Agenda Document Pack - Audit, Performance and Risk Committee - 30/01/2025
Moray Council · 30 January 2025
Back to Audit, Performance and Risk Committee — 30 January 2025 and its agenda
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Audit, Performance and Risk Committee Thursday, 30 January 2025 Council Chambers NOTICE IS HEREBY GIVEN that a Meeting of the Audit, Performance and Risk Committee, Council Chambers, Council Office, High Street, Elgin, IV30 1BX on Thursday, 30 January 2025 at 14:00 to consider the business noted below. AGENDA 1. Welcome and Apologies 2. Declaration of Member's Interests 3. Minute of meeting of 26 September 2024 5 - 10 4. Action Log of Meeting of 26 September 2024 11 - 12 5. Quarter 2 (July to September 2024) Performance Report 13 - 38 6. Quarter 2 (July to Septemember) Performance Report for Children and Families and Justice Social Work 39 - 68 7. Internal Audit Section - Update Report 69 - 82 8. Internal Audit Section Completed Projects Report 83 - 126 9. Childrens Services Joint Inspection Improvement Plan 2024 127 - 142 10. Payment Verification 143 - 146 Page 1
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Item(s) which the Committee may wish to consider with the Press and Public excluded 11. CONFIDENTIAL Update on Improvement Plan for Adult Social Care Commissioning • 8 & 9. Information on proposed terms and/or expenditure to be incurred by the Authority; Watching the Meeting You can watch the webcast live by going to: http://www.moray.gov.uk/moray_standard/page_43661.html Webcasts are available to view for 1 year following the meeting. You can also attend the meeting in person, if you wish to do so, please come to the High Street entrance door and a member of staff will be let into the building. Page 2
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MORAY INTEGRATION JOINT BOARD SEDERUNT Mr Sandy Riddell (Chair) Councillor Scott Lawrence (Voting Member) Mr Derick Murray (Voting Member) Councillor Ben Williams (Voting Member) Mr Sean Coady (Member) Mrs Jeanette Netherwood (Member) Ms Deborah O'Shea (Member) Ms Judith Proctor (Member) Ms Janette Topp (Member) Ms Deirdre McIntyre (Non-Voting Member) Clerk Name: Caroline O'Connor Clerk Telephone: 07779 999296 Clerk Email: committee.services@moray.gov.uk Page 3
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MINUTE OF MEETING OF THE AUDIT, PERFORMANCE AND RISK COMMITTEE Thursday, 26 September 2024 Remote Locations via Connect Remote, PRESENT Mr Sean Coady, Councillor Scott Lawrence, Mr Derick Murray, Mrs Jeanette Netherwood, Ms Deborah O'Shea, Ms Judith Proctor, Mr Sandy Riddell APOLOGIES Ms Deirdre McIntyre, Ms Janette Topp, Councillor Ben Williams IN ATTENDANCE Interim Chief Officer, Angela Pieri, Engagement Lead and Andrew Wallace, Audit Manager, both of Grant Thornton, Service Manager (Primary Care Contracts), Carl Campbell, Service Manager (Education and Social Care), Social Work Service Manager, Chief Internal Auditor, Chief Financial Officer, Corporate Programme Manager, Ms L Van Zyl, Service Manager and Mrs L Rowan, Committee Services Officer as Clerk to the Committee. 1 Chair Mr Sandy Riddell chaired the meeting. 2 Declaration of Member's Interests Mr Riddell stated for transparency that he was Chair of the Mental Welfare Commission Scotland. The Committee noted that there were no other declarations of member's interests. 3 Minute of meeting of 27 June 2024 The minute of the meeting of 27 June 2024 was submitted and approved. Item 3. Page 5
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4 Action Log of Meeting of 27 June 2024 The Action Log of the meeting of 27 June 2024 was discussed and updated accordingly. 5 External Auditors Report to Those Charged with Governance The meeting had before it a report by the Chief Financial Officer asking the Committee to consider the reports to those charged with governance from the Board's External Auditor for the year ended 31 March 2024. The Committee joined the Chair in thanking those involved in providing the External Auditor's Report and thereafter unanimously agreed to note the reports from the External Auditor as set out in Appendices 1 and 2 of the report and recommended them for approval by the Moray Integration Joint Board. 6 2023-24 Audited Annual Accounts The meeting had before it a report by the Chief Financial Officer presenting to the Committee the Audited Annual Accounts for the year ended 31 March 2024. Following consideration, the Committee agreed to note the Audited Annual Accounts for the financial year 2023/24 and the letter of Representation and recommended them to the Moray Integration Joint Board for approval. 7 Quarter 1 (April-June 2024) Performance Report Mr Coady, Head of Service joined the meeting during discussion of this item. The meeting had before it a report by the Corporate Programme Manager updating the Committee on performance as at Quarter 1 2024 (April-June). During discussion, it was noted that there were several areas where it was acknowledged that performance is poor, and it was queried whether future reports could include narrative explaining what measures are being taken to improve performance in these areas. In response, the Interim Chief Officer agreed to include narrative explaining what measures are being taken to improve performance in areas of poor performance in future reports. During further discussion, the Chair noted that the report stated that there was no need for an Equality Impact Assessment as there would be no impact on people with protected characteristics as a result of the report and sought assurance that the Committee was complying with it's legal responsibilities in relation to equalities and suggested that this section be expanded in future reports. In response, the Interim Chief Officer assured the Committee that the Board is committed to acknowledging any inequality in minority groups and advised that it was her intention to refresh equalities training in the near future. Following consideration, the Committee unanimously agreed to note: Page 6
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(i) the performance of local indicators for Quarter 1 (April to June 2024) as presented in the Performance Report at Appendix 1; (ii) the analysis of the local indicators that have been highlighted and actions being undertaken to address performance that is outside of acceptable target ranges as detailed in Appendix 1 of the report; (iii) the performance for 2023/24 against the national indicators, where data is published, as set out in Appendix 2 of the report; (iv) that future performance reports would include narrative explaining what measures are being taken to improve performance in areas of poor performance; and (v) that the Interim Chief Officer intended to refresh equalities training in the near future. 8 Quarter 1 Performance Report for Childrens Social Work and Justice Services The meeting had before it a report by the Chief Social Work Officer/Head of Service informing the Committee on Children and Families and Justice Social Work performance as at Quarter 1. During discussion surrounding the activity that had taken place within Children and Families and Justice Social Work Section it was queried whether future reports could include narrative in relation to outcomes resulting from the activity. In response, the Service Manager agreed to take this point forward and include narrative in relation to outcomes resulting from the activity in future performance reports. During further discussion, the Chair again noted that the Equalities paragraph in the Summary of Implication Section stated that there was no equality impact as a result of the report when he was aware of some good work that had taken place in this area and suggested that this section be expanded to reflect this. In response, the Service Manager agreed to expand the paragraph in relation to equalities in future reports. Following consideration, the Committee unanimously agreed to note the: (i) performance of local indicators for Quarter 1 as presented in the Performance Report at Appendix 1; and (ii) analysis of the local indicators as detailed in Appendix 1 of the report; (iii) that future reports would: • include narrative in relation to outcomes resulting from the activity in future performance reports; • expand the equalities paragraph within the Summary of Implications section of the report. Page 7
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9 Internal Audit Section - Completed Projects The meeting had before it a report by the Chief Internal Auditor providing an update on audit work completed since the last meeting of the Committee. Following consideration, the Committee agreed to note the audit update. 10 Public Sector Internal Audit Standards - External Quality Assessment of Internal Audit The meeting had before it a report by the Chief Internal Auditor providing the Committee with details of a recent external quality assessment undertaken of the Council's Internal Audit Service. The Committee joined the Chair in commending all involved in the recent external quality assessment and thereafter unanimously agreed to note the report and the Action Plan prepared to address the issues raised in the external quality assessment of internal audit. 11 Payment Verification The meeting had before it a report by the Head of Service/Depute Chief Officer providing an update on the review of the Payment Verification (PV) Assurance Service provided by National Services Scotland (NSS) Practitioner Services Division (PSD), on behalf of NHS Grampian. Following consideration, the Committee unanimously agree to note: (i) the arrangements in place in Grampian for the management of the payment verification process; (ii) that the payment verification process has now fully restarted after pausing during COVID-19; and (iii) the actions already taken to address the outstanding issues, with plans for future action to include an update on progress to this committee in January 2025. 12 Annual Performance Report 2023-24 The meeting had before it a report by the Interim Chief Officer presenting the draft Annual Performance Report 2023/24. The Chair thanked the Corporate Programme Manager for circulating the revised Annual Performance Report for 2023/24 after several typos had been noted following publication of the agenda. Following consideration, the Committee unanimously agreed to: (i) note the draft Annual Performance Report 2023/24 at Appendix 1 and subsequent amendments previously circulated; and (ii) recommend to the Moray Integration Joint Board for approval and publication of the Annual Performance Report 2023/24 by 30 September 2024. Page 8
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13 Internal Audit Section - Update Report [Para 6.2.5] The meeting had before it a report by the Chief Internal Auditor providing an update on the work of the Internal Audit Section. Following consideration, the Committee unanimously agreed to note the contents of the report. 14 Internal Audit Section - Completed Project - Email Security [Para 6.2.5] The meeting had before it a report by the Chief Internal Auditor providing an update on audit work completed since the last meeting of the Committee. Following consideration, the Committee unanimously agreed to note the audit update. 15 Update on Improvement Plan for Adult Social Care Commissioning [Para 6.2.2] The meeting had before it a report by the Head of Service/Chief Social Work Officer updating the Committee about progress regarding the Improvement Plan for Adult Social Care Commissioning. Following consideration, the Committee unanimously agreed to note: (i) the progress of the Improvement Plan as set out in Appendix 1 of the report; (ii) the progress within the report as at the end of July 2024 in relation to the recommendations detailed in the Improvement Plan; and (iii) that the updated report includes details of contract values, timelines, and risks. Page 9
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MEETING OF MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE THURSDAY 26 SEPTEMBER 2024 ACTION LOG Item No. Title of Report Action Required Due Date Action By Update for 30 January 2025 1. Quarter 1 (April- June 2024) Performance Report • future performance reports should include narrative explaining what measures are being taken to improve performance in areas of poor performance Future Reports Corporate Programme Manager Quarter 2 report on today’s agenda and the improvement work will continue as ‘business as usual’ 2. Quarter 1 Performance Report for Childrens Social Work and Justice Services Future reports should: • include narrative in relation to outcomes resulting from the activity detailed within performance reports; • expand the equalities paragraph within the Summary of Implications section of the report (action relevant to all reports). Future Reports Head of Service / CSWO Service Managers Quarter 2 report on today’s agenda and the improvement work will continue as ‘business as usual’ 3. Payment Verification Share this report with Aberdeen City and Shire Integrated Joint Boards ASAP Service Manager (Education Action Complete Item 4. Page 11
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Item No. Title of Report Action Required Due Date Action By Update for 30 January 2025 and Social Care) 4. Q1 Performance Report Information to be provided about the support that is on offer to staff to help improve their wellbeing. 27 June 2024 Sean Coady/ Natalie Jeffrey HSCM is finalising a Health and Safety Delivery Plan, which will be shared at the next APR Committee meeting along with the Workforce delivery plan. 5. Internal Audit Section – Completed Projects Update report and progress delivery plan in relation to the Moray Integrated Community Equipment Store audit to be provided to next meeting. 27 June 2024 Service Manager, Provider Services Report deferred as per discussion with APR Chair / Head of Service and Corporate Manager. To be presented to Committee March 2025 6. Joint Inspection of Services for Children & Young People at Risk of Harm Improvement Action Plan and governance structure chart to be provided to next meeting. 27 June 2024 Head of Service / CSWO Report to be presented to Committee on 30 January 2025 as agreed with Chair Page 12
