equality of opportunity between people who share a relevant protected characteristic and those who do not share it; 3. Foster good relations between persons who share a relevant protected characteristic and persons who do not share it. 3. About Us NHS Lanarkshire is the third largest health board in Scotland. We serve a population of over 660,000 across rural and urban communities in Lanarkshire (2021 mid-year estimate) and employ over 14,000 staff working in communities, health centres, clinics and offices and at our three acute hospitals – University Hospital Hairmyres, University Hospital Monklands and University Hospital Wishaw. 23
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6 We aim to continue to provide the best care and treatment we can, within the resources available to us, while ensuring everyone working in NHS Lanarkshire is trained and skilled for their job to deliver a safe and efficient, person centred service. We are committed to delivering high quality, innovative health and social care that is person-centred. Our aim is that everyone is able to live longer, healthier lives at home, or in a homely setting. For more information about our organisation and services, please select the link below to access our website: https://www.nhslanarkshire.scot.nhs.uk/about-us/ 4. NHS Lanarkshire’s Commitments In NHS Lanarkshire’s Equality Strategy 2021-2025 we set out a range of activities that we believed would help us meet our commitment to the equalities agenda and our legal equality duties. The Equality and Diversity Steering Group oversees the delivery of the Equality Strategy actions and publishes progress reports: Bi-annual reports to NHS Lanarkshires: Board, Corporate Management Team, Staff Governance Committee, and the Population Health Primary & Community Services Governance Committee. Equality Impact Assessment (EQIA) NHS Lanarkshire continues to ensure the ongoing importance of embedding equalities into the organisation through the use of equality impact assessment. In 2020 we incorporated considerations of socio-economic impact in line with the Fairer Scotland Duty and in 2022 we further adapted the EQIA tool to give consideration to the articles of the United Nations on the Convention of the Rights of the Child (UNCRC). 24
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7 How we developed NHS Lanarkshire’s Equality Strategy 2021-25 To inform the development of the 2021-2025 Strategy, NHS Lanarkshire Equality and Diversity Steering Group held a series of online workshops, the workshops identified key areas and actions which will be delivered over the next four years by the identified leads. Building on the range of good practice that already exists, the Equality Strategy 2021-2025 includes new areas of work to reflect local and national policies to ensure our equality strategy remains contemporary. An important aspect of the Equality Strategy is recognising that an intersectional approach is key in the design and delivery of any area of work. What this report includes This report is a snap shot of some of the work being carried out in areas committed to in NHS Lanarkshire’s equality strategy 2021-25. These are: 4.1 Strategy, Leadership and Governance; 4.2 Community Engagement; 4.3 Health Inequalities; 4.4 Developing the Workforce. Additional Reports attached to this publication evidence: Progress made towards achieving Equality Outcomes published in 2021. NHS Lanarkshire’s two new Equality outcomes for 2023-25. NHS Lanarkshire Board Diversity Data Workforce Equalities Data. Gender Pay/Occupational Segregation Information. 25
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8 4.1 Strategy Leadership and Governance NHS Lanarkshire as an Anchor organisation What has been done in the last two years? In the Summer of 2021 NHS Lanarkshire along with its board members, held an inequalities seminar, a key focus of which was to reflect on the influence NHS Lanarkshire can have on the wellbeing of the local community, beyond the delivery of healthcare, through its role as an inclusive “anchor” organisation. The term “anchor” refers to the responsibility NHS Lanarkshire has as a large locally rooted organisation who employs many people and deploys resources and assets for the benefit of the local population. We know health inequalities are driven by wider socioeconomic determinants such as poverty, employment, education and place thus we were keen to identify actions we could take to positively influence these wider determinants through our anchor role. Over the last 12-18 months we have reviewed the NHS Lanarkshire baseline position against each of the anchor pillars in the Joseph Rowntree Foundation Anchor Progression framework. The five pillars are: employer; procurement; environment and assets; service delivery; and, corporate and civic responsibilities. This has entailed working with stakeholders to identify current and future actions for each pillar. Most recently we have recognised our role as a local anchor in mitigating the impact of the cost of living crisis and we have developed a delivery plan which outlines the actions we are taking across the five anchor pillars to support patients, communities and staff with their financial wellbeing. 26
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9 What difference have these made? We have identified a range of actions that contribute to our anchor ambitions and indicators of success have been identified for each action. Examples include: development of a Procurement Strategy with targets for increasing investment locally; investing in the Supplier Development Programme with key deliverables to be achieved after one year; promotion of the NHS Community Benefits Gateway to partners; the development of a Community Benefits Plan for the Monklands Hospital Replacement programme with specific targets for the successful contractor, development of a Staff Health and Wellbeing strategy; and, embedding Integrated Equality Impact Assessment into the work streams of the new NHS Lanarkshire health and wellbeing strategy Our Health Together. How will outcomes be sustained? We have worked closely with our Planning and Strategic Delivery Teams in order to ensure our anchor commitments are fully embedded within the ambitions of Our Health Together and the way we work as an organisation in the future. We have also embedded commitment to the anchor principles in the corporate objectives of all Executive Directors. What challenges remain? There are particular challenges around capacity to deliver on some of the ambitions of the anchor plan and in some areas there is only fixed term funding for developments. These risks are being identified and escalated as appropriate and opportunities for other funding sources explored. There are also wider system pressures post Covid-19 which have made it challenging to spread initiatives such as routine enquiry for financial wellbeing to all areas. What next? Anticipated actions for next 2 years NHS Lanarkshire’s anchor commitments include enhancing NHS Lanarkshire’s contribution to community wealth building through offering more targeted employment opportunities for local people, increasing procurement spend locally, and being a role model for environmental sustainability through our buildings, policies and practices. Through working in partnership with other local anchors and communities, we will also prioritise reviewing how we deliver our services to shift models of care towards prevention and early intervention, and to ensure services and programmes are proportionately targeted to those most in need through better understanding our data and the needs of our communities. 27
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10 NHS Lanarkshire Digital Strategy 2023-28 What has been done in the last two years? During 2022, a new five-year digital plan was created with wide-ranging engagement and equality central to its development. To launch in 2023, the digital plan (2023-28) describes the benefits of technologies used by our operational staff, clinical colleagues and also the public and identifies digital equality as a strategic theme and dedicates a section to this topic. Important aspects of equality also feature heavily in the five-year vision. Developing the plan involved engagement with over 400 individuals, 300 of which were public/patient responses. Authoring of the plan was intentionally designed to be inclusive, with 44 authors collaborating to produce this strategic plan. What difference have these made? The 2023-28 digital plan has made digital topics more relatable and easier to understand. This has been achieved by a concerted effort to widen inclusivity, interest, and involvement. The strategy development team engaged with services to better understand their needs, ‘pains’ and missed opportunities. This included using plain language wherever possible and collecting a suite of digital-in-action stories from across a diverse range of Lanarkshire services and settings. The stories were carefully crafted to provide a human perspective to any digital improvement or innovation, by making use of a story-telling method. Making digital more relatable was identified as a key factor in reducing barriers and people feeling supported to work together and improve health and social care services into the next five years. The approach has been well received as people have felt more empowered to share their opinion, challenges and ideas about digital health and technology. Taking an empathetic, honest and open approach to the strategic engagement resulted in a higher quality outcome, deeper and more varied view-points and the resulting difference is a shared strategy that many people can feel they have co- created and can co-deliver. 28
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11 How will outcomes be sustained? Following development and publication of the digital plan, a further round of engagement will be undertaken to confirm the operational delivery plan across our strategic work streams and services. This will ensue that the right stakeholders are involved to co-deliver the strategic aims and objectives. Behind the delivery plan, a programme of work will support the digital team to ‘re- gear’ in readiness for delivering the plan. This will involve careful consideration of how the digital team will collaborate continuously with the public, clinicians, staff and partners by involving them and including digital equality in every aspect of their work. Outcomes from the digital plan will be sustained by ongoing and close alignment to NHS Lanarkshire’s ‘Our Health Together’ healthcare strategy, and the national digital health and care strategy. What challenges remain? Equality must remain central to delivery of the new digital plan. Digital equality has a variety of needs to consider, which require to be understood and acted upon during planning and implementation of new digital solutions. Three important aspects of digital equality have been identified and will remain fundamental to ongoing work: How the Lanarkshire public access health and social care services online, sometimes described as the “patient experience”. How our NHS colleagues deliver health and social care using digital systems. How we design services that make use of digital, to reflect the diverse needs of our population. What next? Anticipated actions for next 2 years Actively including equality into the digital plan has, without doubt, improved the overall outcome for everyone in Lanarkshire. The digital team has a more open and inclusive outlook and wider awareness of the challenges and opportunities available to NHS Lanarkshire. The outcomes of this work are best communicated by sharing two aspects of the five-year digital vision, which are: Be people centred; by ensuring that human needs are at the heart of existing and new digital solutions. Enhance care for everyone; by championing equal improvements for everyone, and ensuring we don’t alienate anyone. By keeping equality at the heart of this engagement, we have seen a distinct difference in the resulting language and tone of the digital plan, the more open and honest responses from people who have engaged, and the general willingness for people to get involved. 29
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12 4.2 Community Engagement Communications What has been done in the last two years? A Community Champions Forum was established to communicate through the pandemic; Public consultation as part of the planning process for a replacement University Hospital Monklands. What difference have these made? The Community Champions Forum (CCF) was formed during the Covid-19 pandemic and had representatives from Lanarkshire diverse communities. The CCF represented and provided a greater understanding of the need of communities. The CCF supported the messaging, design and the sharing of the range of communications that were shared during the pandemic e.g. leaflets, posters, messaging in a range of visual (British Sign Language), written formats and social media materials. The Monklands Replacement Project (MRP) pre-application consultation was facilitated online due to the pandemic. Anyone who required a printed version of consultation materials could contact the MRP team by email/phone/Freepost. Similar to the Community Champions, the MRP also has the Monklands Engagement Forum (MEF). The MEF is a governance sub-group established to support and guide the Monklands Replacement Project team and provide scrutiny in how it informs, engages and consults with people on the MRP. This group is made up of public, patients, carers and third sector representatives. Healthcare Improvement Scotland – Community Engagement also participates. Members offer their perspectives on how NHS Lanarkshire informs, engages and consults with patients, carers and the public on MRP as the project progresses 30