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 30 JANUARY 2025 SUBJECT: QUARTER 2 (JULY - SEPTEMBER 2024) PERFORMANCE REPORT BY: CORPORATE PROGRAMME MANAGER 1. REASON FOR REPORT 1.1 To update the Committee on performance as at Quarter 2 2024 (July - September). 2. RECOMMENDATION 2.1 It is recommended that the Committee consider, provide comment on and note: i) the performance of local indicators for Quarter 2 (July to September 2024) as presented in the Performance Report at Appendix 1; and ii) the analysis of the local indicators highlighted and actions being undertaken to address performance that is outside of acceptable target ranges as detailed in Appendix 1. 3. BACKGROUND 3.1 The purpose of this report is to ensure the Moray Integration Joint Board (MIJB) fulfils its ongoing responsibility to ensure effective monitoring and reporting on the delivery of services and on the programme of work as set out in its Strategic Plan. 3.2 Appendix 1 identifies local indicators for the MIJB and the functions delegated by NHS Grampian and Moray Council, to allow wider scrutiny by the Board. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 Local Indicators are assessed on their performance via a common performance monitoring Red, Amber, and Green (RAG) traffic light rating system. RAG scoring based on the following criteria: GREEN If Moray is performing better than target. AMBER If Moray is performing worse than target but within agreed tolerance. Item 5. Page 13
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RED If Moray is performing worse than target by more than agreed tolerance. 4.2 The detailed performance report for quarter 2 is attached in Appendix 1. Summary 4.3 Performance within Health and Social Care Moray (HSCM) as demonstrated by the agreed indicators up to the end of quarter 2 of the financial year 2024/25 are shown in figure 1. Three indicators are presenting as green, one is amber and seven are red. This represents a reduced performance compared to quarter 1 2024/25. 4.4 Figure 1 provides a summary and the historical trends. A summary of performance for each of the 6 reporting categories is provided below. EMERGENCY DEPARTMENT - AMBER 4.5 There was a slight increase in the rate per 1,000 this quarter from 21.5 to 22.6. This is below the number presenting at the same period last year and this measure has been maintained around the target since October 2023. DELAYED DISCHARGES – RED 4.6 The number of delays at the September quarter 2 snapshot was up to 44, which is just below a high of 46 in February 2024 and significantly above 26 in September 2023. The figure at the snapshot was the highest point this year and has been reduced, currently sitting around 31, but this figure is subject to fluctuations. 4.7 Bed days lost due to delayed discharges increased to 1,115 this quarter, up from 922 in June 2024, well above 845 in the same period last year. This mirrors the increase in the more volatile snapshot days (DD-01) measure and demonstrates an increasing trend overall in Delayed Discharges over the period. EMERGENCY ADMISSIONS – GREEN 4.8 The rate of emergency occupied bed days for over 65s had a small decrease to 2,603 this quarter and is still down on the high of 2,749 in quarter 4 2022/23. 4.9 The emergency admission rate per 1000 population for over 65s has increased through quarter 2 2023/24 to 189.9 and has now decreased four quarters in a row to 177.7. Similarly, the number of people over 65 admitted to hospital in an emergency also had hit a high of 133.2 in quarter 2 2023/24 and has now decreased to 123.8 in quarter 2 2024/25. HOSPITAL RE-ADMISSIONS - RED 4.10 The 7-day re-admissions have increased above target of 3.7% to 4.6%, and the 28-day re-admissions have increased to above target of 7.9% for 2024/25 to 8.9%. MENTAL HEALTH – RED 4.11 After achieving a low 40% in January 2024 there has been some fluctuation in performance through 2024 which is now sitting at 60% of patients being referred within 18 weeks at the end of quarter 2 2024/25. Page 14
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STAFF MANAGEMENT – RED 4.12 Sickness absence for NHS employed staff has remained high at 6.4% at the end of quarter 2 2024/25. Council employed staff sickness has decreased to 7.3% which is the lowest figure see in the last year. Page 15
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Figure 1 – Performance Summary Note: In order to match other national and local data sources indicators are showing the last month in the reporting quarter. *From May 2022, the census figures for April 2021 onwards include delays due to infection control measures in place at hospital (delay reason codes 26X and 46X) Q2 2324 Q3 2324 Q4 2324 Q1 2425 Q2 2425 Target Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep AE Accident and Emergency AE-01 A&E Attendance rate per 1000 population (All Ages) 23.3 21.8 22.6 21.5 22.6 21.9 A DD Delayed Discharges DD-01 Number of delayed discharges (including code 9) at census point 26 37 43 33 40 26 R DD-02 Number of bed days occupied by delayed discharges (including code 9) at census point 845 1162 1501 922 1115 850 R EA Emergency Admissions EA-01 Rate of emergency occupied bed days for over 65s per 1000 population 2628 2598 2509 2606 2603 2681 G‚ EA-02 Emergency admission rate per 1000 population for over 65s 189.9 188.7 179.9 178.7 177.7 187 G‚ EA-03 Number of people over 65 years admitted as an emergency in the previous 12 months per 1000 population 133.2 132.9 125.8 124.2 123.8 131 G‚ HR Hospital Readmissions HR-01 % Emergency readmissions to hospital within 7 days of discharge 3.9% 3.3% 4.4% 3.6% 4.6% 3.7% R HR-02 % Emergency readmissions to hospital within 28 days of discharge 8.6% 7.9% 8.3% 6.9% 8.9% 7.9% R MH Mental Health MH-01 % of patients commencing Psychological Therapy Treatment within 18 weeks of referral 50% 52% 57% 70% 60% 90% R SM Staff Management SM-01 NHS Sickness Absence (% of hours lost) 5.7% 6.6% 5.7% 7.0% 6.4% 4% R SM-02 Council Sickness Absence (% of days lost) 8.4% 9.6% 9.7% 7.5% 7.3% 4% R Health and Social Care Moray Performance Report Code Barometer (Indicator) RAG Page 16
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5. AREAS NOT MEETING TARGETS Delayed Discharge - Red 5.1 There was an increase in the numbers awaiting discharge at census date to 40 and the number of bed days occupied by delayed discharges was 1115, up from 922 the previous quarter. These figures are reflective of the whole system challenges, which are being managed through a number of initiatives and there are significant efforts being made across many teams to reduce delays. 5.2 Community hospitals have a robust flow process that is managed daily to try to support Dr Grays bed base and ensure people are in the most appropriate place for the care and support they require. There are several reasons why people are delayed, with availability of support in the community remaining a key challenge, especially for people living in rural locations. Recruitment to internal care at home teams has now reached the maximum number of hours available for provision. In the community, the level of unmet need reduced slightly but at the end of September there were still 27 people waiting in hospital and 183 in the community awaiting care packages amounting to 1,473 hours of care. Emergency Department - Amber 5.3 The A&E attendance rate has increased slightly to 22.6 which was the same as quarter 4 in 2023/24. This is reflective of a system that is under pressure and consistent with previous reports regarding the increasing demands and number of patients presenting at the emergency department. There continues to be national and local communications to inform people of options and direct them to alternative sources of urgent medical advice such as pharmacists, opticians and dentists. . Hospital Re-admissions - Red 5.4 The re-admission rate at 7 days had been well below target until this quarter and there was a similar peak in Quarter 2 last year. There is also an increase in re- admission rate at 28 days, which is also following a similar pattern to last year. Delayed Discharge and Flow Mitigation 5.5 Health and social care Moray, as part of NHS Grampian, will be joining a new collaborative initiative Discharge Without Delays (DWD), being facilitated by Health Intelligence Scotland. DWD is a whole system programme for frail older people currently accessing hospital services and will aim to use best practice, individual services and related pathways into an integrated model that will strive to deliver Comprehensive Geriatric Assessments, in a timely manner, whilst ensuring no negative impacts from hospital induced harm or dependency to the individual. 5.6 This is an aspirational model, that will deliver an integrated, multi-disciplinary community model, as early as possible when the frail older person begins to show signs of deterioration, limiting the need for hospital admissions. There has been work being progressed by various parts of our system but this will be the opportunity to utilise learning from other NHS Boards and partnerships to collate progress and develop the integrated model. A robust set of whole system outcomes have been determined and are targeted to be delivered by December 2026. This programme is just being established in NHS Grampian and a report with further details will be submitted to this committee in March. Page 17
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Mental Health - Red 5.7 The percentage of patients commencing Psychological Therapy within 18 weeks in quarter 2 has reduced from 70% in quarter 1 to 60%. 5.8 As reported in quarter 1 there are several factors contributing to the fluctuation in the number of referrals made to the service and the length of time individuals may remain in treatment which, within the existing available capacity to meet need, results in the time spent on the waiting list being extended. 5.9 Adult mental health services continue to meet the HEAT target with 95% of people being seen within 18 weeks at quarter 2. Primary Care psychological therapies service is not currently meeting the HEAT target with only 35% of people being referred being seen within 18 weeks in quarter 2. In adult mental health there has been an increase in the number of people being referred due to the availability of groups. However, given the complexity of some of those referred group, work is not always appropriate for their needs and they would require to wait for 1:1 treatment. The primary care psychological therapies service also offers group sessions in an attempt to reduce waiting times for people. However, as with adult mental health, this is not always appropriate for their needs and people require to wait for appointments for 1:1 sessions to become available. Both adult mental health and primary care psychological therapies have been working alongside Grampian colleagues to look at capacity and demand and job planning has taken place for all staff working in these services to maximise the numbers of appointments that can be offered. However, particularly in primary care, the demand for services significantly outweighs the resource available to deliver this and the position remains challenging. Staff Management - Red 5.10 NHS employed staff sickness absences have decreased from 7% at the end of quarter 1, to 6.4% at the end of quarter 2, with Council employed staff sickness decreasing to 7.3%. These figures remain well above the 4% target for both. 5.11 The most common causes of sickness absence continue to be predominantly mental health or muscular-skeletal injuries and there is support available and provided to staff for health and wellbeing matters and from occupational health where appropriate. Staff Management - mitigation 5.12 A variety of approaches are being taken forward to reduce absences due to stress at work. NHSG is working hard to provide personnel with the tools for resilience, and how to recognise stress. The Council have mental health first aiders for peer to peer support, and the NHS have peer supporters also. NHSG are currently promoting an “at your best with rest” to encourage staff to take breaks, and materials have been shared with the Council as well. To reduce anxiety and stress regarding becoming ill from close contact with people, a number of drop-in vaccination clinics were established to allow staff to get flu and covid vaccinations, in the hope of preventing respiratory illnesses. 5.13 Sickness and attendance is a standing item on our workforce, health and safety partnership meeting agenda. Recent discussions have focussed on how we support those involved, so the policies are not viewed as punitive and are applied consistently and regarded as a supportive measure. There is regular communication about people’s responsibilities, for individuals and for managers, Page 18
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and the next health and safety newsletter will reiterate this. Holiday periods still see to be a period of high absence rates, which may mean that annual leave is not being managed well, so this is an area being reviewed. Performance Framework – development 5.14 Once the strategic delivery plan revision is approved there will be a revision of the performance framework and associated indicators reported to this committee to ensure reporting on the specified outcomes is incorporated. The proposals will be discussed at a future Moray Integration Board development session prior to presenting to this committee. 6. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Moray Partners in Care 2022-2032” Performance management reporting is a legislative requirement under section 42 of the Public Bodies (Joint Working) (Scotland) Act 2014. In addition to publishing an Annual Performance Report, the Moray Integration Scheme requires that the MIJB will “monitor the performance of the delivery of integrated services using the Strategic Plan on an ongoing basis” (para 5.2.2 of the Moray Integration Scheme refers). (b) Policy and Legal None directly associated with this report. (c) Financial implications None directly associated with this report. (d) Risk Implications and Mitigation There are no risk issues arising directly from this report. The long-term impact of the COVID-19 on the Health and Social Care system are still unknown and performance measurement will remain flexible to enable the service to be prepared and react to any future developments. (e) Staffing Implications None directly associated with this report. (f) Property None directly associated with this report. (g) Equalities/Socio Economic Impact An Equality Impact Assessment is not required for the Performance Framework because there will be no impact, as a result of the report, on people with protected characteristics. (h) Climate Change and Biodiversity Impacts No climate change or biodiversity implications have been determined for this policy/activity. It should be noted that extreme weather events, such as the recent storms, are expected to occur more frequently and with greater ferocity in future years. In the longer-term there are likely to be issues with the reduction in availability and increases in costs of fossil fuels that will Page 19
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pose challenges for the delivery of care services to people living in rural areas. (i) Directions There are no directions arising from this report. (j) Consultations Senior Management Team, Operational Management Team Health and Social Care, Caroline O’Connor, Committee Services Officer, Moray Council and their comments are incorporated in the report. 7. CONCLUSION 7.1 This report provides the Committee with an overview of the performance of specified Local indicators and outlines actions to be undertaken to improve performance in Section 4 and expanded on in Appendix 1. Authors of Report: Jeanette Netherwood, Corporate Programme Manager, HSCM Background Papers: Available on request Ref: Page 20
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Appendix 1 PERFORMANCE REPORT SUPPORTING CHARTS QUARTER 2 2024/25 (1 JULY 2024 – 30 SEPTEMBER 2024) Item 5. Page 21
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Table of Contents Health and Social Care Moray - 1 - 2022-23 Quarter 1 Performance Report 1. TABLE OF CONTENTS 1. Table of Contents ............................................................................................................................. 1 1. Performance Summary .................................................................................................................... 2 Barometer Overview ........................................................................................................................... 2 2. Delayed Discharge - RED .................................................................................................................. 3 DD-01: Number of delayed discharges (including code 9, Census snapshot, at end of quarter) ....... 3 DD-02: Number of Bed Days Occupied by Delayed Discharges per quarter (inc code 9) per 1000 18+ population ........................................................................................................................................... 4 3. Emergency Admissions - GREEN ...................................................................................................... 5 EA-01: Rate of emergency occupied bed days for over 65s per 1000 population .............................. 5 EA-02: Emergency Admissions rate per 1000 population for over 65s .............................................. 6 EA-03: Number of people over 65 years admitted as an emergency in the previous 12 months per 1000 population .................................................................................................................................. 7 4. Emergency Department – AMBER .................................................................................................. 8 AE-01: ED Attendance rates per 1,000 population (All Ages) ............................................................. 8 5. Hospital Re-admissions - RED .......................................................................................................... 9 HR-01: Percentage of Emergency Re-admissions to hospital within 7 days - Moray Patients ........... 9 HR-02: Percentage of Emergency Re-admissions to hospital within 28 days - Moray Patients ....... 10 6. Mental Health – RED ..................................................................................................................... 11 MH-01: Percentage of patients commencing Psychological Therapy Treatment within 18 weeks of referral ............................................................................................................................................... 11 7. Staff Management - RED ............................................................................................................... 12 SM-01: NHS Sickness Absence % of Hours Lost ................................................................................ 12 SM-02: Council Sickness Absence (% of Calendar Days Lost) ............................................................ 12 Appendix 1: Key and Data Definitions .................................................................................................. 14 RAG Scoring Criteria .......................................................................................................................... 14 Peer Group Definition ....................................................................................................................... 14 Appendix 2: Strategic Priorities............................................................................................................. 15 Appendix 3: National Health and Wellbeing Outcomes ....................................................................... 17 Page 22
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Performance Summary Health and Social Care Moray - 2 - 2022-23 Quarter 1 Performance Report 1. PERFORMANCE SUMMARY BAROMETER OVERVIEW Moray currently has 11 local indicators. Of these 3 are Green, 1 is Amber and 7 are Red. Figure 1 - Performance Summary Q2 2324 Q3 2324 Q4 2324 Q1 2425 Q2 2425 Target Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep AE Accident and Emergency AE-01 A&E Attendance rate per 1000 population (All Ages) 23.3 21.8 22.6 21.5 22.6 21.9 A DD Delayed Discharges DD-01 Number of delayed discharges (including code 9) at census point 26 37 43 33 40 26 R DD-02 Number of bed days occupied by delayed discharges (including code 9) at census point 845 1162 1501 922 1115 850 R EA Emergency Admissions EA-01 Rate of emergency occupied bed days for over 65s per 1000 population 2628 2598 2509 2606 2603 2681 G‚ EA-02 Emergency admission rate per 1000 population for over 65s 189.9 188.7 179.9 178.7 177.7 187 G‚ EA-03 Number of people over 65 years admitted as an emergency in the previous 12 months per 1000 population 133.2 132.9 125.8 124.2 123.8 131 G‚ HR Hospital Readmissions HR-01 % Emergency readmissions to hospital within 7 days of discharge 3.9% 3.3% 4.4% 3.6% 4.6% 3.7% R HR-02 % Emergency readmissions to hospital within 28 days of discharge 8.6% 7.9% 8.3% 6.9% 8.9% 7.9% R MH Mental Health MH-01 % of patients commencing Psychological Therapy Treatment within 18 weeks of referral 50% 52% 57% 70% 60% 90% R SM Staff Management SM-01 NHS Sickness Absence (% of hours lost) 5.7% 6.6% 5.7% 7.0% 6.4% 4% R SM-02 Council Sickness Absence (% of days lost) 8.4% 9.6% 9.7% 7.5% 7.3% 4% R Health and Social Care Moray Performance Report Code Barometer (Indicator) RAG Page 23
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Delayed Discharge - RED Health and Social Care Moray - 3 - 2022-23 Quarter 1 Performance Report 2. DELAYED DISCHARGE - RED Trend Analysis The number of delays at the September quarter 2 snapshot was up to 44, which is just below a high of 46 in February 2024 and significantly above 26 this time last year. Bed days lost due to delayed discharges increased to 1,115 this quarter up from 922 in June 2024 and well above 845 in the same period last year. This mirrors the increase in the more volatile snapshot days (DD-01) measure and demonstrates that the trend is indeed increasing overall in Delayed Discharges over the period. WDD-01: NUMBER OF DELAYED DISCHARGES (INCLUDING CODE 9, CENSUS SNAPSHOT, AT END OF QUARTER) Purpose Reliably achieving timely discharge from hospital is an important indicator of quality and is a marker for person centred, effective, integrated, and harm free care. Strategic Priority 2: HOME FIRST Linked Indicator(s) DD-02 National Health & Wellbeing Outcomes 2, 3, 5, 7 Figure 2 – Delayed Discharges Indicator Trend – Increasing The number of delayed discharges at census date increased over the last quarter. Source Public Health Scotland Page 24
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Delayed Discharge - RED Health and Social Care Moray - 4 - 2022-23 Quarter 1 Performance Report DD-02: NUMBER OF BED DAYS OCCUPIED BY DELAYED DISCHARGES PER QUARTER (INC CODE 9) PER 1000 18+ POPULATION Purpose This monitors the number of people delayed in hospital once medically fit for discharge. Longer stays in hospital are associated with increased risk of infection, low mood, and reduced motivation. Strategic Priority 2: HOME FIRST Linked Indicator(s) DD-01 National Health & Wellbeing Outcomes 2, 3, 5, 7 Figure 3 – Delayed Discharge Bed-days Indicator Trend – Increasing The number of bed-days lost increased over the last quarter. Source Public Health Scotland Page 25
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Emergency Admissions - GREEN Health and Social Care Moray - 5 - 2022-23 Quarter 1 Performance Report 3. EMERGENCY ADMISSIONS - GREEN Trend Analysis The rate of emergency occupied bed days for over 65s had a small decrease to 2,603 this quarter and is still down on the high of 2,749 in quarter 4 2022/23. The emergency admission rate per 1000 population for over 65s has increased through quarter 2 2023/24 to 189.9 and has now decreased four quarters in a row to 177.7. Similarly, the number of people over 65 admitted to hospital in an emergency also had hit a high of 133.2 in quarter 2 2023/24 and has now decreased to 123.8 in quarter 2 2024/25. EA-01: RATE OF EMERGENCY OCCUPIED BED DAYS FOR OVER 65S PER 1000 POPULATION Purpose EA-01, EA-02, and EA-03 are all interconnected and provide a narrative when viewed together of whether emergency admissions and bed days are within tolerance and indicate where potential risks could arise. Strategic Priority 1: BUILDING RESILIENCE Linked Indicator(s) EA-02, EA-03 National Health & Wellbeing Outcomes 1, 2, 3, 5 Figure 4 – Emergency Occupied Bed-days (Over 65s) Indicator Trend – Steady Despite a month on month increase since December 2023 there has been a steady but small increasing trend which is not significant but could indicate a reversal in the overall decreasing trend since April 2023. Source Health Intelligence Page 26
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Emergency Admissions - GREEN Health and Social Care Moray - 6 - 2022-23 Quarter 1 Performance Report EA-02: EMERGENCY ADMISSIONS RATE PER 1000 POPULATION FOR OVER 65S Purpose EA-01, EA-02, and EA-03 are all interconnected and provide a story when viewed together of whether emergency admissions and bed days are within tolerance and indicate where potential risks could arise. Strategic Priority 1: BUILDING RESILIENCE Linked Indicator(s) EA-01, EA-03 National Health & Wellbeing Outcomes 1, 2, 3, 5 Figure 5 – Emergency Admissions (Over 65s) Indicator Trend – Decreasing After a small decrease in this measure in December 2023 the last three quarters saw a continuing decrease in this measure. Source Health Intelligence Page 27
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Emergency Admissions - GREEN Health and Social Care Moray - 7 - 2022-23 Quarter 1 Performance Report EA-03: NUMBER OF PEOPLE OVER 65 YEARS ADMITTED AS AN EMERGENCY IN THE PREVIOUS 12 MONTHS PER 1000 POPULATION Purpose EA-01, EA-02, and EA-03 are all interconnected and provide a story when viewed together of whether emergency admissions and bed days are within tolerance and indicate where potential risks could arise. Strategic Priority 1: BUILDING RESILIENCE Linked Indicator(s) EA-01, EA-02 National Health & Wellbeing Outcomes 1, 2, 3, 5 Figure 6 – Number of Over 65 People Emergency Admissions Indicator Trend – Decreasing After a small decrease in this measure in December 2023 the last three quarters saw a continuing decrease in this measure. Source Health Intelligence Page 28
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Emergency Department – AMBER Health and Social Care Moray - 8 - 2022-23 Quarter 1 Performance Report 4. EMERGENCY DEPARTMENT – AMBER Trend Analysis There was an increase in the rate per 1,000 this quarter to 22.6. This is still below the number presenting at the same period last year. This measure has been trending steadily around the target since October 2023. AE-01: ED ATTENDANCE RATES PER 1,000 POPULATION (ALL AGES) Purpose A greater system-wide understanding of how people access emergency care, and why certain choices are made, will allow local health systems to develop intelligence about avoidable attendances at emergency departments and target their responses. Strategic Priority 3: PARTNERS IN CARE Linked Indicator(s) HR-01, HR-02 National Health & Wellbeing Outcomes 1, 2, 3, 5 Figure 7 – ED Attendance Rate Indicator Trend – Stable During quarter 2 the attendance rate per 1,000 population has remained stable, sitting just above the target level. Source Health Intelligence Page 29
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Hospital Re-admissions - RED Health and Social Care Moray - 9 - 2022-23 Quarter 1 Performance Report 5. HOSPITAL RE-ADMISSIONS - RED Trend Analysis The 7-day re-admissions have increased to above target to 4.6%, and the 28-day re-admissions have decreased further to well above target at 8.9%. HR-01: PERCENTAGE OF EMERGENCY RE-ADMISSIONS TO HOSPITAL WITHIN 28 DAYS - MORAY PATIENTS Purpose Re-admissions are often undesirable for patients and have also been shown to be associated with the quality of care provided to patients at several stages along the clinical pathway, including during initial hospital stays, transitional care services and post-discharge support. (This measure lags by a month due to the time required for a potential 28 day discharge to occur) Strategic Priority 1: BUILDING RESILIENCE Linked Indicator(s) HR-02, AE-01 National Health & Wellbeing Outcome 1, 2, 3, 5 Figure 8 – 7-dayEmergency Readmissions Indicator Trend – Stable 7-day Hospital Re-admissions have generally remained around the target of 3.7% for the last four quarters, only having the odd month above target. Source Health Intelligence Page 30
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Hospital Re-admissions - RED Health and Social Care Moray - 10 - 2022-23 Quarter 1 Performance Report HR-02: PERCENTAGE OF EMERGENCY RE-ADMISSIONS TO HOSPITAL WITHIN 7 DAYS - MORAY PATIENTS Purpose Re-admissions are often undesirable for patients and have also been shown to be associated with the quality of care provided to patients at several stages along the clinical pathway, including during initial hospital stays, transitional care services and post-discharge support. Strategic Priority 1: BUILDING RESILIENCE Linked Indicator(s) HR-01, AE-01 National Health & Wellbeing Outcome 1, 2, 3, 5 Figure 9 – 28-day Emergency Readmissions Indicator Trend – Increasing 28-day Hospital Re-admissions have increased significantly over the quarter. Source Health Intelligence Page 31