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13 and share information/presentations given at meetings with the wider groups they represent. How will outcomes be sustained? Ongoing engagement with the Community Champions Forum will be used to inform future campaigns and communication material and make sure we continue to involve people in service planning and design. The Champions Network continues to meet regularly addressing issues such as Winter Planning and Cost of Living. With a view to enhancing the voice of young people in our engagement process, the MRP has established a partnership with North Lanarkshire Council’s Health & Social Care Academy. The Care Academy provides opportunities for school students with a specific interest in health and social care to learn about the subject and potentially find their way to employment in the sector. What challenges remain? Work on identifying and developing relationships with Seldom Heard Groups still needs to be developed. What next? Anticipated actions for next 2 years We will continue to make best use of the Community Champions Forum, especially with regards to the updated NHS Lanarkshire healthcare strategy ‘Our Health Together’. ‘Our Health Together’ will be the main focus of our engagement activities. Our aim is to develop a wide-ranging engagement programme involving patients, unpaid carers, our staff and local communities (including children and young people) and will work together to develop plans that deliver the best possible outcomes. A successful engagement process for Our Health Together will ensure: People understand the case for change; A diverse range of people are motivated to get involved; and Innovative solutions are co-designed/co-produced with people. To achieve this, people (public, patients, carers, staff and other stakeholders) will be at the heart of Our Health Together. This person-led approach will ensure Our Health Together is: About people; Produced by people; and Based on decision making that is informed by people. Equally with the Monklands Engagement Forum as the Monklands Replacement Project we will continue to be supported and advised by the group. 31
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14 Development of a New Quality Strategy 2023-28 What has been done in the last two years? The quality team has been working over the past 11 months (April 2022 to February 2023) to develop a new Quality Strategy that will replace the existing one which ran from April 2018- March 2023. A core part of this process has been the engagement process put in place to ensure that we have consulted a wide range people both staff and service users while writing this strategy. What difference have these made? We have engaged with staff and service users in a number of ways. For staff we have ensured that early consultation was achieved by taking initial ideas to a number of governance groups in the Boards including the Equality and Diversity group, the North Care and Clinical Governance Group and the Area Clinical Forum. For service users, we developed an online survey that was available both electronically on a website and via a QR code. Quality staff also took this survey out into the community and asked service users attending vaccination centres for feedback. Over 400 service users and 290 staff provided feedback. How will outcomes be sustained? The survey will be analysed and the feedback used directly in the developed of the new quality strategy. What challenges remain? We are trying to reach out to some harder to reach groups with our engagement survey and will continue to work towards this over the next few months. What next? Anticipated actions for next 2 years The development and engagement process will continue until we are ready to publish in April 2023. The strategy will also feed into the yearly implementation plans which will be used to measure the main themes within the overall quality strategy. 32
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15 National Model of Complaints Handling Procedure What has been done in the last two years? Significant development work to further embed the national model Complaints Handling Procedure (CHP) has continued. This work has been underpinned and driven by acknowledging that an effective complaint handling procedure should be user-focused, accessible, simple, timely, thorough, proportionate, consistent, objective, impartial and fair. We are also striving to seek early resolution and to analyse complaint outcomes to drive improvement. Examples of work include: Stage 2 Investigation Toolkit The toolkit has been deployed from October 2022. The overarching purpose is to ensure that NHS Lanarkshire Complaint Procedures: Take a consistently person-centered approach; Implement a standard process; Ensure that staff and people have confidence in complaint handling; and Ensure that learning from complaints is used to continuously improve services. The toolkit includes: Person Centred Complaint Handling principles, which contains guidance on person centred investigations and responses, making information accessible and involving patients and families. Consent guidance. Guidance on agreeing the issues to be investigated with the complainant. Guidance on producing high-quality person-centred complaint responses. In summary, the toolkit provides an agreed set of guidance, templates, and tools to be used by complaint investigators at each stage, from the point of receipt through to closure. The toolkit includes accessibility considerations. Programme for assurance (of best-practice handling) and embedding learning from complaints Developments include: The Healthcare Complaints Analysis Tool (HCAT) has been piloted on closed maternity complaints. A post complaint (Stage 2) satisfaction survey is in place and can be provided in different formats. 33
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16 Lessons learned from complaints are included in the organisational learning bulletin. Quality Assurance processes have been developed and implemented / reported – applying to a sample of closed complaint files. What difference have these made? Staff and complainant feedback. Quality assurance mechanisms to reflect on best practice handling. Increasing the number of complaints resolved at Stage 1 . How will outcomes be sustained? Quality Assurance of cases and analysis of complaint satisfaction results to monitor quality of complaint handling, and make improvements where required. Ongoing roll-out and embedding of Stage 2 toolkit across the organisation. Education and awareness raising. What challenges remain? Patient affairs activity continues to be variable, with national recognition of the changing nature of complaints, including increased complexity and challenging behaviours. Transition and alignment of processes will take further time to embed. We are also seeking to reduce backlogs, to a refreshed era of higher risk/profile complaints taking priority, and diverting resources. Whilst transiition will contribute to alleviating previously oultined risks, it still be within the confines of the existing resource/budget. What next? Anticipated actions for next 2 years As above – further development to embed consistent and robust complaint handling mechanisms across NHS Lanarkshire. 34
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17 Unsolicited service User Feedback What has been done in the last two years? In NHS Lanarkshire our main way of capturing unsolicited patient feedback is via Care Opinion. Care Opinion is a not-for-profit social enterprise which enables people to share the story of their care, and perhaps help care services make changes. We promote the use of Care Opinion by advertising in our hospitals and community health centres how service users can post their stories on the website. We continue to train staff in the use of Care Opinion and how to be responders to stories posted about their service. What difference have these made? NHS Lanarkshire continues to receive a consistently high number of stories: 767 were posted by members of the public between 1st April 2021 and 31st March 2022. 61% of the stories received are of a positive nature and 39% are critical of the experience they received. For the 767 stories posted there were 1,051 responses posted in response. This is due to the author having contact with more than one area or service. Authors tag their story with words to reflect how they feel about the service they received; what was good and what could be improved. This information is used by the service the story relates to, to make improvements to their areas. How will outcomes be sustained? Monthly statistical reports on the information captured from Care Opinion including the number of stories, breakdown of positive/critical stories, changes identified as a result is shared with the Corporate Management Team and Operational Unit who then cascade this information to frontline teams. 35
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18 The information and feedback within the stories is used for learning and to make improvements to services based on what the service user has told us. What challenges remain? We aim to respond to a story within five days however sometimes it takes longer to access information to be able to formulate a response and this will exceed the five days, however every story receives a response. 10% of stories took longer than five days to provide a response and a deep dive of these stories was carried out. This provided assurance that it was appropriate that more time was taken to provide the appropriate response. What next? Anticipated actions for next 2 years We plan to continue to promote use of Care Opinion and to explore how we can assist service users who may require assistance to use the website. Feedback received via Care Opinion will continue to inform service planning and delivery. 4.3 Health Inequalities Health Promoting Health Service What has been done in the last two years? Since January 2022, the Health Promoting Health Service (HPHS) team have worked with the NHS Lanarkshire Realistic Medicine Team to meet the broad outcomes of the Chief Medical Office HPHS Letter 2018:3 and the principles of Realistic Medicine, in particular, a personalised approach to care and shared decision making. Highlights are as follows: Recruitment of a Health Improvement Senior (HPHS) for each of the 3 acute sites. Establishing the relationships to deliver on their programme of work and implementing tests of change (ToC) to demonstrate the benefit of using a holistic needs assessment to embed in routine care. Development of a Holistic Needs Assessment (HNA) to understand the issues affecting patients and help address these to facilitate safe discharge home. The HNA is uploaded to Portal Care Plans to ensure there is a record of the action 36
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19 taken. A webpage has been created to support patients in improving and maintaining a healthy lifestyle by providing information on different health topics and health services in their area.: https://www.NHS Lanarkshireanarkshire.scot.nhs.uk/services/health-improvement/health- promoting-health-service/ Staff engagement sessions to ascertain the wellbeing of staff and what they need from the developing Staff Health and Wellbeing (SHWB) Strategy. Following these sessions and the results from the SHWB Survey, the acute hospitals held SHWB events with contributions from the agencies that staff wanted information on. What difference have these made? The HNA has highlighted the needs of people who suffer the greatest inequalities within our communities and connecting them with the support they require to return safely to home and maintain their health and wellbeing. How will outcomes be sustained? The aim is to demonstrate how to complete an HNA to further support staff to complete this as close to admission as possible. This will highlight needs at the earliest point possible to aid understanding of what the issues are and to signpost to support or have a referral made, timeously prior to discharge to ensure discharge is not delayed. This links in with the Discharge without Delay programme. Discussions have been ongoing with Practice Development to have the HNA embedded into the admission paperwork. What challenges remain? On-site pressures in terms of workforce and workload has limited the integration of using a HNA amongst staff and there continues to be a reliance on referral to the Heath Improvement Seniors (HPHS). Time-limited funding. What next? Anticipated actions for next 2 years Funding is only available until September 2023, therefore, initially actions will be concentrated on securing further funding. Should this be established, there will be a continuation of support of staff to undertake the HNA and to support the development of this into routine paperwork and care. There will be a continued support of staff health and wellbeing activities in line with the published NHS Lanarkshire Staff Health and Wellbeing Strategy and Action Plan. 37