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Mental Health – RED Health and Social Care Moray - 11 - 2022-23 Quarter 1 Performance Report 6. MENTAL HEALTH – RED Trend Analysis After achieving a low 40% in January 2024 there has been little variation in performance through 2024 with now 60% of patients being referred within 18 weeks at the end of quarter 2 2024/25. MH-01: PERCENTAGE OF PATIENTS COMMENCING PSYCHOLOGICAL THERAPY TREATMENT WITHIN 18 WEEKS OF REFERRAL Purpose Timely access to healthcare is a key measure of quality and that applies equally in respect of access to mental health services. Strategic Priority 3: PARTNERS IN CARE Linked Indicator(s) National Health & Wellbeing Outcome 1, 2, 3, 5 Figure 10 – Psychological Therapy Treatment within 18 Weeks Indicator Trend – Steady but low The short term monthly trend tends towards just under 60% in this measure in the last year. Source Health Intelligence Page 32
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Staff Management - RED Health and Social Care Moray - 12 - 2022-23 Quarter 1 Performance Report 7. STAFF MANAGEMENT - RED Trend Analysis Sickness absence for NHS employed staff has remained high at 6.4% at the end of quarter 2 2024/25. Council employed staff sickness has decreased to 7.3% which is the lowest figure see in the last year. SM-01: NHS SICKNESS ABSENCE % OF HOURS LOST Purpose Attendance at work of all employees is essential in the interests of the effective and efficient operation of services. Strategic Priority 1: BUILDING RESILIENCE Linked Indicator(s) SM-02 National Health & Wellbeing Outcome 8 Figure 11 – NHS Sickness Absence Indicator Trend – Steadily increasing This indicator has been varying but steadily increasing since early 2022. Source Health Intelligence SM-02: COUNCIL SICKNESS ABSENCE (% OF CALENDAR DAYS LOST) Purpose Attendance at work of all employees is essential in the interests of the effective and efficient operation of services. Strategic Priority 1: BUILDING RESILIENCE Linked Indicator(s) SM-01 National Health & Wellbeing Outcome 1, 2, 3, 5 Page 33
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Staff Management - RED Health and Social Care Moray - 13 - 2022-23 Quarter 1 Performance Report Figure 12 – Moray Council Sickness Absence Indicator Trend – Decreasing but high This indicator been on a steady decrease but is still above target. Source Council HR Page 34
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Staff Management - RED Health and Social Care Moray - 14 - 2022-23 Quarter 1 Performance Report APPENDIX 1: KEY AND DATA DEFINITIONS RAG SCORING CRITERIA GREEN If Moray is performing better than target. AMBER If Moray is performing worse than target but within specified tolerance. RED If Moray is performing worse than target but outside of specified tolerance. PEER GROUP DEFINITION Moray is defined as being in Peer Group 2 in the Local Government Benchmarking Framework Family Group 1 Family Group 2 Family Group 3 Family Group 4 East Renfrewshire East Dunbartonshire Aberdeenshire Edinburgh, City of Perth & Kinross Aberdeen City Shetland Islands Orkney Islands Moray Stirling East Lothian Angus Scottish Borders Highland Argyll & Bute Midlothian Falkirk Dumfries & Galloway Fife South Ayrshire West Lothian South Lanarkshire Renfrewshire Clackmannanshire Eilean Siar Dundee City East Ayrshire North Ayrshire North Lanarkshire Inverclyde West Dunbartonshire Glasgow City Page 35
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Staff Management - RED Health and Social Care Moray - 15 - 2022-23 Quarter 1 Performance Report APPENDIX 2: STRATEGIC PRIORITIES Page 36
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Staff Management - RED Health and Social Care Moray - 16 - 2022-23 Quarter 1 Performance Report •EA-01: RATE OF EMERGENCY OCCUPIED BED DAYS FOR OVER 65S PER 1000 POPULATION •EA-02: EMERGENCY ADMISSIONS RATE PER 1000 POPULATION FOR OVER 65S •EA-03: NUMBER OF PEOPLE OVER 65 YEARS ADMITTED AS AN EMERGENCY IN THE PREVIOUS 12 MONTHS PER 1000 POPULATION •HR-01: PERCENTAGE OF EMERGENCY RE-ADMISSIONS TO HOSPITAL WITHIN 28 DAYS -MORAY PATIENTS •HR-02: PERCENTAGE OF EMERGENCY RE-ADMISSIONS TO HOSPITAL WITHIN 7 DAYS -MORAY PATIENTS •SM-01: NHS SICKNESS ABSENCE % OF HOURS LOST •SM-02: COUNCIL SICKNESS ABSENCE (% OF CALENDAR DAYS LOST) BUILDING RESILIENCE •DD-01: NUMBER OF DELAYED DISCHARGES (INCLUDING CODE 9, CENSUS SNAPSHOT, AT END OF QUARTER) •DD-02: NUMBER OF BED DAYS OCCUPIED BY DELAYED DISCHARGES PER QUARTER (INC CODE 9) PER 1000 18+ POPULATION •UN-01: NUMBER OF LONG-TERM HOME CARE HOURS UNMET AT WEEKLY SNAPSHOT •UN-02: NUMBER OF PEOPLE WITH LONG-TERM CARE HOURS UNMET AT WEEKLY SNAPSHOT HOME FIRST •OA-01: NUMBER OF REVIEWS OUTSTANDING AT END OF QUARTER SNAPSHOT •MH-01: PERCENTAGE OF PATIENTS COMMENCING PSYCHOLOGICAL THERAPY TREATMENT WITHIN 18 WEEKS OF REFERRAL •AE-01: A&E ATTENDANCE RATES PER 1000 POPULATION (ALL AGES) PARTNERS IN CARE Page 37
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Staff Management - RED Health and Social Care Moray - 17 - 2022-23 Quarter 1 Performance Report APPENDIX 3: NATIONAL HEALTH AND WELLBEING OUTCOMES 1 - PEOPLE ARE ABLE TO LOOK AFTER AND IMPROVE THEIR OWN HEALTH AND WELLBEING AND LIVE IN GOOD HEALTH FOR LONGER. 2 - PEOPLE, INCLUDING THOSE WITH DISABILITIES OR LONG-TERM CONDITIONS, OR WHO ARE FRAIL; ARE ABLE TO LIVE, AS FAR AS REASONABLY PRACTICABLE, INDEPENDENTLY AT HOME, OR IN A HOMELY SETTING IN THEIR COMMUNITY. 3 - PEOPLE WHO USE HEALTH AND SOCIAL CARE SERVICES HAVE POSITIVE EXPERIENCES OF THOSE SERVICES, AND HAVE THEIR DIGNITY RESPECTED. 4 - HEALTH AND SOCIAL CARE SERVICES ARE CENTRED ON HELPING TO MAINTAIN OR IMPROVE THE QUALITY OF LIFE OF PEOPLE WHO USE THOSE SERVICES. 5 - HEALTH AND SOCIAL CARE SERVICES CONTRIBUTE TO REDUCING HEALTH INEQUALITIES. 6 - 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. 7 - PEOPLE USING HEALTH AND SOCIAL CARE SERVICES ARE SAFE FROM HARM. 8 - 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. 9 - RESOURCES ARE USED EFFECTIVELY AND EFFICIENTLY IN THE PROVISION OF HEALTH AND SOCIAL CARE SERVICES. Page 38
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 30 JANUARY 2025 SUBJECT: QUARTER 2 (JULY TO SEPTEMBER) PERFORMANCE REPORT FOR CHILDREN AND FAMILIES AND JUSTICE SOCIAL WORK BY: INTERIM CHIEF SOCIAL WORK OFFICER/HEAD OF SERVICE 1. REASON FOR REPORT 1.1 To inform the Committee on Children and Families and Justice Social Work performance as at Quarter 2. 2. RECOMMENDATIONS 2.1 It is recommended Committee scrutinise, comment, and note: i) the performance of local indicators for Quarter 2 as presented in the Performance Report at Appendix 1; and ii) the analysis of the local indicators as detailed in Appendix 1. 3. BACKGROUND 3.1 The purpose of this report is to inform the Committee of the quarterly performance data which provides the analysis of the delivery of Children, Families and Justice Social Work services. 3.2 Appendix 1 identifies local indicators for the Moray Integration Joint Board and the functions delegated by NHS Grampian and Moray Council of Children, Families and Justice Social Work services to allow wider scrutiny by the Committee. 4. SUMMARY 4.1 Work is underway to develop and agree the refresh of our key performance indicators to enable us to record local data and measure this against the national performance indicators. 4.2 Appendix 1 provides a summary and the historical trends. • Child Protection activity • Looked after Children • Justice and Youth Justice Item 6. Page 39
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4.3 Statistics for Child Protection activity are provided against the academic calendar which runs from August to July annually. This is because this data is gathered and analysed by the Children Services Partnership and reported to the Child Protection Committee (CPC) through the Child Protection Minimum Data Set. Appendix 1 begins with Child Protection Q4 from page 1 to 10, Financial Q2 data is from page 11 to 24. Any trends or anomalies in this data are considered through the CPC Data subgroup and reported accordingly. 4.4 Statistics for Looked After Children, Justice and Youth Justice are reflected across the financial calendar which runs from April to March which is the reporting calendar for this data. A summary of performance for each of the reporting categories is provided below. 4.5 Child Protection activity a. At the end of this Child Protection (CP) Quarter 4, 66 children were registered on the Northeast Child Protection Register (NECPR) at a rate of 3.7 per 1,000 of 0–17-year-olds within the population. The national and comparator data will be available at the end of the CP year (after August 2025) which will enable us to benchmark our data at that point. 4.6 Looked After Children a. At the end of Financial (Fin) Quarter 2, the number of looked after children (175) was 9.9 per 1,000 of 0–17-year-olds within the population (total: 17,668). This is lower than the national average which is 12.3 based on the most recent comparator statistics which date from 2022-23. This figure includes 9 Unaccompanied Asylum-Seeking Children (UASC) and 6 children who are cared for on a part time basis (Short Breaks). b. 90% (47/54) of children in foster care are cared for by Moray Council foster carers. The Carer Recruitment Campaign continues to focus on recruitment of foster carers and supported lodgings carers. Resultantly, there has been an improved ability to have children and young people cared for by Moray Council foster carers. Thus, reducing the need to purchase external agency care. The Carer Recruitment Campaign is continuing where it is anticipated that the use of in-house carers will increase. c. The target for children living with kinship carers is adjusted annually to the median of comparator authorities which was 25.1% for 2021/22 (this is a more than target based on the assumption Kinship care is preferable, where it is safe and appropriate, to non-family care). Currently 24% of looked after children in Moray are in approved Kinship care with family members. Moray is currently 0.1% below this median. d. 16% of our Looked After Children are cared for in residential care. The target for this indicator (this is a less than target based on the assumption foster care and kinship care is the preferred option, when it is safe and appropriate, where possible) is adjusted annually to the median of comparator authorities (17.5% 2022/23). This figure includes Page 40
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6 young people who are cared for on a part time (Short Breaks) basis. For illustrative purposes on performance, excluding those who have Short Breaks, (children and young people who are in the care of their families) the figure is 13% which is 5.5% lower than the National comparator median. Overall, Moray is 1.5% lower than the National comparator. e. 90% of brothers and sisters remain together in care settings. The Maintaining Relationships Project is developing an approach and policy to ensure that brothers and sisters are able to remain together as far as possible and where this is their assessed needs. f. For UASC, Moray has not adopted the model used by other local authorities of using residential homes. The Moray model comprises of a combination of local authority housing and supported lodgings care settings. As such, the uncertainty regarding the future numbers of UASC should not have an impact on residential care capacity for Moray. g. Statistically it is difficult to ascertain how other authorities record their numbers as the level of detail is not readily available. While nationally significant, the numbers of looked after children are comparatively small which can provide significant percentage variance. An example of this is that in Moray, all UASC and Short-term breaks are included within our Looked After numbers. The service is aware not all comparator authorities do this and is currently undertaking an exercise to consider what our comparator authorities record. 4.7 Justice and Youth Justice a. At the end of Financial (Fin) Quarter 2, there were 502 people open to Justice Services of whom 36 are care experienced young people (CEYP) (Youth Justice 12 and Justice 24). b. Overall, the number of CEYP in both Justice Social Work and Youth Justice has been on a reducing trend from 13% at the end of March 2021 to 7.2% at the end of Fin Quarter 2. Work continues to identify and support care experienced young people within these services, to offer early support where possible and reduce the risk of re-offending. c. The majority of individuals supported by Youth Justice and Justice Social Work are male (87% Justice Social Work, 93% Youth Justice). Gender responsive support is offered to females taking account of research and data indicating women in the justice system are more likely to have experienced trauma and more likely to be a sole carer for a child or family member. d. The Justice Social Work Service submitted 100% of reports to Court by their due date. This includes requests from our local Court and nationally. 5. KEY MATTERS RELEVANT TO RECOMMENDATION 5.1 Detailed charts and indicator data is attached in Appendix 1. Page 41
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6. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” This report notes that a review of key performance indicators is currently being developed in respect of the wider service functions that will align with key priority areas across the Children’s Services partnership. (b) Policy and Legal None arising as a direct result of this report. (c) Financial implications None arising as a direct result of this report. (d) Risk Implications and Mitigation None arising as a direct result of this report. (e) Staffing Implications There are no proposed changes to the staffing or reporting relationships. (f) Property None arising as a direct result of this report. (g) Equalities/Socio Economic Impact None arising as a direct result of this report. (h) Climate Change and Biodiversity Impacts None arising as a direct result of this report. (i) Directions None arising as a direct result of this report. (j) Consultations Children and Families and Justice Social Work Senior Management Team, HSCM Operational Management Team (OMT). 7. CONCLUSION 7.1 This report provides the Committee with an overview of the performance of specified local and National indicators. Author of Report: Jim Lyon, Interim Chief Social Work Officer/Head of Service Background Papers: Appendix 1 Page 42
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APPENDIX 1 1 | P a g e CHILDRENS AND JUSTICE SOCIAL WORK - QUARTER 2 (JULY-SEPT 2024) PERFORMANCE REPORT PLEASE NOTE THIS REPORT IS SPLIT INTO TWO SECTIONS. THE FOLLOWING SECTION USES THE ACADEMIC CALENDAR (1 AUG – 31 JULY). THE INFORMATION PRESENTED REPRESENTS CP QUARTER 4 WHICH IS LATEST AVAILABLE DATA (MAY TO JULY 24). At the end of the CP Quarter 4, 621 referrals were made into the Access Team for 478 children (as per graph 1). Graph 1: CP Quarter 4 - Referrals received by Access Team The potential referral routes are Social Work, SCRA, Police, Courts, Education, Health, 3rd Sector, community, family and young person. When a referral has been received it can be categorised as: IRD – immediate child protection concerns. Enquiry – information gathering to determine next steps (if any). Assessment – team will conduct an initial assessment of needs. Pie chart 1: Sources of referral 224 182 215 174 149 155 0 50 100 150 200 250 May-24 Jun-24 Jul-24 Referrals No of referrals in last month No of children Item 6. Page 43