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20 Healthy Lifestyle in Pregnancy Service (HLiP) What has been done in the last two years? Adapted in response to the first wave of the pandemic and lockdown restrictions to Attend Anywhere (Near Me) online consultations and telephone appointments depending on the patient’s choice/digital access Adapted in response again to restrictions and went through a recovery process to move to a blended model of service delivery which continued with online and telephone consultations but face to face appointments were available again across Lanarkshire, following pathways and guidance within each individual healthcare setting. “Meet the Team” videos created and website platform developed to allow potential service users to find out more about the service and put faces to the professionals they will be meeting. This url was also included within the Badger.net app that is used throughout pregnancy and maternity staff can signpost to this and the leaflets available in the reading library as part of the discussion/referral process for this clinic. This has also been included as part of a social media campaign. The videos and website is available Healthy Lifestyles in Pregnancy Service | NHS Lanarkshire (scot.nhs.uk) What difference have these made? During the first wave of the pandemic where those pregnant had restricted access to support, the service continued to be able to support those with a Body Mass Index of 30 and above with lifestyle change to minimise risk and provide support for both physical and mental health. This support was then increased in the return to face to face appointments where service users were hugely grateful for the intensive support received where access to other support was still limited. Referrals have increased as a result of the increased awareness and midwives find it useful to have the resources to signpost to. How will outcomes be sustained? A blended model of service delivery still exists however the majority of service users prefer face to face but online/telephone appointments are still available and in action. 38
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21 A continued improvement plan remains in pace to increase referrals and engagement to the service with ongoing training and awareness sessions commenced with future dates set. New resources (posters and flyers) are in development and will be available soon and are to be included as part of a new social media campaign in 2023. Future service user evaluations will also take place. What challenges remain? The service is a pan Lanarkshire service however access to clinic space within some localities is not available meaning some service users need to travel to other locations. Local target of 40% eligible referred not met (Q1 18% referred, Q2 18% referred) therefore there are approx. 80% of eligible women not being referred. It may be that they have been offered referral and declined but there is no way of recording this on the system. Service is a 0.4WTE service therefore should referrals increase there is a risk of increased waiting times. What next? Anticipated actions for next 2 years Continued improvement plan for increasing referrals and engagement with ongoing training and awareness raising sessions and social media campaign. Development of Gestational Diabetes (GDM) pathway in line with HLiP pathway for consistency with introduction of physiotherapist input. Continue to scope and explore with Obstetric colleagues’ potential for metabolic clinic pathway for those with BMI≥50 kg/m2 Increase reach with clinical space within other localities and areas of need. 39
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22 Condom Distribution Schemes What has been done in the last two years? Introduction of the Condoms by Post Service in response to standard service disruption during COVID-19. New partnership with local foodbanks to provide free condoms for individuals accessing these services directly. What difference have these made? In 2021, the team carried out a social media campaign to promote the Condoms by Post Service. Over a 7-week period, 1,472 requests were made and fulfilled with the majority of requests coming from Scottish Index of Multiple Deprivation (SIMD) 1-3 postcode areas. We asked some additional evaluation questions during the campaign 100% of those asked if this would be their preferred way to get condoms on a permanent basis, answered “yes”. We also received positive qualitative comments. The service now averages around 170 requests per month and has maintained a high level of requests from SIMD areas 1-3. The partnership with the local foodbanks is measured more qualitatively via feedback from the volunteers and staff on site with our team and the condoms have been positively received, even within faith based settings. How will outcomes be sustained? The Condoms by Post Service was easily incorporated during the pandemic as condoms were not easily accessible in other areas, so in terms of time and cost, there was no issue as our focus could be shifted to the postal service. Now that our other services are fully operational again, we have had to consider some changes in terms of the number of packs per order and frequency of orders and will continue to monitor uptake to ensure it is manageable as there is no extra budget or staff time to fulfil this work. The project co-ordinator will work a locality at a time, involving our department locality staff who have knowledge and links in their local areas. It is hoped that the process will become easier as the work continues as we will have more and more evidence of good partnership working and positive feedback from other staff and volunteers already involved. 40
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23 What challenges remain? Promotion of the service remains a challenge, our previous experience of paid for social media campaigns have been very positive and resulted in an increase in orders. However, the campaigns are expensive to run and the additional costs in products being requested make it cost prohibitive. As above, as we increase our reach and the number of foodbanks we provide condoms to, we need to cover this cost from our limited budget. What next? Anticipated actions for next 2 years The team will continue to offer Condoms by Post as a permanent part of the overall Condom Distribution Scheme and look at new ways of promoting the service. We are also involved in National conversations with other boards around the development of a postal testing scheme for sexually transmitted infections and the potential to also offer free condoms with these tests, which would increase demand locally, if a standard national offering cannot be put in place. We are currently working across Clydesdale, Motherwell and Wishaw localities, with 5 foodbanks signed up to offer free condoms and information on the wider Condom Distribution Scheme and sexual health services for some of the most vulnerable in our communities. Over the next 2 years, we plan to increase the number of venues across all localities in Lanarkshire. 41
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24 4.4 Developing the Workforce Staff Health and Wellbeing Strategy What has been done in the last two years? ‘Your Health Matters- Your Opinion Counts’ Staff Engagement Programme- implemented in April 2022 to allow staff the opportunity of reporting on what helped them manage their health and wellbeing during the previous 12 months. This platform also encouraged staff to consider what supports they would want to have in place going forward and to inform the Staff Health and Wellbeing (SHWB) strategy. The SHWB Strategy launched in November 2022 as a platform to ensure good health and wellbeing is at the core of the organisation and is everyone’s responsibility. https://www.NHS Lanarkshireanarkshire.scot.nhs.uk/download/staff-health- wellbeing- strategy/?wpdmdl=48788&refresh=639c6bc22e62e1671195586&ind=16679 07541132&filename=Staff-HWb-Strategy-A4_online_v3-1.pdf SHWB week (31 October – 4 November 2022) -the week was implemented to further support staff to manage their health and wellbeing and also offered a platform to launch the NHS Lanarkshire Staff Health and Wellbeing Strategy (2022-2025). What difference have these made? The findings from the Staff Engagement Programme contributed to the sessions that were implemented as part of SHWB week as well as informing the content of the SHWB strategy. The SHWB Strategy outcomes will be reviewed in 12 months. The measures that are being monitored over the next year are: iMatter / Referrals to support services (Salus Staff Support, Staff Care and Wellbeing and Psychological Staff Support Service)/Workforce data. 42
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25 Attrition rates/Supplementary staffing/ Staff Engagement opportunities collating both quantitative and qualitative feedback from staff on their perception of staff health and wellbeing. ‘Your Health Matters –Your Opinion Counts’ engagement programme/Town Hall (virtual) Staff Health and Wellbeing week/Safety Culture Cards/Your Health Matters webpage analytics. Evaluation of SHWB week is being finalised and will be circulated early 2023. How will outcomes be sustained? Outcomes will be reported to the SHWB Strategic group for discussion and review. What challenges remain? Continuing to engage with staff recognising that capacity to do this will have limitations due to the current workforce climate. Consideration of different options to support staff to effectively manage their own health and wellbeing where possible with a focus on the ‘harder to reach’ staff groupings. The importance of staff health and wellbeing at work being a top priority for NHS Lanarkshire senior leadership team and ensuring SHWB is everyone’s responsibility. What next? Anticipated actions for next 2 years The Staff Health and Wellbeing Action plan is being drafted. It is anticipated that it will be approved by the SHWB Strategic group early in 2023. 43
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26 Employability What has been done in the last two years NHS Lanarkshire has provided paid work placements, for six months as part of the ‘Kickstart’ programme, which is aimed at under 25 year olds to enable them to build their transferable skill set, knowledge and confidence. NHS Demonstrator Programme aimed at over 25 year olds who had been unemployed for over 12 months, NHS Lanarkshire provided paid work placements for 6 months to help build skills, knowledge and confidence. Foundation Apprenticeships: Introduced Foundation Apprenticeships into the organisation for Social Services & Health care and Business Skills, fifth year school pupils have a work placement in NHS Lanarkshire one day a week during the academic term, this helps them understand the workplace whilst completing modules towards an apprenticeship. This is an attraction tool to encourage these young people to look at NHS as a career option. What difference have these made? In some cases, these opportunities have changed people’s lives by bringing them into the workplace and supporting them to work independently and to be able to bring more income into the home. The Foundation Apprenticeship’s will help towards building a future workforce for NHS Lanarkshire. How will outcomes be sustained? By continuing to engage with these types of programmes and committing to funding the paid aspect of the programmes. By having an infrastructure in place to support such activity. What challenges remain? 44
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27 Funding for infrastructure has now been confirmed for 2 years. However, funding from Board/SG for paid placements for those furthest form the job market is still to be secured. Also, commitment from service to recruit Modern Apprentices What next? Anticipated actions for next 2 years We plan on developing a Modern Apprenticeship Programme to attract more young people to work in NHS. There would also be a lot more school activity to attract young people to the NHS and assist with future workforce planning. International Recruitment What has been done in the last two years Scottish Government devolved responsibility to the territorial boards to recruit Nursing, Midwives and Allied Health Professionals (NMAHP) with targets set for 2021/22, 2022/23. We recruited an International Recruitment Manager and administration support for this area of work. In addition, 1.6 whole time equivalent practice education facilitators were recruited to support the nurses through the Objective Structured Clinical Exam (OSCE) training required to join the Nursing and Midwifery Council register. To date latest numbers as January 30 Adult nurses,1 Physiotherapist and 1 Radiographer have joined NHS Lanarkshire. We are expecting The next cohorts will arrive in April and July 2023. Pastoral support has also been put into place for these individuals. What difference have these made? An intense training programme has been put in place to support the nurses to pass their OSCE (100% pass required). To date everyone has passed and we are currently waiting December 22 results. These Nursing, Midwifery and Allied Health Professionals have been able to fill vacancies across our Acute sites. 45