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APPENDIX 1 2 | P a g e In CP Quarter 4, 47.3% of the referrals were made by the Police (294), followed by Education 11.1% (69), Health and Social Work 16.6% (103), Family and or Anonymous 14.5% (90), and 10.5% coming from other professionals (65) (as per pie chart 1). Where the number of referrals are higher than the number of children, this can be attributed to the fact there can be multiple sources of referrals about a child (e.g. Health, Education and Police). This potentially reflects consistent thresholds across the partnership. Initial Referral Discussions (IRDs) are a multi-agency decision making forum where information is shared and considered between partnership representatives regarding potential or actual risk of harm to children and young people. We have been working with our partner agencies to more robustly apply the criteria for IRDs, for example, where families are supported by a Social Worker, then we hold a relevant meeting which involves the family and young person, rather than professionals only. This is a likely explanation for a reduction in IRD numbers from CP Quarter 1 to CP Quarter 4. Graph 2: IRDs and number of children subject to an IRD Graph 2 shows the quarterly trend in IRDs (between 1 Aug 2023 and 31 July 2024). In CP Quarter 4, 84 children were involved in 47 IRDs. Of the 84 children, 21 had been subject to two or more IRDs in the past (25%). For each quarter, the number of children is greater than the number of IRDs as each IRD can consider multiple children within a family. Most referrals for IRDs in CP Quarter 4 came from the Police (46.4% [39]), closely followed by Social Work (39.3% [33]). The IRD process determines the most suitable pathway for the child to ensure their safety and any support required. An IRD can consider initiating a Child Protection Planning Meeting, which deliberates the child’s name being placed on the North-East Child Protection Register (NECPR/CPR/Register). 66 65 63 47 125 105 89 84 0 20 40 60 80 100 120 140 Q1 Q2 Q3 Q4 IRDs No. of IRDs since 1 Aug No. of children since 1 Aug Page 44
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APPENDIX 1 3 | P a g e Pie chart 2: Main reasons for IRD As per chart above, throughout CP Quarter 4, physical assault remains a consistent reason for an IRD being held (26, 55%), followed by sexual assault (24, 51%) domestic abuse (11, 23%) and other reason (this includes cumulative neglect) (12, 25%). We are interested to consider over a period whether there is any impact for the reasons an IRD is convened in relation to the delivery of the following training, Safe and Together and Graded Care Profile, which is still being delivered. Pie chart 3: Child protection concerns During CP Quarter 4, Domestic Abuse, Child affected by parent/carer mental ill health and Parental Drug Use remain the main child protection concerns. *Note there may be more than one concern documented for each child* Joint consideration with adult mental health services is required to see if there can be any further support and developments in this area for reporting next quarter. Page 45
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APPENDIX 1 4 | P a g e Following the IRDs, 31 Child Protection Investigations were carried out, 7 Initial Child Protection Planning Meetings were convened, and 26 Joint Investigative Interviews were requested. From 31 Child Protection Investigations (31 children) this resulted in only 7 Initial Child Protection Planning Meetings and the families that did not progress to this had actions closed following support from social work, or social work requested a commissioned service. We have been working with the child protection lead in education to support more robust child planning processes and understanding of significant harm, e.g. a Senior Social Worker will attend future Education Child Protection Coordinator Network meetings. Graph 3: Joint Investigative Interviewing Graph 3 shows the trend across the year 2023/24 for joint investigative interviews and Scottish Child Investigative Interviews. 16 26 9 12 12 9 13 7 7 13 10 413 22 8 11 9 6 13 7 7 13 9 4 3 4 1 1 3 0 0 0 0 0 1 0 0 2 4 6 8 10 12 14 16 18 0 5 10 15 20 25 30 Aug-23 Sep-23 Oct-23 Nov-23 Dec-23 Jan-24 Feb-24 Mar-24 Apr-24 May-24 Jun-24 Jul-24 JII and Scottish Child Interview Model No. of children subject to a JII as decision of IRD No. of JII - SCIM No. of JII - 5 - day No. of children who declined/or did not complete JII No. of SCIM JIIs undertaken Page 46
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APPENDIX 1 5 | P a g e Graph 4 – JII & SCIM Graph 4 shows the activity of Joint Investigative Interviewing across CP Quarter 4, during which 27 children were recommended for Joint Investigative Interview (JII); 22 interviews were completed and five children either declined or a different form of interview was carried out. The Social Work Data Group, chaired by a Service Manager, will track physical assaults across CP Quarter 4, from IRD to JII considering intervention and support, safety planning and outcomes for the children and young people. Graph 5: Initial Child Protection Planning Meetings Graph 5 shows the trend across the last three reporting years (2021-2024) for the number of Initial and Pre-birth Child Protection Planning Meetings, and the number of children. The number of children subject to CPPMs is higher than the number of meetings held, due to some meetings considering sibling groups. 13 10 4 13 9 4 0 1 02 2 1 11 8 3 13 9 4 0 2 4 6 8 10 12 14 May-24 Jun-24 Jul-24 JIIs using SCIM No. of children subject to a JII as decision of IRD No. of JII - SCIM No. of JII - 5 - day No. of children who declined/or did not complete JII No. of SCIM JIIs undertaken How many JIIs used SCIM Page 47
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APPENDIX 1 7 | P a g e The high numbers in CP Quarter 1 and CP Quarter 2 can be attributed to large numbers of children within a small number of families. At the end of CP Quarter 4, 7 Initial and Pre-birth Child Protection Planning Meetings were held for 12 children of these, 9 children’s names were place on the register. Graph 6: Conversions from IRD to ICCPM Graph 6 above shows the trend from 2020 through to 2024 and specifically CP Quarter 4, where the conversion rate from ICPPM to Child Protection Registration was 75%. 13 20 28 30 8 18 16 25 8 10 22 18 25 39 19 14 75 78 100 76 100 77 94 91 75 73 45 78 78 83 94 75 0 20 40 60 80 100 120 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Aug- Oct Nov- Jan Feb- Apr May- Jul Aug- Oct Nov- Jan Feb- Apr May- Jul Aug- Oct Nov- Jan Feb- Apr May- Jul Aug- Oct Nov- Jan Feb- Apr May- Jul 2020/21 2021/22 2022/23 2023/24 Conversion Rates % IRD to Initial and Pre-Birth CPPMs % Initial and Pre-Birth CPPMs to Registration The conversion rate from referral to IRD is 7.6% The conversion rate from IRD to CPI is 65% Conversion rate from CPI to ICPPM is 38.7% Page 49
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APPENDIX 1 8 | P a g e During CP Quarter 4, there were 20 Review Child Protection Planning Meetings (RCPPM) held for 44 children, where their circumstances were reviewed with their families, lead professionals and advocates, to assess if the identified risks had been sufficiently reduced to consider removing the child’s name from the register. Graph 7: Child Protection Registration Trends The trend is depicted across Graph 7 from 2021-2024 and shows in CP Quarter 4, that 13 children were de-registered and 9 new children were registered. This meant at the end of CP Quarter 4, the number of children who were on the Child Protection Register (CPR) had reduced by 4 (from 70 to 66). 5 10 15 21 6 8 9 14 25 34 16 9 31 35 44 50 42 37 27 32 50 79 70 66 9 6 6 15 14 13 20 9 9 5 25 13 0 10 20 30 40 50 60 70 80 90 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Aug-Oct Nov-Jan Feb-Apr May-Jul Aug-Oct Nov-Jan Feb-Apr May-Jul Aug-Oct Nov-Jan Feb-Apr May-Jul 2021/22 2022/23 2023/24 Child Protection Register Number of Registrations Number on Register Number of De-Registrations Page 50
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APPENDIX 1 9 | P a g e Pie chart 4: CP Quarter 4 registration reasons Graph 8: Registration Categories Graph 8 above indicates the trend in registration categories across the reporting period (from August 2023 to July 2024). There has been a significant reduction in new registrations for the category Child affected by parental mental ill-health, with figures showing a reduction from 8 new registrations in CP Quarter 3 (Feb 2024 – Apr 2024) to 0 in CP Quarter 4 (May 2024 – July 2024). New Reg Concern: Domestic Abuse, 4, 23% New Reg Parental Alcohol Use, 3, 18% New Reg Concern: Parental Drug Use, 2, 12% New Reg Concern: Physical Abuse, 1, 6% New Reg Concern: Emotional Abuse, 4, 23% New Reg Concern: Other Concern, 3, 18% CP Q4 REGISTRATION REASONS 3 1 8 6 8 1 7 11 4 43 5 3 33 16 1 23 1 1 5 5 4 1 8 9 2 4 2 3 0 2 4 6 8 10 12 14 16 18 Q1 Q2 Q3 Q4 Registration Categories Services find it hard to engage Child Affected by Parent/Carer Mental Ill-Health Child experiencing mental health problems Domestic Abuse Parental Alcohol Use Parental Drug Use Physical Abuse Emotional Abuse Criminal Exploitation Neglect Other Concern Page 51
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APPENDIX 1 10 | P a g e 37% of IRDs was for the category sexual abuse which does not follow through to registration reasons because the majority were not familial and were more due to experiences of sexual abuse from a peer, where the family are supportive and assessed as able to protect the young people. 45% of IRDs was for physical abuse which does not follow through to registration reasons as most physical assaults were from parents struggling with their parenting role, and with appropriate support to families, child protection plans were not necessary. Graph 9: Family Groups As shown in Graph 9, at the end of CP Quarter 4, there were 13 family groups consisting of one child, 8 family groups with 2 children and 10 family groups of 3 or more children on the register. Graph 10: Previous Registrations 25 8 0 5 10 15 20 25 30 Jul-24 Previous Registrations No. of children with 1 previous registration No. of children with more than 2 previous registration Page 52
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APPENDIX 1 11 | P a g e At the end of the CP Quarter 4, there were 25 children on the register who had 1 previous registration and 8 with 2 or more previous registrations. No child or young person’s name was placed back on the register within 24 months of de-registration (as indicated in Graph 10). Graph 11: Time on NECPR Graph 12: Age of children on the register Graph 12 shows the trend for 2023/24 against CP Quarter 4 data where all age categories have remained consistent with only a slight fluctuation throughout the Quarter. The number of young people aged 16 years old has remained static since December 2023. 42 15 10 1 0 34 21 5 6 0 22 32 6 5 1 <6 months 6 mths < 1 year 1 year < 18 mths 18 mths < 2 years > 2 years Time on the NECPR Jul-24 Jun-24 May-24 Page 53
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APPENDIX 1 13 | P a g e THE FOLLOWING SECTIONS REPORT AGAINST THE FINANCIAL QUARTER (JULY-SEPT 2024) Graph 13: Number of children looked after away from home and at home Graph 13 identifies that at the end of Financial (Fin) Quarter 2, there were 175 children who were looked after by Moray. This figure has remained relatively stable throughout the reporting period. Pie chart 5: Care setting categories At the end of Fin Quarter 2, 47% of children were in family settings at home or in kinship care with 53% in other settings such as foster care or residential homes. This is a positive indication that many looked after children can remain within their network of family and friends. Alongside this, 90% of siblings remain together in a care setting. Siblings who are not together are because of family circumstances or assessed needs. There is planned work via the Maintaining Relationships Project to sustain and increase the percentage of siblings remaining together in care settings in line with the Children’s Service Plan. Foster care (54) and kinship care (44) are the highest categories followed by children looked after at home (38). Our residential houses (10) remain at approximately the same level as the Out of Area residential category (11). The carer recruitment campaign has seen new 176 178 185 187 183 180 182 172 172 177 179 175 173 175 160 165 170 175 180 185 190 Aug-23 Sep-23 Oct-23 Nov-23 Dec-23 Jan-24 Feb-24 Mar-24 Apr-24 May-24 Jun-24 Jul-24 Aug-24 Sep-24 No. of Looked After Children Page 55
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APPENDIX 1 14 | P a g e foster carers approved to support young people remaining in Moray in family care settings. A significant majority of young people are in family-based care rather than residential care. At the end of Fin Quarter 2, 12% of our looked after children were cared for on a full-time basis in residential accommodation. If short breaks are included the figure increases to 14.8%. The indicator (to be kept within or lower) is adjusted annually to the median of comparator authorities (17.5% 2022/23). As such, Moray is below the median indicator when considering full-time care on its own and including short breaks. This highlights in Moray there is a priority to support young people in family-based care, where possible, to provide a positive model of family life. One young person was placed in secure care from November 2023 on remand at the direction of the Court. This aligns with the recent changes in Justice legislation for children under 18 where they are remanded into the care of local authorities rather than Young Offenders Institutions. Moray hosts a group of 10 young people who are Unaccompanied Asylum-Seeking children and young people via the National Transfer Scheme. These children and young people are allocated to the Throughcare and Aftercare Team by the Home Office and are counted as looked after children to ensure they receive full support. Initially, these young people are in Supported Lodgings care settings or Supported Accommodation. The team continues to successfully support them to move into their own independent housing once they have been granted asylum. The approach adopted by Moray is seen by COSLA as a model of good practice as it offers flexibility and has an ability to respond to the differing needs of young people. Graph 14: Moray foster care households At end of Fin Quarter 2 there were 54 children living in foster care, with 48 (89%) children living with foster carers employed by Moray Council and six (11%) living with independent 28 36 37 37 36 35 27 25 25 28 31 0 5 10 15 20 25 30 35 40 36 Q2 Q3 Q4 Q1 Q2 Q1 2023/24 2023/24 2023/24 2024/25 2024/25 Moray Foster Care Number of Moray Council Fostering households Number of Moray Council Foster Carers with “Active” placements at the end of the period Page 56
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APPENDIX 1 15 | P a g e foster carers. Those young people living with independent foster carers are all in long-term care with Permanence Orders. Not all fostering households have children living in their care. At the end of Fin Quarter 2 this comprises four in total. This is a small number due to family circumstances or matching considerations of their registration approval where foster carers are inactive for a short period of time. Graph 15: Children who live in foster care Graph 16 identifies the number of children cared for by Moray foster carers, 48 which is an increase from Fin Quarter 2 in 2023 which was 43. However, this includes some quarterly fluctuations where the pattern is relatively stable. The number of approved Moray foster carer households available for children has seen a small decrease. Although the carer recruitment campaign is resulting in new fostering households, this is balanced by other foster households ceasing or changing the type of fostering they provide. The challenge in recruiting and retaining foster carers is both a local and national issue. The carer recruitment campaign is significant in recruiting foster carers where this is also accompanied by work in relation to retention. This is focused on the support provided to foster carers including supervision, training and finances. Foster carers are graded by the level of skills learned and developed, ranging from Level 1 to Level 4 being the highest. 44 43 45 47 45 48 46 45 47 46 51 51 50 48 11 11 7 7 7 7 7 6 6 6 6 6 6 6 0 10 20 30 40 50 60 Children in Foster Care Local Authority Foster Care Foster with other orgs paid for by Local Authority Page 57
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APPENDIX 1 16 | P a g e Graph 16: Kinship carers Kinship care is split into two groups: pre-approved kinship homes awaiting presentation at the Kinship Panel for approval and kinship households already approved at Panel. Graph 17: Residential care Residential care is divided into those in residential care within Moray and those out with Moray. Children cared for within Moray live in the authority's own children’s houses, Cala and Action for Children’s two houses in Buckie and Elgin. The figure for this category is 10. 30 32 29 31 32 30 29 30 31 29 29 29 29 28 30 29 26 26 32 34 32 31 30 32 33 32 32 31 10 14 14 16 11 7 9 10 12 9 7 8 8 8 0 5 10 15 20 25 30 35 40 Aug-23 Sep-23 Oct-23 Nov-23 Dec-23 Jan-24 Feb-24 Mar-24 Apr-24 May-24 Jun-24 Jul-24 Aug-24 Sep-24 Kinship Care Settings No. of households providing Kinship Placements No. of Children in Approved Placements No. of Children in Pre-Approved Placements 13 14 14 14 13 12 13 12 12 13 13 12 11 10 11 11 11 11 11 11 11 10 10 11 11 9 9 11 0 2 4 6 8 10 12 14 16 Aug-23 Sep-23 Oct-23 Nov-23 Dec-23 Jan-24 Feb-24 Mar-24 Apr-24 May-24 Jun-24 Jul-24 Aug-24 Sep-24 Residential Care Placement: Residential in Moray Placement: Out of Area Page 58
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APPENDIX 1 17 | P a g e Out of area care tends to be specialist residential houses or residential schools. There has been a consistent focus on providing this care in Moray where possible, so children remain close to their families and support network. The figure for this category is 11. There is work in place to reduce the number of young people in Out of Area care. These are expensive care options but also do not support young people in maintaining their various links in Moray including health, education, family and friends. Graph 18: Through care after care data As illustrated in Graph 18, from 30 September 2024, there were 75 young people receiving care from the Through Care After Care (TCAC) Team including nine receiving continuing care support. The team is divided into three sections: • Through Care: Young people receiving support to plan and prepare for independence. • After Care: Young people who have left care but are receiving continuing support. • Continuing Care: Young people who choose to remain where they live beyond their 18th birthday until they are 21 although it can be in place from 16. These young people cease to be formally looked after by Moray but are legally entitled to continue living where they are. This provides stability in a familiar and nurturing setting. There is a focus on continuing care to ensure young people in different care settings are all provided the opportunity to remain where they are living potentially up until the age of 21. This is a key responsibility for the organisation and partners as corporate parents. The team is responsible for supported unaccompanied asylum-seeking children and young people via the National Transfer Scheme. This is an increasing workload for the team, which is dependent, in part, on the numbers of young people arriving in Kent, making future forecasting a significant challenge. 35 33 28 8 9 9 37 40 38 0 5 10 15 20 25 30 35 40 45 Jul-24 Aug-24 Sep-24 Through Care, After Care and Continuing Care Through Care Continuing Care Aftercare Page 59
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APPENDIX 1 18 | P a g e Justice and Youth Justice. Graph 19: Care experienced young people open to Justice Services Nationally, care experienced young people (CEYP) are overrepresented in the Scottish Justice Systems. At the end of Fin Quarter 2, 7.2% (36 of 502) were CEYP (up to age 26) within the Justice System (Youth Justice 12, Justice Social Work 24) depicted in graph 19, showing an increase from 4.5% at end of Fin Quarter 1. An error in reporting resulted in the figures for the Youth Justice team not being included in this data and the Fin Quarter 1 figure should have been 6.4%. This figure has consistently remained below 12% throughout 2023/24. Work continues to identify and offer early intervention and support where possible to identify CEYP and offer early help where possible to reduce the amount of time in which they are involved with justice services. The aim is to reduce the risk of re-offending to prevent CEYP requiring these services in the future. 435 424 421 424 403 415 422 450 440 449 443 466 472 44 46 46 41 38 39 45 38 40 36 37 32 30 9.18 8.93 8.99 9.46 9.52 9.47 8.35 7.58 7.29 6.39 7.23 6.82 7.17 0 1 2 3 4 5 6 7 8 9 10 0 100 200 300 400 500 600 Sep-23 Oct-23 Nov-23 Dec-23 Jan-24 Feb-24 Mar-24 Apr-24 May-24 Jun-24 Jul-24 Aug-24 Sep-24 Care Experienced People in the Justice System Open to Justice Team No. open to Youth Justice % CEYP open to both MYJ and JS Page 60
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APPENDIX 1 19 | P a g e Graph 20: Ages of young people in Youth Justice The average age of a young person receiving Youth Justice services is 15 years old which is predominately males accounting for 93% of young people supported by the service. Pie chart 6: Gender of young people in Youth Justice Pie chart 7: Justice Report Types At the end of Fin Quarter 2, 13% of individuals in Justice Social Work were women, which has remained relatively static over the past year. It is recognised women in the justice process 0 0 1 1 1 1 1 1 0 0 0 0 1 1 33 29 31 30 24 22 22 27 21 22 21 21 21 21 14 15 14 15 15 14 15 14 13 16 13 15 10 7 2 0 0 0 1 1 1 3 4 2 2 1 0 1 49 44 46 46 41 38 39 45 38 40 36 37 32 30 0 10 20 30 40 50 60 Aug-23 Sep-23 Oct-23 Nov-23 Dec-23 Jan-24 Feb-24 Mar-24 Apr-24 May-24 Jun-24 Jul-24 Aug-24 Sep-24 Youth Justice Age Bands Age Band: 5-10 Age Band: 11-15 Age Band: 16-17 Age Band: 18+ No. open to Youth Justice 87% 13% JSW Gender Male Female 28 2 Youth Justice Gender Male Female Page 61
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APPENDIX 1 20 | P a g e are more likely to have experienced trauma and are also more likely to be a sole carer for a child or family member. In line with The Promise, Justice Social Work is committed to keeping women in their local communities where it is safe to do so and provide robust alternatives to custodial sentences. Currently the Justice team offers a gender responsive service which includes a weekly women’s group and a woman only unpaid work group. Support is offered in partnership with other services to promote opportunities for individuals to engage with community resources which will be available beyond their time within the justice service. Graph 21: Justice social work reports (JSWR) Justice social work reports (JSWR) remain a priority to reduce any delays in sentencing and for Fin Quarter 2 the target of 100% on time has been met. Whilst reports are prepared at the request of any Court for an individual living in Moray, most reports are submitted to Elgin Sheriff Court. There has been small reduction in sentencing reports completed in Fin Quarter 2 due to a reduction in requests received from Courts. The trend of small increases or decreases is expected each month or quarter. Pie chart 8: Justice Report Types Page 62
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APPENDIX 1 21 | P a g e In addition to a standard JSWR report the Court may request additional assessments such as a Drug Treatment and Testing Order (DTTO) assessment and a Restriction of Liberty Order (ROLO) assessment as shown in pie chart 8. The imposition of a ROLO or DTTO can be a direct alternative to custody so effective assessments for these Orders can offer a robust community-based disposal. Graph 22: Structured deferred sentences (SDS) An SDS is a flexible intervention providing structured social work support for an individual after conviction but prior to sentencing. Successful completion of an SDS reduces the need for a statutory Court Order, in turn reducing the overall length of time an individual is open to the service. There has been a reduction in SDSs in Fin Quarter 2 which will have been impacted slightly by the reduction in overall reports requested. There was also a slight increase in report requests for a ROLO which indicates a more serious offence or pattern of offending for which a recommendation for an SDS would unlikely be suitable. Graph 23: Bail supervision 3, 3% 39, 36% 62, 58% 3, 3% Type of Report JSWR DTTO Assessment JSWR ROLO Assessment JSWR Standard JSWR Unpaid Work/DTTO/ROLO Assessment 15 5 7 1 MALE Q1 FEMALE Q1 MALE Q2 FEMALE Q2 Structured Deferred Sentences Number imposed Page 63
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APPENDIX 1 22 | P a g e Bail supervision is an alternative to remand and the priority for this in Moray is women, young people, those with caring or parental responsibilities and those with issues relating to mental health or addictions. There is no significant change in either numbers of assessments requested, or bail supervision orders imposed in Fin Quarter 2. Less than 25% of assessments result in bail supervision being imposed. National data is not available to compare, however, working groups have confirmed this variation is not isolated to Moray. Currently the prison population is significantly high, and bail supervision is one area of work which is hoped will assist in reducing these numbers whilst offering more positive outcomes for individuals within their local communities. Graph 24: CPO with supervision requirement Fin Quarter 2 has seen an increase in the imposition of Community Payback Orders (CPO), despite a small reduction in reports being submitted. Most individuals made subject to a CPO are seen on the day of sentencing, for those where this has not been possible, an appointment with their allocated worker is made within seven days of an Order being imposed. Missed targets this quarter all relate to individuals not attending appointments. 54 5 58 413 1 11 2 0 10 20 30 40 50 60 70 Male Q1 Female Q1 Male Q2 Female Q2 Bail Supervision Bail Sup. Assessments Bail Sup imposed Page 64
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APPENDIX 1 23 | P a g e Diversion from Prosecution Diversion from prosecution allows someone accused of offences to be dealt with outside of the formal justice system. The Justice Social Work team undertakes all assessments of suitability; however, the Youth Justice team will complete any interventions or support for young people aged 16 and 17. The referral rate varies which is a result of the process of cases being marked by the Procurator Fiscal. There can occasionally be delays in the commencement of these cases where additional agreement is required from the Procurator Fiscal, e.g. an extended period for completion. Successful completion of a diversion from prosecution means an individual will not have a conviction for the alleged offence which may impact their current or future employment or education alongside other significant areas of their life. Graph 25: Diversion from prosecution: Female Page 65
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APPENDIX 1 24 | P a g e Graph 26: Diversion from prosecution: Male Policy Team. Support and protection of children and young people procedure rollout As noted in the previous report, the Policy Team within Children and Families and Justice Social Work, in collaboration with partner agencies, lead on the revision of the Moray Multiagency Child Protection Procedure now known as Support and Protection of Children and Young People. This procedure has been successfully rolled out via a comprehensive implementation plan targeting several practitioners across the partnership, as illustrated on the figure below. Page 66