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28 How will outcomes be sustained? These outcomes will be sustained by ensuring we keep these individuals in post and provide support when required as we would do with any other staff member. What challenges remain? Part of the package is to provide 12 weeks’ accommodation for these individuals to settle in when they arrive whilst they are preparing to pass OSCE training. NHS Lanarkshire have limited access to accommodation provision. If we had more we could recruit more International Nurses, Midwives and Allied Health Professionals to help relieve further vacancy pressures on the organisation. The funding package would also need to be available to support them arriving into Scotland. What next? Anticipated actions for next 2 years Review the projected workforce gaps and determine where International recruitment could be of benefit, then consider the funding and infrastructure required to support this. Whilst this has been a focussed piece of work lead by Scottish Government, International recruitment has always existed within NHS Lanarkshire most apparent within the medical job family. Leadership and Management Development, Organisational Development What has been done in the last two years? We have actively targeted members of the staff equality networks to raise awareness of and encourage applications to leadership programmes and sessions offered by NHS Lanarkshire. This was delivered through the Organisational 46
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29 Development Leadership training team presenting at EMEN meetings and through targeted articles in EMEN newsletters. Current Leadership programmes: The 6 Critical Practices for Leading a Team - This programme has been designed to assist new Managers to help them excel in tough and demanding roles. It contains a collection of carefully selected content focusing on mind-set, skills and tools to provide new Managers with relevant and practical resources to use day to day. The 7 Habits of Highly Effective People - This programme equips existing Managers with the skills, knowledge and behaviours necessary to cope with leadership challenges and empower them to lead with character and integrity. This leadership programme is unique in that it is not just about what leaders do but also about who leaders are. The 4 Essential Roles of Leadership - This programme is aimed at Senior Managers and explores the four essential roles of leaders: Inspiring Trust, Create Vision, Execute Strategy and Coach Potential, which lay the foundation for effective leadership. Leadership programmes are further supported by: ‘Leadership Thinking Newsletter’ NHS Lanarkshire’s monthly newsletter directing leaders to handpicked materials designed to challenge leadership thinking on a range of relevant topics such as Resilience as A Leader, Managing Wellbeing as A Leader, Collaborative Leadership, Psychological Safety plus more. Leadership Thinking Lunchtime Club Monthly sessions focus on different aspects of Leadership and encourages participants to share their ideas and best practice. Group discussions focus on the monthly newsletter containing materials on ‘Something to read, something to do and something to watch’ leadership content. What difference have these made? The number of people who have accessed our learning and organisational development offerings from the EMEN and LGBT+ staff networks has been noted by those managing our programmes. Participants from all programmes and sessions have provided feedback on the impact our leadership programmes had on their work and personal lives. The Leadership Thinking Lunchtime Club has been facilitated to embed inclusion through the use of diversity scenarios in learning activities which has resulted in positive feedback received from attendees. 47
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30 How will outcomes be sustained? We will continue to promote learning and organisational development programmes through the staff equality networks and will analyse feedback to ensure these programmes meet the needs of our staff members to enhance their leadership and management skills. Future learning and development course development will have a ‘golden thread’ of equality, diversity and inclusion interwoven to ensure scenario based exercises, case studies and discussions are inclusive of minority communities and those with protected characteristics, and equalities are embedded across all learning. What challenges remain? Encouraging awareness of, application to and attendance of under-represented minority groups at learning and organisational development offerings may present a challenge as promotion is mainly through our staff equality networks and their newsletters. Those who are not part of these networks may be missed so we will continue to adapt how we promote opportunities to staff from under-represented groups in response to emerging knowledge and feedback. What next? Anticipated actions for next 2 years Protected characteristics of attendees are not recorded in Learning and Organisational Development but more detailed information on the demographics of all staff attending training is available in the workforce data later in this report which will enable us to compare data every two years. We will continue to work with all staff groups to encourage participation and use feedback to ensure these programmes meet the needs of our staff members to enhance their leadership and management skills through measurable outcomes. 48
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31 5. Equality Outcomes The Equality Act 2010 (Specific Duties) (Scotland) Regulations 2012 stipulated that all Health Boards across NHS Scotland were required to develop and publish a set of equality outcomes to further one or more of the three needs of the Public Sector Equality Duty (PSED). The purpose of the specific duties in Scotland is to help public bodies, such as NHS Lanarkshire, in their performance of the PSED. Due, to service pressures and limitations brought on by the Covid-19 pandemic NHS Lanarkshire only developed and published two Equality Outcomes in 2021, with a commitment to publish new equality outcomes in 2023. The Equality Outcomes published in 2021 were: Equality Outcome 1: Near Me: To provide an alternative method of patient care that increases the ease of access for all patients in Lanarkshire. Equality Outcome 2: Staff Equality Networks: To provide a safe and supportive environment for staff to discuss issues relating to a particular protected characteristic. The two-year update on the progress on these outcomes are documented below. As part of development of NHS Lanarkshire’s Equality Strategy 2021-25 two further Equality Outcomes were developed are being published to complement existing ones in 2023. These are Equality Outcome 3: Healthcare needs assessment of resettled populations in Lanarkshire: In partnership with public health and other key partners, design and undertake a holistic Health Needs Assessment (HNA) of the resettled population in Lanarkshire in order to inform a plan of health care delivery and health improvement. Equality Outcome 4: Greenspace and biodiversity: To protect, preserve, and enhance NHS Lanarkshire greenspace and ensure it is biodiverse and accessible to staff, service users, and the wider community. 49
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32 5.1 Equality Outcomes 1 & 2: Update Reports. April to December 2022 Equality Outcome 1: Near Me What has been done in the last two years? Near Me is NHS Scotland’s secure video consultation solution enabling patients, families and/or carers to have the option of virtual appointments with NHS Lanarkshire clinicians. During the COVID-19 pandemic services were unable to provide face to face consultations and there was a rapid rollout of Near Me across NHS Lanarkshire. The number of Near Me consultations in NHS Lanarkshire reached a peak of 10,235 consultations in March 2021 at the height of the pandemic however as services entered recovery phase usage has decreased to an average of 3,500 consultations in 2022. In total 185,800 Near Me video consultations took place between March 2020 – November 2022. YouTube Link: https://youtu.be/L7-20V0gyHM Near Me has been used across Primary, Secondary, Mental Health, Social Work and Third Sector organisations to sustain care and support to patients. Psychology and mental health are the biggest users of Near Me in NHS Lanarkshire with 34,000 individual consultations carried out in 2021. This decreased to 24,000 individual consultations in 2022 to November 2022 however these services also carried out 1000 group consultations with a total of 3,800 participants in this time period. Information leaflets for callers have been translated into 31 languages. What difference have these made? Benefits identified by patients during Near Me end of call survey with 24,500 respondents Dec 2021-Oct 2022: Don’t have to travel to appointments. Saved time and money. Less chance of infection. 50
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33 Don’t have to take so much time off work or change my usual activities. Feel more relaxed and find it easier to explain my situation. Improved access to services. Easier to have relative or carer join the consultation. How will outcomes be sustained? Community Near Me resources will be set up in third sector and community facilities across Lanarkshire. These Near Me resources will be bookable, free of charge, private spaces supported by the resource staff. The Technology Enabled Care team will: - monitor the number of Near Me consultations and patient evaluations monthly and support services to increase usage. - provide on-going Near Me training for staff in a range of formats including in person, MS Teams and online and - increase public awareness of Near Me by in person information sessions, social media, public facing websites. What challenges remain? Challenges identified by survey of 26 clinicians from 5 specialties in University Hospital Monklands (2022): Clinician preference on consultation type. Uncertainty about when video consultations should be used. Clinician perception that patients prefer face to face or telephone consultations. No suitable private space for consultation. Don’t have suitable equipment or Wi-Fi connection. Perception that patients don’t have suitable digital devices or connectivity. What next? Anticipated actions for next 2 years Priorities: Work with services to identify opportunities to embed Near Me into service design. Digital inclusion: work with third sector organisations and other community resources to develop a network of community Near Me facilities. On-going training and education for staff and patients. Work with interpretation service and national TEC team to identify the number of video consultations using interpretation and BSL interpretation support. Work with interpretation service to review available information and resources to ensure it is accessible to the widest range of citizens. 51
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34 Equality Outcome 2: Staff Equality Networks. What has been done in the last two years In response national guidance, NHS Lanarkshire has established three staff networks o provide a safe and supportive environment for staff to discuss issues relating to a particular protected characteristic which are at various stages in their development: Ethnic Minority Employee Network (EMEN). LGBT+ network. Disability network. What difference have these made? Ethnic Minority Employee Network (EMEN): The EMEN was launched in February 2021 and currently has 335 members. It provides a space where staff from ethnic minorities are able to discuss issues they face and identify network actions that can be taken to address these or link into appropriate directorates to support them. EMEN meetings are held quarterly with an average of 30-40 members in attendance. Over the last two years, 16 speakers have been invited to speak on issues pertinent or of interest to the members, speakers have included: Neena Mahal, previous Chair of NHS Lanarkshire on ‘Her leadership journey as an Ethnic Minority (EM) woman’. Lesley McDonald, NHS Lanarkshire Board Whistleblowing Champion. NHS Lanarkshire Quality Directorate – reporting racist and other hate crime incidents against staff. British Medical Association (BMA) – experience of racism by BMA ethnic minority members survey results. To maintain on-going engagement with members unable to attend meetings, EMEN has published 4 newsletters which reflect key activities and areas of focus for the network. 52
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35 The EMEN has also been accessed as a consultation platform for a number of projects which include: Staff health and wellbeing strategy. Datix (motivated incidents against staff) reporting. Digital Strategy. International Nurse Recruitment. International Medical Graduate mentorship. The EMEN was central to promotion and distribution of the NHS Scotland inclusive pride badge, highlighting EM and LGBT+ intersectionality, which saw almost 2,000 badges distributed amongst staff. Lesbian, Gay, Bisexual, Transgender Plus (LGBT+) Network: The LGBT+ network was launched in February 2022 and currently has 43 members. Its executive committee was agreed in November 2022 and it is anticipated that this vital step will generate momentum in forming an action plan. The LGBT+ network has hosted a number of speakers including: NHS Lanarkshire Board Whistleblowing Champion. Equality and Diversity Team on ‘Active Bystander’ programme. NHS Lanarkshire Quality strategy engagement. This highlights the collective focus of the individual networks and how key drivers are intersectional across the protected groups. Tabled agenda items included the use of gender pronouns in electronic signatures, promoting network membership, NHS Scotland inclusive pride badges and recognising key LGBT+ calendar dates. In addition, the network has connected with the Scottish LGBTI Police Association to share best practice and learning and it is hoped that it will link with wider NHS LGBT+ networks as it develops. Disability Network 53