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APPENDIX 1 25 | P a g e The briefing paper outlined the key changes to the procedure, whilst the interactive briefing sessions offered a walkthrough of various processes through Alfie’s story, a video series (developed by the charity Not in Our Community) exploring the realities of criminal exploitation from the perspective of a young person. Commissioning. Pie chart 9: Contract categories Pie chart 9 identifies the seven main category areas of the contracts held within the Children & Families and Justice commissioning team. The family support category covers a range of services which deliver prevention and early intervention to avoid family breakdown and possible out of area care. This category covers three family support services (Families Together, Functional Family Therapy and Youth Point Services) and the Independent Advocacy contract. For the services delivered to children with a disability, the short breaks service contract commenced this quarter with the incumbent provider following a commissioning process including tender advertisement, ensuring there was continuity and no gap in service provision. There is a new service for children with a disability – group activities, which was tendered, evaluated and awarded to Action for Children, this contract was due to commence 1 November 2024. A local framework was developed to formalise the contractual agreements for 3 young people to reside locally and be supported with their physical disabilities in a residential home. There are currently 8 young people residing in residential care in Moray provided by Action for Children. This contract expires 31 March 2025 and during Fin Quarter 2 the commissioning team gathered the views of the young people, developed and finalised the specification with the tender being advertised as part of the commissioning process. The three family support services report a combined total of 116 children, young people and their families on their current workload, broken down in the illustration below: Page 67
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APPENDIX 1 26 | P a g e All three family support services have capacity for referrals, which has been communicated across social work teams. The three family supports services are reporting and providing evidence on achieving 21 contractual outcomes with a further 11 in progress: Families Together have reported 88 children and young people (from 57 families) being positively impacted following families being supported with financial gains and debt management as part of the Children First service. The illustration above details service outcomes. The independent relational advocacy service has been contracted for a full year and the referral rate is beginning to stabilise. There are two lots for this contract, lot 1 for all the young people and lot 2 for their parents, carers and siblings. They currently have 143 children, young people, parents or carers and siblings on their caseload, including 36 looked after children and 39 subject of child protection. In Fin Quarter 2, independent advocates supported children and families in 46 meetings. Graph 27: Meetings attended by independent advocacy service Pie chart 10: LAC and CP on current caseload A direct award contract for self-regulation and behaviour management was finalised (previously this was for foster care) which commences on 1 November 2024, will include adoptive, kinship and supported lodgings care. For the first year, the Scottish Government expanded the Scottish Living Wage uplift to cover the providers of children’s services which the commissioning team continues to implement. The commissioning team attended 4 training sessions – modern slavery, trauma informed, and 2 x child criminal exploitation. These courses have helped to contribute to the language of the specifications and contract monitoring going forward. On 13 September 2024 there was a commissioning development day held with adult services commissioning and service managers in relation to the contract monitoring process. LAC & CP on Current Caseload LAC Under CP Page 68
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 30 JANUARY 2025 SUBJECT: INTERNAL AUDIT SECTION - UPDATE REPORT BY: CHIEF INTERNAL AUDITOR 1. REASON FOR REPORT 1.1 This report provides Committee with an update on the work of the Internal Audit Section. 2. RECOMMENDATION 2.1 Committee is asked to consider the contents of this report, seek clarification on any points noted and otherwise note the report. 3. BACKGROUND 3.1 Public Sector Internal Audit Standards (PSIAS) require the Chief Internal Auditor to prepare and present reports to committee on internal audit’s activity relative to the audit plan and on any other relevant matters. 4. KEY MATTERS RELEVANT TO RECOMMENDATION Audit Plan 2025/26 4.1 The Internal Audit Plan details a list of projects the Internal Audit Service will review to provide management and members with an independent opinion that the MIJB’s risk management, governance and internal control processes are operating effectively. Internal audits' approach to annual audit planning is risk-based, with all areas that may be subject to audit review contained within an ‘audit universe.’ The audit universe is reviewed and updated on an ongoing basis to include all significant activities and systems. In addition, consultation has also been undertaken with the Chair of the Audit, Performance and Risk Committee and the with senior officers to highlight any projects for review. In accordance with agreed reposting arrangements, the Audit Plan 2025/26 will be submitted to Moray Council’s Audit and Scrutiny Committee on 12 February 2025 and thereafter to the next Audit, Performance and Risk Committee on 27 March 2025. Item 7. Page 69
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NHS Grampian Internal Audit Reports 4.2 As the Chief Internal Auditor of the Moray Integration Joint Board (MIJB), my role includes providing assurances of internal controls of systems and practices required by the MIJB to deliver services, irrespective of whether they use Council or NHS systems. I can provide members of the MIJB Audit, Performance and Risk Committee with audit reports of reviews undertaken regarding operating practices that use Moray Council owned systems due to my role as the Council’s Auditor. However, over the last few years, I have been trying to obtain copies of internal audit reports of NHS Grampian systems of interest to the MIJB that I can share with members. My intention is for members of the Audit, Performance and Risk Committee to receive similar assurances, irrespective of whether they relate to Council or NHS Grampian systems. 4.3 I have been in discussion with the senior management of NHS Grampian and their Internal Audit Provider to allow me to receive copies of their internal audit reports for reporting to the Audit, Performance and Risk Committee. This has required significant discussions and a requirement to sign an agreement to several reporting and assurance conditions. Despite certain reservations that have involved obtaining additional clarification from senior management of NHS Grampian, I have now signed this agreement. I will therefore be reporting internal audit reports from the NHS Grampian Internal Audit Provider of interest to the MIJB to future Audit, Performance and Risk Committees. Follow Up Reviews 4.4 Internal audit reports are regularly presented to members, detailing not only findings but also management's responses to the recommendations with agreed dates of implementation. Internal Audit will also undertake follow up reviews to evidence the effective implementation of these recommendations. Please see detailed the following completed follow up review: Purchasing Cards 4.5 An audit was previously undertaken of the systems and procedures for the management, use and control of purchasing cards. A purchasing card is similar to a personal credit card issued by the Council's Bank used by the Moray Council to enable purchases of supplies and services to be made quickly and efficiently. Cards are available to officers on approval of their budget manager. It provides flexibility and a cost effective alternative to the Council's standard requisition ordering process. Purchasing cards are managed by a payment card software application administered by the Bank. The audit scope for this review was to assess the key controls and systems in place in the management and use of purchasing cards. The Follow Up Report to review the implementation of the agreed recommendations is given in Appendix 1. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Moray Partners in Care 2022-2032” Internal audit work supports good governance and assists in securing appropriate systems of internal control. Page 70
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(b) Policy and Legal The internal audit service is provided in terms of paragraph 7:1 of the Local Authority Accounts (Scotland) Regulations 2014, and there is a requirement to provide a service in accordance with published Public Sector Internal Audit Standards. (c) Financial Implications No implications directly arising from this report. (d) Risk Implications Audit reports highlight risk implications and contain recommendations for management to address as a means of mitigating. (e) Staffing Implications No implications directly arising from this report (f) Property No implications. (g) Equalities/ Socio Economic Impacts No implications. (h) Climate Change and Biodiversity Impacts None directly arising from this report. (i) Directions None arising directly from this report. (j) Consultations There have been no direct consultations during the preparation of this report. 6. CONCLUSION 6.1 This report provides committee with an update on internal audit work progressed in the latest review period. Author of Report: Dafydd Lewis, Chief Internal Auditor Background Papers: Internal Audit Files Ref: mijb/ap&rc/ Page 71
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APPENDIX 1 Moray Council Internal Audit Section DEPARTMENT: Economy, Environment & Finance SUBJECT: Purchasing Cards REPORT REF: 24'019 Follow Up Audit Review Risk Ratings for Recommendations High Key controls absent, not being operated as designed or could be improved. Urgent attention required. Medium Less critically important controls absent, not being operated as designed or could be improved. Low Lower level controls absent, not being operated as designed or could be improved. No. Audit Recommendation Priority Accepted (Yes/ No) Date of Completion Status / Explanation Key Control: Procedures are in place and frequently reviewed to govern use of the corporate purchasing cards system. 5.01 In accordance with agreed timescales, Purchasing Card Procedures should be reviewed annually and made available on the Interchange for user reference. Medium Yes 30/04/2024 Implemented. The Purchasing Card Procedures Manual has been reviewed and presented on the Interchange for user reference in June 2024. Going forward, the procedures will be reviewed on an annual basis. Key Control: A robust purchase card application process is in place accompanied by a controlled process for issue of cards on acceptance of terms of operation. Item 7. Page 73
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Moray Council Internal Audit Section 2 Risk Ratings for Recommendations High Key controls absent, not being operated as designed or could be improved. Urgent attention required. Medium Less critically important controls absent, not being operated as designed or could be improved. Low Lower level controls absent, not being operated as designed or could be improved. No. Audit Recommendation Priority Accepted (Yes/ No) Date of Completion Status / Explanation 5.02 All officers must sign and return a Payment Card Terms of Use Form to the Payments Service before being issued a purchasing card and access granted to the Payment Card System. Medium Yes 30/04/2024 Implemented. Audit testing has confirmed administrative processes have been strengthened to ensure purchasing cards are not despatched to new users until the signed terms of use acceptance form has been received by the Payments Service. A tidy up exercise has also been undertaken to ensure conditions of use acceptances are on file for all existing cardholders. Key Control: Usage of purchase cards is controlled by imposed limits, is for purchases not suitable for standard procurement routes, is appropriately detailed for authorisation and scrutiny purposes and supports the continued appropriateness of card retention. 5.03 Consideration should be given to aligning all purchasing Low Yes 31/07/2024 Implemented. An exercise has been confirmed as undertaken to align cardholder Page 74
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Moray Council Internal Audit Section 3 Risk Ratings for Recommendations High Key controls absent, not being operated as designed or could be improved. Urgent attention required. Medium Less critically important controls absent, not being operated as designed or could be improved. Low Lower level controls absent, not being operated as designed or could be improved. No. Audit Recommendation Priority Accepted (Yes/ No) Date of Completion Status / Explanation cardholders who hold a standard single transaction limit to the current transaction limit of £1,000 to ensure consistency. transaction limits. There are now 15 officers holding single transaction limits over the standard £1,000 threshold, all due to assessed operational requirements, compared to the 151 officers with higher than standard limits in the original audit review. 5.04 The Bank should be informed to correct the errors found in Cardholders spending limits noted during the audit review. Low Yes 31/07/2024 Implemented. As referred to in 5.03 above, an exercise has been undertaken to review all cardholder spending limits and errors previously identified have been advised to the Bank, resulting in amended limits being applied. Key Control: Purchase Card transactions are appropriately authorised by the relevant budget manager. 5.05 Full transaction listings of purchase card transactions should be issued for information to all budget managers every quarter, in Medium Yes 30/04/2024 Implemented. A catch-up exercise has been undertaken to issue full transaction listings for 2023/24 and the reports have been evidenced as issued for Quarter 1 of 2024/25. No delay is expected for issue of reports to budget Page 75
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Moray Council Internal Audit Section 4 Risk Ratings for Recommendations High Key controls absent, not being operated as designed or could be improved. Urgent attention required. Medium Less critically important controls absent, not being operated as designed or could be improved. Low Lower level controls absent, not being operated as designed or could be improved. No. Audit Recommendation Priority Accepted (Yes/ No) Date of Completion Status / Explanation compliance with purchasing card procedures. managers going forwards due to streamlining of the recording process with the newly implemented electronic transaction logging. 5.06 Agreed timescales should be established where payment card transactions not authorised by a budget manager are referred to the appropriate Head of Service to resolve and if required, authorise the outstanding expenditure. Medium Yes 30/04/2024 Implemented. Significant improvement has been seen in the prompt authorisation of transactions since the initial audit. Payments Section has introduced new processes since the end of June 2024. Transactions must now be approved before they can be downloaded for processing, giving greater impetus for budget managers to act timeously and for unapproved transactions to be identified and pursued by Payments. Unapproved Page 76