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36 The Disability network was launched on 31st October 2022. The network was established following a staff survey which received 115 responses and overwhelmingly confirmed the desire for a disability network which currently has 86 members. Network meetings will be held quarterly and it is hoped an executive committee will be established in the early part of 2023. How will outcomes be sustained? Network Support NHS Lanarkshire has named Board and Corporate Leads to support and champion the networks. Evidenced its support for Employee networks with a creation of a post to support the establishment of new networks, their co-ordination and ongoing work. The employee networks are a part of NHS Lanarkshire’s Equality Strategy 2021-25. Network Executive groups are supported by the Organisational learning and development team with sessions to enable effective team working and planning. NHS Lanarkshire Senior Team have agreed protected time allocated for employees to attend network meetings identifying that they be members of more than one group. They have also agreed protected time for network executive group members to attend committee meetings and key actions. Named contacts have been identified in key employment/support areas: Human Resources and Occupational Health. Action Plans EMEN has a robust 3-year action plan (2021-24) that supports its work and identifies future development areas and direction. The action plan is steered by NHS Lanarkshire’s statutory obligations under The Equality Act 2010. The action plan has been shared with a number of Boards across Scotland and has been recognised as an exemplar of good practice and will be used as a basis for the action plans of our other networks. The LGBT+ & Disability staff networks will be supported to develop and implemented their actions respectively. Consultation The employee networks have been identified as key consultation groups and have already been accessed to gather feedback on a number of key NHSL strategies 54
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37 and policies. The Networks will continue to be platforms for local and national consultations. Wider Networks The work of the EMEN extends outside of geographical boundaries as its Chair and vice-chair are members of the Scottish Government National Ethnic Minority Forum influencing National strategies and practice. The post which supports NHS Lanarkshire employee networks is a member of the national NHS Staff Networks Co-ordinators group – to support sharing of good practice and resources. It is anticipated that LGBT+ and Disability network chairs will sit on emerging National forums. What challenges remain? Workforce and organisational pressures directly impact ability of members to attend the networks but the Board’s continuing support of the networks is seen as a positive driver. Engagement with members unable to attend meetings has already been identified as a challenge however the EMEN produces regular newsletters to keep its members informed, share ambitions, opportunities and outcomes. Building staff trust in effectiveness of networks and benefits of membership will continue to be a challenge – this has been particularly identified as a key challenge across all networks. Encouraging membership, engagement and attendance to network meetings will be an on-going challenge. However, evidence that the networks have a positive influence on workplace culture, inclusion and recognition will hopefully address these. Changing local and national priorities/landscape may affect how the networks are view, respected and appreciated but we are confident NHS Lanarkshire is an exemplar for driving forward the equalities agenda and will address and challenge these as these change. What next? Anticipated actions for next 2 years On-going development of the staff networks is a key action for the Equality and Diversity Team, with additional support for the newer LGBT+ and Disability networks. It is envisioned that all three networks executive groups will begin working collectively in identifying shared/intersectional outcomes as they evolve and strengthen. 55
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38 It is anticipated that all the networks will initially produce their own newsletters but it is anticipated that these will come together as a joint multi- networks newsletter which reflects key activities and areas of focus. We will continue promotion of the networks to all staff through staff communication channels. Continued membership of the National Ethnic Minority Forum by the EMEN Chair and the LGBT+ and Disability Network Chairs will join any new National forums. 5.2 NHS Lanarkshire Equality Outcomes 2023 – 2025 Equality Outcome 3: Healthcare needs assessment of resettled populations in Lanarkshire - In partnership with health Improvement and other key partners, design and undertake a holistic Health Needs Assessment (HNA) of the resettled population in Lanarkshire in order to inform a plan of health care delivery and health improvement. If working in partnership outline which organisation this outcome is for. NHS Local Authority H&SC Partnership Third Sector College / University Other Please state: Other Community Planning Partners x x x x x 56
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39 The aspects of the General Duty met: Eliminate unlawful discrimination, harassment and victimisation. Advance equality of opportunity. Foster good relations between people. Protected Characteristic covered: Age, race, religion or belief, gender reassignment, disability, pregnancy/maternity, sex and sexual orientation. Context and Evidence: The UK Government has made a commitment to resettle refugees from various countries via the United Kingdom Resettlement Scheme (UKRS), and to provide Afghan Locally Employed Staff (LES) and their families with resettlement in the UK. The Scottish Government (SG) in conjunction with COSLA has made a continued commitment to support the UKRS, resettle some of the Afghan families and to take a proportionate number of the UASC. In response to the crisis in Ukraine, the SG and COSLA have indicated their commitment to support Ukrainian people coming in to live with relatives and friends, via the Homes for Ukraine scheme or The Scotland Super Sponsor scheme. In December 2021 the Home Office and MEARS established an emergency contingency accommodation for single male asylum seekers at an hotel in East Kilbride. The UK Government has recently indicated that as part of the widening Asylum Dispersal Strategy, most areas in the UK will be expected to participate in supporting the arrivals and integration of people seeking asylum. In summary the current situation is that there are various groups of people coming to settle in Lanarkshire, who will require healthcare and support. Resettlement is an evolving picture and as well as having a response team to quickly mobilise and coordinate activity in support of the health and social care needs of resettlement cohorts residing and arriving, a population health programme is also required to reduce health inequalities and improve health and wellbeing in the medium and longer-term. In partnership with public health and other key partners, a holistic Health Needs Assessment (HNA) of the resettled population in Lanarkshire (recognising that this is not static) will be designed and undertaken in order to inform a plan of health care delivery and health improvement. The HNA will be utilised to inform the development and implementation of a Lanarkshire Resettlement Population Health Plan incorporating health care, public health and health improvement activity which responds to the varying health needs of this heterogeneous population. 57
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40 Why are you setting this outcome? 1. To deliver on the UK Government’s Home Office Resettlement Policy and associated schemes. 2. To ensure that Lanarkshire’s Resettlement Population have access to appropriate healthcare and support that optimises their health and wellbeing potential. 3. To reduce an escalation of ill health through prevention programmes that respond to the needs of varying cohorts of settled or incoming people. 4. To mitigate against the impact of health inequalities for the resettled population. To inform prioritisation of Public Health, Healthcare and Health Improvement activity and use of multi-agency resources. Measures/Indicators: 1. Fund and recruit a Senior Health Promotion Officer for the Resettlement Programme. 2. A HNA Steering Group with all key partner stakeholders established with terms of reference. 3. HNA tool identified and tailored. 4. HNA undertaken, report written and disseminated. Evidence of recommendations and actions progressed. Lead Area: Health Improvement Link to Local and National Priorities: https://www.gov.uk/government/publications/resettlement-policy-statement https://www.gov.uk/guidance/afghan-citizens-resettlement-scheme Link to local and national priorities: Scottish Government: Everyone Matters: 2020 Vision; Workforce Framework; Implementation Plan 58
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41 Equality Outcome 4: Greenspace and biodiversity - Protect, preserve, and enhance NHS Lanarkshire greenspace and ensure it is biodiverse and accessible to staff, service users, and the wider community. If working in partnership outline which organisation this outcome is for. NHS Local Authority H&SC Partnership Third Sector College / University Other Please state: The aspects of the General Duty met: Advance equality of opportunity. Foster good relations between people. Protected Characteristic covered: Age, race, religion or belief, gender reassignment, disability, pregnancy/maternity, sex and sexual orientation. Context and Evidence: There is a growing threat to public health from the current climate crisis. If left unabated, these impacts will have negative consequences for the health and wellbeing of our communities, with those from more deprived communities most at risk and more likely to suffer health consequences. We recognise that we can positively contribute to local areas in many ways beyond providing healthcare. NHS Lanarkshire’s estate provides diverse greenspace resources for both people and wildlife and these natural environments form the foundation of a healthy environment. Our outdoor estate is a valuable and under-used asset. If planned and managed well, it can make a significant contribution to the physical and mental health and wellbeing of our staff, patients, visitors and local communities. The Lanarkshire Green Health Partnership (LGHP) was formed in April 2018 and is helping to connect health & social care with nature. Lanarkshire is rich in greenspace, parks and nature but this has historically been an underused asset. We are aiming to raise awareness and confidence of the workforce and community to access, promote and utilise our green health spaces. x 59
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42 Additionally, the LGPH is supporting work to increase active travel opportunities by improving the infrastructure within our sites to support this. We have already had successes in this area over the last year and have: Introduced therapeutic gardening sessions for our patients across a number of sites. A number of participants in the programme were supported to achieve the John Muir Discovery Award. Food growing programme introduced in University Hospital Hairmyres. Donations of food harvested were donated to Clydesdale food bank. Delivered secure cycle parking units on some sites. Loaned bikes and e bikes to staff for active commuting. Promotion of health walks through ‘Get Lanarkshire Walking’ Why are you setting this outcome? A key aim of the Lanarkshire Green Health Partnership is to enhance the NHS estates to offer therapeutic spaces for hospital inpatients, outpatients and community volunteers by providing growing sessions (led by a third sector organisation - Clydesdale Community Initiatives). This not only helps to facilitate health and wellbeing outcomes for the individuals but also increases biodiversity to the greenspaces. Improves the health and wellbeing of user groups: o Enhanced physical and mental health. o Increased social connectivity. o Improved aspirations. o Improved employment/voluntary opportunities. Innovative volunteering: o Affords individuals who would not normally be able to access regular volunteering with opportunities as part of their treatment pathway. o Improved physical activity levels. Measures/Indicators: Increased use of estate by patients, staff and visitors. Established connections between the NHS estate, community greenspaces and wider green networks. Increased awareness for the benefits and opportunities of increasing greenspace and biodiversity. Deliver opportunities for volunteering and development. Greenspace management plan developed. 60
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43 Greenspace design and practice incorporated into new buildings, refurbishment programmes and programmes of work for estates teams. These will be monitored through: Annual biodiversity audit. Reporting progress through National Sustainability Assessment Tool and the Public Sector Climate Change Duties Report. Staff Surveys. Lead Area: Lanarkshire Green Health Partnership. Link to Local and National Priorities: This area of work links with: NHS Lanarkshire: Corporate Objectives. Sustainability and Climate Change Strategy. Pillar underpinning the development of the Boards Clinical Strategy ‘Our Health Together’. National: Direct Letter (2021) 38 – A policy for NHS Scotland on the Climate Emergency and Sustainable Development. NHS Scotland climate emergency and sustainability strategy: 2022-2026. International: UN Sustainable Development Goals. 61
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44 6. NHS Lanarkshire Board Diversity Data The table below outlines the number of men and women who are currently members of Lanarkshire NHS Board (as at December 2022) Executive Directors of the NHS Board are appointed to the NHS Board by virtue of their positions as: Chief Executive; Director of Finance; Executive Medical Director; Executive Nurse Director; Director of Public Health Two Non-Executive Directors are appointed to the NHS Board by virtue of their positions as Chair of the Area Clinical Forum and as Employee Director / Chair of the Area Partnership Forum Two non-Executive Directors are nominated by the Local Authorities to serve on the NHS Board The remaining eight non-Executive Directors (including the Chair) were appointed through a national recruitment process overseen by the Scottish Government Public Appointments Unit Female % Male % Total Members December 2022 n=9 (47%) n=11 (53%) 20 The gender composition of the 11 Publicly Appointed Non-Executive Directors of the Board (including the Chair) at February 2023 is 3 females (27%) and 8 males (73%). 62
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45 7. Workforce Data Data definition Due to the nature of reporting, and the differing systems used, there are variances on the equal opportunities monitoring data presented in terms of the percentage (%) of the workforce cohort being analysed, as relative denominators will vary, as follows: Overall workforce characteristics – data reflects all substantive staff employed as at 31st December 2022 (excluding bank staff); Training – data reflects all learning opportunities undertaken in the calendar year 2022; Leavers – data reflects all substantive post holders who left during the calendar year 2022; Recruitment – data reflects all applicants (for substantive and bank posts) during the calendar year 2022; and Employee relations – data reflects all conduct cases during the calendar year 2022. Presentation of the data The data is presented in six distinct sections: 7.1 Workforce characteristics; 7.2 Training; 7.3 Leavers; 7.4 Recruitment; 7.5 Employee relations; and 7.6 Equal Pay Analysis 63
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46 Each section provides detail on sex; disability; ethnic group, age; and sexual orientation. The denominator relative to the subject area is detailed at the top of the page of each respective section. Data within the recruitment section details the proportions of staff that applied, were interviewed and subsequently were identified as preferred candidates and this is presented in a table format for all characteristics. 7.1 Workforce characteristics as at 31st December 2022: total headcount of 13,962 Sex of the workforce %. 64
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47 Sexual orientation of the workforce %. Disability declared % of the workforce. 65
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48 Age Profile % of the workforce. Ethnicity of the workforce %. 66
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49 Religion/Beliefs of the workforce %. 67.7% 5.2% 0.2% 0.2% 23.7% 0.1% 2.3% 0.6% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% White Prefer not to say Other Mixed Information Not Held Caribbean or Black Asian African Ethnicity % (Aggregated) of Workforce (Headcount) 67
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50 7.2 Training. 1/1/2022 to 31/12/2022, all training opportunities (inclusive of both face to face and eLearning packages) undertaken by staff: training opportunities = 179,666 Sex %. Sexual Orientation %. 68
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51 Ethnicity %. Disability %. 69
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52 Religion/Belief %. Age of Workforce %. 70
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53 7.3 Leavers 1/1/2022 to 31/12/2022: total headcount = 2,087 Sex of Leavers %. Sexual Orientation of Leavers %. 71
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54 Ethnicity of Leavers %. Religion/belief of Leavers %. 72
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55 Age Profile of Leavers %. 7.4 Recruitment. 1/1/2022 to 31/12/2022: 26,260 applications, 7,131 interviewed, 4,901 preferred candidates Sex. Sex Applicant Interviewed Preferred candidate In another way 0.4% 0.4% 0.5% Female 68.1% 77.3% 80.2% Male 27.4% 18.7% 16.6% Information not held 3.9% 3.6% 2.6% Prefer not to say 0.2% 0.1% 0.0% Disability. Disability Applicant Interviewed Preferred candidate Yes 2.3% 2.9% 2.2% No 93.8% 93.5% 95.1% Information not held 3.9% 3.6% 2.6% 73
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56 Religion. Religion Applicant Interviewed Preferred candidate Buddhist 0.4% 0.3% 0.2% Christian - other 33.1% 16.1% 10.2% Church of Scotland 6.7% 13.3% 12.3% Information not held 4.6% 4.6% 3.8% Hindu 2.9% 1.1% 1.1% Jewish 0.0% 0.1% 0.0% Muslim 11.1% 4.2% 3.2% No Religion 23.3% 36.4% 43.4% Other 0.9% 1.1% 1.0% Prefer not to say 2.4% 3.9% 4.0% Roman Catholic 14.3% 18.6% 20.6% Sikh 0.3% 0.3% 0.1% Sexual Orientation. Sexual Orientation Applicant Interviewed Preferred candidate Bisexual 3.1% 2.0% 2.0% Information not held 4.3% 3.7% 2.8% Gay/Lesbian 1.8% 2.5% 2.7% Heterosexual 85.8% 87.6% 87.8% Other 1.6% 1.0% 0.8% Prefer not to say 3.3% 3.2% 3.9% Ethnicity. Ethnicity Applicant Interviewed Preferred candidate African – African, African Scottish or African British 15.2% 5.5% 1.7% African - Other 19.7% 5.2% 1.0% Asian – Bangladeshi, Bangladeshi Scottish, Bangladeshi British 0.3% 0.1% 0.1% 74
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57 Ethnicity continued Applicant Interviewed Preferred candidate Asian – Chinese, Chinese Scottish, Chinese British 0.3% 0.2% 0.4% Asian - Other 5.4% 3.1% 2.5% Asian – Bangladeshi, Bangladeshi Scottish, Bangladeshi British 1.6% 0.9% 0.7% Asian – Pakistani, Pakistani Scottish, Pakistani British 5.5% 2.6% 2.1% Caribbean or Black – Black, Black Scottish, Black British 0.1% 0.0% 0.0% Caribbean or Black – Caribbean, Caribbean Scottish, Caribbean British 0.0% 0.1% 0.1% Caribbean or Black – Other 0.1% 0.0% 0.0% Mixed or Multiple Ethnic Group 0.5% 0.5% 0.6% Information not held 3.9% 3.6% 2.6% Other Ethnic Group – Arab, Arab Scottish, Arab British 1.3% 1.1% 0.9% Other Ethnic Group – Other 0.4% 0.2% 0.1% Prefer not to say 0.6% 0.6% 0.7% White – Gypsy Traveller 0.0% 0.0% 0.0% White – Irish 0.5% 0.9% 1.1% White – Other 2.1% 2.0% 2.0% White – Other British 3.7% 6.8% 6.8% White - Polish 0.4% 0.6% 0.6% White - Scottish 38.5% 66.1% 75.8% 75
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58 7.5 Employee relations conduct cases 1/1/2022 to 31/12/2022: 67 cases Sex. Disability. 76
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59 Religion. Sexual Orientation. 77
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60 Age Profile. Ethnicity. 78
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61 7.6 Equal Pay Analysis The data utilised is as at 31st December 2022 for all tables. The data presented covers all substantively employed staff and the average hourly rate of basic pay i.e. excluding overtime. Note: Comparison is on the basis of average pay for males and females (excluding overtime) for the cohort detailed by row. A positive percentage indicates a pay gap with males being paid more than females. A negative (-) prefixed percentage indicates that there is a pay gap with females being paid more than males. Job Family F-GC F-GC as % of JF Total Average BHR (F) M-GC M-GC as % of JF Total Average BHR (M) BHR variance (£) BHR Variance (%) Total Agenda for Change Staff 11,341 87 17.50 1,681 13 17.50 0.00 0 17.56 Medical and Dental Staff 443 50 44.48 448 50 45.81 1.33 3 45.15 Senior Manager 26 53 38.25 23 47 30.92 -7.33 -24 34.81 Total for Organisation 11,810 85 18.56 2,152 15% 23.87 5.31 22 19.38 F-GC = Female Gender Count. M-GC = Male Gender Count. JF = Job Family. BHR = Basic Hourly Rate. BHR variance (£) = Variance in £s of hourly rate for male vs. female. BHR variance (%) = BHR variance / average M-BHR. 79
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62 8. Procurement NHS Lanarkshire continues to ensure equality is mainstreamed into our procurement processes including: Carrying out public procurement, and mainstreaming the general equality duty through use of the Scottish Government’s Single Procurement Document, which is used as a template for the selection of suppliers including Equality and Diversity. In developing methodologies and strategies for the procurement of goods, works and services, NHS Lanarkshire ensures that it gives due regard to all of its duties under the Equality Act and pursuant Regulations, and considers how inequalities of outcome caused by socio-economic disadvantage may be reduced through the conduct of procurement processes. NHS Lanarkshire seeks to use collaborative contracts and frameworks where possible in order to help achieve its equality aims. An example of where equality and diversity is promoted is the NHS Scotland uniforms contract which was awarded to Dimensions UK Ltd. Part of the contract is subcontracted to Haven PTS, a Scottish based supported business where at least 30% of employees are disabled or disadvantaged persons. NHS Lanarkshire continues to recognise that our activities have an effect on the society in which we work, and that developments in society affect our ability to work successfully, and operates to a procurement strategy which is committed to achieving environmental, social and economic aims that tackle these effects. Our tendering activity has increased in recent years and the governance increased through development of Standing Financial Instructions, Procurement Operating Procedures and work instructions in line with the Public Procurement Reform (Scotland) Act 2014 and Public Contracts (Scotland) Regulations 2015. This ensures 80
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63 that the environmental, social, equality and diversity aspects of procurements are addressed appropriately. NHS Lanarkshire also actively promote the use of national frameworks, as mentioned above, and these have been awarded under the same procurement regulation requirements. The use of contracts is mandated through the use of electronic ordering from catalogues thus reducing off contract spend and maximising the environmental, social and economic benefits achieved. 9. Conclusion In this two-year update report we have given some examples of our progress over the last two challenging years. In a post Covid-19 world we clearly recognise that Equality and inequalities are no longer add-ons, but an integral part of everything NHS Lanarkshire does. We continue to evidence the on-going commitment of the organisation’s leadership and staff as advocates for change and endeavour to make systematic and targeted changes that make a real difference. We hope we have shown our strong commitment to improving and changing the experiences of our service users and staff in a meaningful and inclusive way. 81
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1 REPORT Item No: 13 SUBJECT: Performance Update – Quarter 4 (January – March 2023) TO: Performance, Finance & Audit Committee Lead Officer for Report: Morag Dendy, Head of Planning, Performance and Quality Assurance Author of Report: Stephen Forrest, Performance Manager DATE: 21 June 2023 1. PURPOSE OF REPORT 1.1 This paper is coming to the Committee: For approval For endorsement To note 1.2 The purpose of the report is to provide an update to the Committee on the areas for improvement which have been identified as part of the Quarterly Performance Review for the period 1 January 2023 to 31 March 2023 (Quarter 4). 2. ROUTE TO THE BOARD 2.1 This paper has been: Prepared By: Performance Manager Reviewed By: Senior Manager, Strategy & Performance Endorsed By: 3. RECOMMENDATIONS 3.1 The Committee is asked to note the contents of the report and its appendix. 4. BACKGROUND/SUMMARY OF KEY ISSUES 4.1 The Chief Officer has joint quarterly performance review meetings with the Chief Executive of NHS Lanarkshire and the Chief Executive of North Lanarkshire Council. These meetings are supported by a Chief Executive Performance Framework comprising a range of performance measures from across both health and social work systems, including relevant targets and trajectories.
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2 4.2 Based on a traffic-light system there are areas for improvement identified within the performance framework each quarter for those that are flagged as Red or Amber. The performance review meetings are used as a means for jointly agreeing corrective actions. 5. AREAS FOR IMPROVEMENT 5.1 The areas for improvement and corrective actions are attached as Appendix 1. 6. CONCLUSIONS 6.1 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 The Chief Executive Performance Review process is structured in a way to allow performance levels to be assessed against each of the 9 national outcomes. 7.2 ASSOCIATED MEASURE(S) None 7.3 FINANCIAL None 7.4 PEOPLE None 7.5 INEQUALITIES EQIA Completed: Yes No N/A 8. BACKGROUND PAPERS None 9. APPENDICES Appendix One - Areas for Improvement (Quarter 4, January – March 2023) ............................................................................. CHIEF OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact Stephen Forrest on telephone number 07810155410.
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3 Appendix 1 – Areas for Improvement (Quarter 3, October - December 2022) 1. Alcohol Brief Interventions Target 2022/23 2022/23 Q3 2022/23 Q4 Performance Compared to Previous Quarter Performance Compared to Same Quarter Previous Year RAG Status Alcohol Brief Interventions (all settings) NHSL 7381 n/a 647 - Narrative & Corrective Action As services within the HSCP/NHSL move toward the use of the Electronic Patient Recording (EPR) system MORSE, it is suspected that the practice of routinely conducting and recording ABI may have decreased. It is also possible that there is some inconsistent practice whilst the transition to MORSE is facilitated and teams are required to maintain dual EPR. The numbers included within these reports include all interventions recorded via Morse and all manual returns which are entered via an Access database. A steering group has been formed to facilitate the development of a SOP and devise a suitable training product for staff to encourage the use and proper recording of ABI. The ABI Steering Group has agreed a new reporting structure and this has been adopted. A highlight report has been made available to the steering group indicating services/teams that have low or no interventions recorded. 2. Cervical Screening Target 2022/23 2022/23 Q3 2022/23 Q4 Performance Compared to Previous Quarter Performance Compared to Same Quarter Previous Year RAG Status Cervical Screening Uptake 80% 72.9% 72.5% Narrative & Corrective Action The position remains similar to Q3. Work is ongoing to promote Cervical Cancer Screening Awareness Week in June. This supports training being delivered in partnership with all sectors (NHSL/Locality Level) to promote cancer screening programmes and early detection. An increase of 0.2 WTE for the Public Health Quality Improvement Facilitator offers some additional capacity for the service to improve the current position. Targeted campaign work is taking place to increase screening awareness and the uptake of cervical screening and HPV in the lowest uptake areas (Bellshill and Airdrie) and also with specific populations in the community (SIMD 1&2). Cancer Screening Workshops continue to be carried out with Lanarkshire Carers BAME group.
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4 The Practice Cervical Screening Audit is now being conducted across the North Partnership, which involves GP Clinical Leads and Quality Coordinators auditing the process in each practice to inform a briefing promoting best practice and recommending improvements, where necessary. 3. Immunisations Target 2022/23 2022/23 Q3 2022/23 Q4 Performance Compared to Previous Quarter Performance Compared to Same Quarter Previous Year RAG Status Immunisations – % of 5 year olds 95% 92.7% 92.2% Narrative & Corrective Action Performance in Lanarkshire is reflective of a wider trend being experienced across Scotland where there is a gradual and slight decline in uptake of immunisation. The decline in uptake appears more significant in 2022 when compared with previous years.
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5 The data is being reviewed by colleagues in Public Health to identify any drivers of the decline, the potential implications and to link these findings to Health Improvement work streams. Ongoing work to improve the position includes the use of media campaigns, improved access to local clinics and better parent/carer contact prior to appointments. 4. 6-8 Week Reviews Target 2022/23 2022/23 Q2 2022/23 Q3 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% 74.7% 69.5% Narrative & Corrective Action Performance remains below target and there is continued decline through 2022, resulting in a level of completion that is among the lowest experienced in NHSCP. This performance metric and the associated risk is monitored by the North Health & Social Work Managers, Associate Medical Director and Senior Nurse. Initial analysis of the underlying data has found a significant issue in the distribution of late and/or missed checks among a relatively small group of practices. Further investigation and analysis is required to fully understand the proportionality of reviews that were completed late and those were no assessment was carried out. Further investigation and analysis is also required to also understand where the issue may relate to the non, or misreporting of reviews that have taken place as required. Initial analysis has been carried out by locality:
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6 The monitoring and analysis is providing some intelligence on hotspots associated with GP Practices and Health Visitors. It should be noted that there is a significant increase at 10 weeks, which could be relating to recording practice, or reviews out with 6-8- week window. There is local practice and control measures in place to ensure reviews are carried out, however significant variation in recording practice across the North HSCP make this a time consuming and inefficient task, as hard-copy forms have to be physically located and checked against patient records. At a locality level, specific issues have been identified, such as individual practices storing and not returning forms and therefore their data was not being captured. Changes have been made to improve returns and collections, however it is possible that such practice may be more widespread and contributing to poor performance. The Local initiatives, such as that in Bellshill to understand waiting times information from GP's has found that enough appointments are being offered and there are no waits for those practices who do not participate in CHS; this is continually monitored by the locality to reduce the rate of breach. Further initiatives are also in place in Bellshill, Motherwell and Wishaw to improve the quality of the assessment, reduce the level of returns and improve engagement with GP practices A multi-disciplinary meeting has been called for the North HSCP to analyse and provide context to all of the underlying data, gauge the clinical risk presented by the performance and to inform the planning of the corrective actions required. This complements and supports ongoing recovery and improvement work within the wider service to understand the performance across the Universal Pathway. Use of a digital platform is actively being investigated and would assist with recording practice and operational management, although this is not expected to be live for some time. 5. Delayed Discharge / Home Support / Reablement Target 2022/23 2022/23 Q3 2022/23 Q4 Performance Compared to Previous Quarter Performance Compared to Same Quarter Previous Year RAG Status Delayed discharge bed days - standard delays 31,796 Q1 – 7184 Q2 – 8966 Q3 – 8166 Q4 – 7531 8,309 8,178 Narrative & Corrective Action In Q4 of 2022/23 the delayed discharge performance continued to be significantly above target; 8178 bed days is 2328 days above the target of 5850. The “Fire Break” and associated Op Flow works are likely to have impacted and improved the Q4 position, with significant multi- disciplinary work undertaken to improve patient flow during Q4. The longer-term impact of the continued work of Op Flow is not known and will be quantified as part of the project evaluation.
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7 There remains sustained pressure on services supporting discharge, with reduced capacity in Reablement services and challenges with recruitment and retention to posts at all grades within Home Support. The level of turnover and difficulties with recruitment of the roles Home Support Worker, Support Officer and Service Delivery Coordinators have placed significant strain on supporting discharge as the North HSCP are experiencing some of the highest referral rates recorded – w/c 16th January, the North partnership received 158 referrals (peak winter pre-pandemic average was 77). Sickness absence within the Home Support workforce continues to impact on the capacity of the service to support timely discharge. Several improvement actions are in place to address the issues currently being experienced. Additional Healthcare Support Workers are being recruited so that District Nursing Teams can enhance the care offering to those on both Home Support and District Nursing caseloads, freeing up further Home Support capacity to concentrate on other cases. The service has also made some amendments to the workforce model to offer additional review capacity, which will release capacity to the mainstream Home Support service. Ongoing work is in place to develop the operating model for Reablement; to increase and protect capacity within the service for dedicated Reablement and rehabilitation as key priorities. Local and national work continues to support improved performance in discharge, including further development of the PDD process and the continued progress of the Discharge without Delay project. Local improvement work, including the development and expansion of the Rapid Response, Home Assessment and Hospital at Home teams is expected to impact positively on DD performance. 6. Reablement / Integrated Equipment & Adaptation Service / Home Assessment Team Target 2022/23 2022/23 Q3 2022/23 Q4 Performance Compared to Previous Quarter Performance Compared to Same Quarter Previous Year RAG Status Reablement - Number Of People Completing Reablement Process 2,000 (500 per quarter) 1049 1418 Reablement - % Of New or Increased Home Support Packages Which Are Reablement 70% 55.0% 61.2% Reablement - % Of People With No or Reduced Home Support Service Required At End Of Process 70% 50.3% 56.1% IEAS - % Deliveries Achieved Within 7 Working Days 80% 63.4% 51.5% Narrative & Corrective Action
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8 IEAS continues with a Programme of improvement works, with improvements to premises and focussed recruitment activity in progress at the time of reporting. Sustained workforce challenges, specifically recruitment and retention of suitably skilled and experienced IEAS staff have resulted in challenges with the delivery and uplift of equipment. Specific resources have been assigned to addressing outstanding uplifts within the areas of highest demand and this, alongside other focussed activity has released pressure and some capacity in the system to address performance with timely deliveries. It should be noted that whilst such services continue to support Delayed Discharge improvement works, such activity naturally requires a reduced focus and capacity to support Community Services. The service is undertaking an exercise to self-assess their performance, using Scottish Government baseline figures for Equipment/Adaptations. It is hoped that a more integrated Performance Framework can be developed for services in this area, showing how the services complement and interact with each other, such as combined and/or complementary metrics for Reablement and the Home Assessment Team (HAT). It is notable that whilst the percentage of Reablement Home Support packages is below target that the HAT received increasingly more referrals. A Home Assessment Team Development Plan is in place to streamline and reduce duplication of service from the teams working in this area. The dynamic between Integrated Rehabilitation, Hospital Social Work, Home Assessment Team and Reablement has been recognised as allowing an opportunity to provide one seamless combined service. The development plan is currently focussed on services to support discharge, however a second phase is planned looking at the interaction with Hospital at Home and other services placed to support admission prevention and avoidance
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9 Multi-disciplinary and multi-agency focus groups are planned to look at the available resources and patient/client pathways, which will inform the implementation of the development plan. A governance framework has been developed to support this work, which is overseen by the Home Support Programme Board. An Assistive Technology was implemented in February 2023 to support further innovation in this area and is actively working with services across the North HSCP, including a trial of the KOMP system for medication prompts as an alternative to in-person visits. At May 2023, the team have received 187 referrals and 57 of these have resulted in the supply/purchase of technology that has benefitted the person in regaining independence in an area of their life; the impact on wider services will be quantified as the new service is developed and then evaluated. 7. CAMHS Target 2022/23 2022/23 Q3 2022/23 Q4 Performance Compared to Previous Quarter Performance Compared to Same Quarter Previous Year RAG Status 21 24 18 18 9 3 43 4 1 31 0 5 10 15 20 25 30 35 40 45 50
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10 Percentage of patients commencing treatment within 18 weeks of referral 90% 19.1% 28.7% Narrative & Corrective Action The introduction of the CAPA (The Choice and Partnership Approach) for Child and Adolescent Mental Health Service (CAMHS) should see some improvement in managing the available capacity within the service. Consultant availability has been more closely aligned to demand and the CAPA model allows for more patient input in how their appointments are managed, which should also reduce wastage in the system. From 22nd August 2022 -16th April 2023, the waiting list initiative have offered an additional 1499 appointments, with 1099 attendances, 389 not brought, 7 patients transferred and 153 patients meaningfully redirected to other more appropriate supports. The waiting list for the Neurodevelopmental Service remains an issue for the service, however an increase in WTE, formal induction process and completion of staff training and development has prompted some positive movement. Adoption of Trakcare is also allowing for better monitoring of demand and capacity within the service, and will provide the evidence needed to build a sustainable future service capable of meeting demand. There is ongoing work to validate and correct the waiting list, primarily to provide assurance that the right children on list but also to identify any other support that can be put in place for those on the list whilst they wait. A Test of Change is planned with wider partners (education, GP’s and SW) to improve on understanding of neuro specific challenges for children and how they can be supported through Child’s Plan whilst they wait to be seen. A range of groups have also been developed to support parents. These groups focus on sleep, behaviour and eating. The service has also completed a commissioning process to secure neurodevelopmental assessments from an independent company. The first group of patients will begin their assessments in August 2023. A NDS Operational Group and NDS Steering Group have been established. The first will manage the practicalities of delivering the service in collaboration with an outside provider, as well as internal capacity and demand challenge. The second will provide assurance to the CAMHS Recovery and Renewal Programme Board that the commissioned provider is delivering ask of initial tender as well as delivery of learning achieved from Tests of Change. 8. Psychological Therapies Target 2022/23 2022/23 Q3 2022/23 Q4 Performance Compared to Previous Quarter Performance Compared to Same Quarter Previous Year RAG Status Percentage of patients commencing treatment within 18 weeks of referral 90% 85.1% 85.8% Narrative and Corrective Action
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11 Trajectories, completed by the PHS embedded analyst using the recommended methodology from PHS, indicate that the RTT is likely to be achieved by the end of the calendar year. Of note, these projections are based on a number of assumptions including retention of current staffing and recruitment to vacant posts, levels of demand, continuation of funding. Psychological Services have focused on addressing the longest waits through various means. A Consultant Psychologist is now in post to coordinate the management of longest waits in Adult Psychological Therapies Teams (PTT). Sharing out longest waits across localities, where appropriate, allows patients to be seen more quickly and reduces variation across geographical boundaries. Early screening appointments for patients referred to Adult PTT are now routinely offered to ensure that patients are directed to services that will best meet their needs at the earliest point in time. A stepped care approach to delivering evidence based therapies is now established utilising online therapy programmes, digital therapies and group-based interventions, and offering face-to-face psychological therapies where this is deemed the most appropriate form of psychological therapy. A focus on staff wellbeing continues in order to support our workforce and promote staff retention. Consultants are now in place to lead on Quality Improvement and Research which, in addition to service improvement and adding to the evidence base, will also create and maintain an enthusiastic workforce. Centralisation of recruitment processes and the creation of generic job descriptions has led to a noticeable improvement in reducing vacancies across the service. Performance for March shows 86.7% with 739 patients waiting over 18 weeks. Longest wait is 51 weeks. 9. Adult Mental Health Target 2022/23 2022/23 Q3 2022/23 Q4 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% 63.8% Consultant Outpatient WT - Older Adult Psychiatry - 12wks (NHSL) (NORTH HOSTED) 90% 80.2% Narrative & Corrective Action Both Adult MH and OA Psychiatry services have yet to recover performance to the target set, largely owing to increasing demand and significant backlog effected by lockdown restrictions. A programme of recovery commenced in 2021 and has seen progress where there a no patients waiting in excess of 52 weeks for PT. The Scottish Government Target for Psychological Therapies is for 90% of patients to commence therapy within 18 weeks of referral (RTT) by 31/3/23 – at March 2023 NHS Lanarkshire had achieved 86.72, which represents an improvement in spite of clinical vacancies (clinician vacancy rate 8% - 14.65WTE vacancies of 177.82WTE) and increased complexity of cases presented.
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12 Some increase in overall staffing and use of hybrid delivery has allowed for some improvement, however analysis suggests that continued improvement is contingent on maintaining or improving current staffing levels, therefore the service focus is currently on retention of staff within NHS Lanarkshire Psychology services. A large MDT Research conference planned for January 2024 in collaboration with University partners and provides current staff with continued professional development and engagement with the wider professional network. It is anticipated that such events will assist in the recruitment and retention of staff, however it should be noted that whilst efforts to recruit and retain staff should yield some improvement, performance in Psychiatry services is also heavily impacted nationally by challenges around recruitment and retention of Consultants, which is recognised and managed as a risk on the MH & LD Risk Register. 10. Waiting Times Performance - Medical Children & Young People (Consultant Led) Target 2022/23 2022/23 Q3 2022/23 Q4 Performance Compared to Previous Quarter Performance Compared to Same Quarter Previous Year RAG Status Medical Paediatrics WT - 12 wks (NHSL) (NORTH HOSTED) 90% 46.4% 49.2% Narrative & Corrective Action Acute Paediatrics have started to realise some recovery in their medical waiting time target. Focussed work has been carried out to address this challenge. This includes ongoing robust vetting and allocation of experienced colleague time to address longest waits. It is anticipated that the level of acuity within acute paediatrics will reduce over summer months. This will secure planned appointment capacity is met within months ahead to further progress current performance position.
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13 A Paediatric Consultant post was successfully recruited in March. Unfortunately, they will not take up post until after summer. Meantime, additional capacity is being provided by a locum consultant and extension of a temporary contract to a retired consultant colleague. The Paediatric Programme Board is in process of being re-established. They are being supported with dedicated project leadership time. An initial workshop has been undertaken and information gathered will inform focus of work going forward. Particular attention will be required on sustainability of service delivery due to concurrent challenges in consultant level workforce (age demographic of colleagues, reduced number of whole time equivalency training places and changes to shape of speciality training which provides additional capacity within current rotas). Performance for April shows 49.3% with 898 children waiting over 12 weeks. Longest wait is 49 weeks. 11. Waiting Times Performance – AHP and Community Services Target 2022/23 2022/23 Q3 2022/23 Q4 Performance Compared to Previous Quarter Performance Compared to Same Quarter Previous Year RAG Status SLT - Paediatrics - 12wks (NORTH HOSTED) 50% 27.1% 28.8% Narrative & Corrective Action Speech and Language Therapy continue to face significant challenges around meeting of waiting time target. A service improvement plan is in process and the management team have been provided with support. A service improvement workshop was facilitated on April 25th by a project lead and service improvement colleague who have been provided with ongoing dedicated time to support service improvement change capable of addressing this challenge. The workshop was led by the professional lead and colleagues invited included SLT Senior Management Team, Team Leads, SLT Service Improvement colleagues, Practitioners and representation from aligned university. The workshop focussed on mapping of current pathways into and through the service. This has provided the detail needed that will appropriately inform next steps. A formal work plan will be able to be shared in months going forward. The SLT management team should be acknowledged for their transparency and positive approach to the process and leadership of SLT colleagues. This facilitated positive contribution from all involved. It should be noted that significant work has already been undertaken and the workshop used that as a benchmark of current position of strengths and weaknesses to identify what wider organisational support could provide to progress position.
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14 EHealth The current limitation of eHealth systems makes it difficult to robustly report performance and presents a challenge as info is collated through local arrangements.Trakcare is not being used to full potential across the service. However, it is being used with success in one area. Small changes will be required to ensure that fully fit for present and future purpose. This will then be tested prior to being expanded into other teams. Morse- SLT are currently not on MORSE. They are on the MORSE work plan. This will be an important piece of work as it will provide transparency of intervention and will align with wider children’s services aspiration of having a system that is capable of sharing information of children across our scope of care and within NHS Lanarkshire. This will also support team leaders to have provide organisational assurance of the quality of work being delivered across teams and by individuals Processes Wide variance of process across the system (and individual teams). Standardised and consistent processes require to be developed that reflect pathway and support a consistent measure of locally agreed 12 week treatment target. Waiting List coordinator colleagues are working with team to offer support needed that will improve local systems. Work Force A review of current workforce demographic is required to inform our future planning. Consideration required of :- Age – succession planning for retirements in 2 year, 5 year, 10 year plan Challenging landscape of newly registered staff recruitment- links require to be built with Universities. A university colleague attended on day and will continue to link in with future work force planning. Opportunities for expansion of Band 4 roles. Environment SLT are spread across multiple sites facilitate collaborative working with other health care colleagues and education. This will require further mapping to ensure we continue to have capacity to deliver future care in right place at right time by right people. Performance for April remains at 28.8% with 1407 children waiting over 12 weeks. Longest wait is 75 weeks. 12. Stop Smoking Service Target 2022/23 2022/23 Q1 2022/23 Q2 Performance Compared to Previous Quarter Performance Compared to Same Quarter Previous Year RAG Status
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15 Sustain and embed successful smoking quits, at 12 weeks post quit, in 40% of SIMD areas. 902 82 304 Narrative & Corrective Action There is an intention to review all NHSL Board targets in this area. It should also be noted that there is a delay in receiving validated smoking cessation data. Lanarkshire Stop Smoking Service Local Delivery Plan performance In 2021/22, LDP performance in NHS Lanarkshire was 85.0% of target which was better than the Scottish average figure of 78.3% and was the 5th highest figure across all NHS Boards. Extrapolating quarter one 2022/23 figures indicates that the % of the LDP target achieved will reduce across all NHS Boards. Quarter two figures will be available by the end of May at which point the forecast of performance against the LDP target will be updated for all NHS Boards. Lanarkshire Stop Smoking Service overall performance In terms of overall performance, the service is ranked 9th across Scotland. The areas of strength in comparison with other boards include our performance with regard to LDP targets and the delivery of Stop Smoking services within community pharmacies. The areas for improvement in comparison with other boards include our delivery of Stop Smoking Specialist services. There are outline plans to introduce additional Local Improvement Targets (LITs) and to implement the recommendations from the deep dive review. A full report will be published end of June 2023 in response to National review. The national review of stop smoking services is due to report in June 2023, which will inform further improvements, particularly within specialist services. It is expected that this report will recommend revisions to LDP targets and a more focused approach on priority areas such as Pregnant women, people living in deprived areas, people who smoke who also have mental health problems and people who are hospitalised. Vaping NHS Lanarkshire is working with partners including ASH Scotland, Fast Forward, Landed and University of Edinburgh to develop resources with regards to youth vaping. The prevalence of vaping is influencing the wider national discussion and media focus on Tobacco control and has prompted a proposal from Scottish Government to establish a national expert group for E-cigarettes and vaping.
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16 13. Sickness Absence Target 2022/23 2022/23 Q3 2022/23 Q4 Performance Compared to Previous Quarter Performance Compared to Same Quarter Previous Year RAG Status Sickness Absence (NHSL, North) 8.31% 7.41% Sickness Absence (NLC) - days lost per person 11.32 8.56 11.96 Narrative & Corrective Action All long and short-term sickness absence continues to be managed in accordance with the relevant policies for NHSL and NLC, with monitoring of policy application managed within each service and organisation. The performance in this area reflects wider performance within the partner organisations; in NHSL, Nursing and Midwifery continues to be the most challenged cohort of staff. Within NHSL, sickness absence is being targeted within the Sustainability & Value Programme as a key area of focus. Anecdotal evidence supports a management view that some grip and control in this area was lost during the C19 pandemic due to significant changes in practice and changes in operational management post-pandemic. Additional analysis and improvement planning has been commissioned through the North HSCP. In NLC monthly meetings are taking place between Senior Managers, Service Managers, and HR Business Partners where monthly absence performance is reviewed within the respective teams.