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Moray Council Internal Audit Section 5 Risk Ratings for Recommendations High Key controls absent, not being operated as designed or could be improved. Urgent attention required. Medium Less critically important controls absent, not being operated as designed or could be improved. Low Lower level controls absent, not being operated as designed or could be improved. No. Audit Recommendation Priority Accepted (Yes/ No) Date of Completion Status / Explanation transactions at the time of the follow-up audit relate to only recent transactions with no recurring control issue identified. Key Control: VAT on purchasing card transactions is accurately documented and accounted for with full recovery of applicable input tax elements. 5.07 A reminder should be issued to all services to remind officers of VAT accounting requirements for payment card transactions. High Yes 30/04/2024 Implemented. A reminder of the VAT accounting requirements has been added to the annual terms of use confirmation issued to all cardholders in March 2024. In addition, the Purchasing Card guidelines have been augmented in June 2024 to include more clarity and detail on VAT requirements. The new electronic receipt logging process implemented in June 2024 has also provided a Page 77
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Moray Council Internal Audit Section 6 Risk Ratings for Recommendations High Key controls absent, not being operated as designed or could be improved. Urgent attention required. Medium Less critically important controls absent, not being operated as designed or could be improved. Low Lower level controls absent, not being operated as designed or could be improved. No. Audit Recommendation Priority Accepted (Yes/ No) Date of Completion Status / Explanation further opportunity to communicate VAT accounting requirements to all cardholders. Process enhancements implemented can be seen to have strengthened the VAT accounting system. 5.08 Consideration should be given for the Payments Service to undertake further monitoring of payment card transactions with the aim of maximising VAT recovery where documentary evidence is required of valid VAT receipts / invoices from services. High Yes 31/07/2024 Implemented. Since the audit took place, mandatory electronic VAT receipt submission within the Purchasing Card system has been introduced. This has assisted the monitoring process with electronic receipt submissions being validated by the Payments service and any documentation unsuitable for VAT reclaim being immediately identified and further queried as a routine process to ensure maximisation of VAT recovery is achieved. Page 78
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Moray Council Internal Audit Section 7 Risk Ratings for Recommendations High Key controls absent, not being operated as designed or could be improved. Urgent attention required. Medium Less critically important controls absent, not being operated as designed or could be improved. Low Lower level controls absent, not being operated as designed or could be improved. No. Audit Recommendation Priority Accepted (Yes/ No) Date of Completion Status / Explanation 5.09 The agreed procedure for the Payments Service of issuing routine escalation reports on purchase card transactions with potential VAT implications to Heads of Service should be reinstated to promote VAT recovery arrangements. High Yes 30/04/2024 Implemented. A catch-up exercise has been undertaken to issue VAT information reports to Heads of Service (HOS) for 2023/24 and for Quarter 1 of 2024/25. No delay is expected for issue of reports to HOS going forwards due to streamlining of the recording process with the newly implemented electronic transaction logging. With the requirement for receipt production on transaction logging, the need to escalate to HOS is expected to decrease and will be reviewed in time to assess if still appropriate and impactful. Page 79
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Moray Council Internal Audit Section 8 Risk Ratings for Recommendations High Key controls absent, not being operated as designed or could be improved. Urgent attention required. Medium Less critically important controls absent, not being operated as designed or could be improved. Low Lower level controls absent, not being operated as designed or could be improved. No. Audit Recommendation Priority Accepted (Yes/ No) Date of Completion Status / Explanation 5.10 Investigation of an electronic document imaging facility to record VAT receipts / invoices on transaction logging should continue with the aim of implementing more effective VAT accounting and documentation retention arrangements. Medium Yes 31/07/2024 Implemented. Mandatory electronic receipt logging has been introduced as part of the Purchasing Card system in June 2024. This is already showing benefits in effective VAT accounting and document retention arrangements and is deemed to be a welcome improvement to Purchasing Card administration. Key Control: Processes are in place to ensure purchase card permissions are fully withdrawn from cardholders on termination of employment. 5.11 In accordance with operating arrangements, the payment card system should be updated Medium Yes 30/04/2024 Implemented. A tidy up exercise has been completed regarding budget managers within the payment card system. Monthly processing Page 80
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Moray Council Internal Audit Section 9 Risk Ratings for Recommendations High Key controls absent, not being operated as designed or could be improved. Urgent attention required. Medium Less critically important controls absent, not being operated as designed or could be improved. Low Lower level controls absent, not being operated as designed or could be improved. No. Audit Recommendation Priority Accepted (Yes/ No) Date of Completion Status / Explanation promptly to reflect current budget management responsibilities when notified of officers leaving the employment of the Council. of leavers is being undertaken. 5.12 Greater care should be taken on inputting payroll reference numbers when setting up employees on the purchasing card system. Low Yes 30/04/2024 Implemented. A reminder on input accuracy has been issued to relevant officers and follow- up testing has confirmed accurate set up of new users on the purchasing card system. Page 81
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 30 JANUARY 2025 SUBJECT: INTERNAL AUDIT SECTION COMPLETED PROJECTS REPORT BY: CHIEF INTERNAL AUDITOR 1. REASON FOR REPORT 1.1 To provide an update on audit work completed since the last meeting of the Committee. 2. RECOMMENDATION 2.1 Committee is asked to consider and note this audit update. 3. BACKGROUND 3.1 Public Sector Internal Audit Standards (PSIAS) require the Chief Internal Auditor to prepare and present reports to the committee on internal audit’s activity relative to the audit plan and any other relevant matters. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 In line with the approved internal audit plan, the following reviews were completed: Governance arrangements to prevent Fraud and Corruption 4.2 A review was undertaken of the Council and the Moray Integration Joint Board’s (MIJB) governance arrangements to prevent fraud and corruption. The Chartered Institute of Public Finance and Accountancy Code of Practice on Managing the Risk of Fraud and Corruption was used as the template for developing the audit programme of testing. This review was part of a joint audit exercise with the internal audit providers of NHS Grampian and Aberdeenshire / Aberdeen City Councils. As the Integration Joint Boards deliver services through officers and systems of the Council and NHS Grampian, this approach has allowed for a more overarching and complete review to be undertaken. In addition, the opportunity for sharing knowledge and expertise has benefited all the internal audit providers in the delivery of this audit review. Item 8. Page 83
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4.3 The responsibility for preventing and detecting fraud and corruption rests with management. However, the Internal Audit Service has a role in supporting these arrangements by assessing the adequacy of these controls and leading investigations of irregularities concerning finances, property, services, or policies of the Council. Regarding allegations of fraud or corruption within NHS Grampian, it is the responsibility of the NHS Counter Fraud Authority to investigate. Findings noted where further improvements are needed in developing agreed procedures between the Internal Audit Service and the NHS Counter Fraud Authority, as officers of both NHS Grampian and the Council use systems of both organisations to deliver services. Improvements were also noted where further development is needed within the Council to enable more effective reporting of irregularities. The audit report for this project is given in Appendix 1. Moray Growth Deal 4.4 The Moray Growth Deal is a transformational programme of over £100 million, designed to drive economic growth across Moray over a ten year period. The Moray Growth Deal brings together the Scottish and UK Governments, Moray Council, partners from across the public and third sector, and businesses to work collaboratively to deliver the Deal’s vision for the area. Moray Council is the accountable body for the Growth Deal and has the responsibility to hold to account partner organisations in the delivery of the overall programme. 4.5 This audit reviewed the governance and administrative procedures for managing the Moray Growth Deal. A check was also made for a sample of grant claims for projects currently in delivery, including the verification of expenditure claimed by a partner organisation to supporting evidence. Overall, from the audit undertaken and within the scope of this review, effective arrangements are in place for the governance and administration of the Moray Growth Deal. The audit report for this project is given in Appendix 2. Out of Area Placements 4.6 A review of the systems and procedures of people receiving adult care services who are Out of Area (OOA) was undertaken. The term “Out of Area” relates to an individual's care and support being delivered in a local authority area that is different from the local authority with the statutory responsibility for providing that care and support. In Health & Social Care Moray Adult Services, OOA placements are managed within Learning Disability, Mental Health, Physical and Sensory Disabilities and Older Persons Services. Overall, a “limited opinion” has been detailed as the assurance level for this review; audit testing noted significant concerns regarding the progress undertaken in determining ordinary residence status for OOA placements and the contractual arrangements with care providers. The audit report for this project is given in Appendix 3. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Moray Partners in Care 2022-2032” Internal audit work supports good governance and assists in securing appropriate systems of internal control. Page 84
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(b) Policy and Legal The internal audit service is provided in terms of paragraph 7:1 of the Local Authority Accounts (Scotland) Regulations 2014, and there is a requirement to provide a service in accordance with published Public Sector Internal Audit Standards. (c) Financial Implications No implications directly arising from this report. (d) Risk Implications and Mitigation Audit reports highlight risk implications and contain recommendations for management to address as a means of mitigating. (e) Staffing Implications No implications directly arising from this report (f) Property No implications. (g) Equalities/ Socio Economic Impacts No implications. (h) Climate Change and Biodiversity Impacts None directly arising from this report. (i) Directions None arising directly from this report. (j) Consultations There have been no direct consultations during the preparation of this report. 6. CONCLUSION 6.1 This report provides Committee with a summary of findings arising from audit project completed during the review period. Author of Report: Dafydd Lewis, Chief Internal Auditor Background Papers: Internal Audit Files Ref: Page 85
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Appendix 1 1 Final Internal Audit Report Governance arrangements to prevent Fraud and Corruption October 2024 Distribution: Interim Chief Officer Health & Social Care Moray (MIJB) Head of Governance Strategy & Performance Chief Financial Officer Head of Human Resources ICT & Organisational Development Audit & Risk Manager The Internal Audit Section provides Management with an opinion on the internal control environment and also categories risk ratings for recommendations as high, medium or low (detailed explanation provided in Appendix1). The audit recommendations for this review have been classified as follows Assurance Level Risk Ratings for Recommendations Priority 1 0 Substantial Priority 2 3 Priority 3 2 Confidentiality and Disclosure Clause This report (“Report”) was prepared by the Internal Audit Section of Moray Council. The matters raised in this Report are only those which came to our attention during our internal audit work. Whilst every care has been taken to ensure that the information provided in this Report is as accurate as possible, the Moray Council Internal Audit Section has only been able to base findings on the information and documentation provided and consequently, no complete guarantee can be given that this Report is necessarily a comprehensive statement of all the weaknesses that exist, or of all the improvements that may be required. This Report was prepared solely for the use and benefit of the Moray Council, Moray Integration Joint Board or the Grampian Valuation Joint Board. Moray Council's Internal Audit Section accepts no responsibility and disclaims all liability to any third party who purports to use or rely for any reason whatsoever on the Report, its contents, conclusions, any extract, reinterpretation, amendment and/or modification. Accordingly, any reliance placed on the Report, its contents, conclusions, any extract, reinterpretation, amendment and/or modification by any third party is entirely at their own risk. Please refer to the Statement of Responsibility in Appendix 2 of this report for further information about responsibilities, limitations and confidentiality. Item 8. Page 87
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Appendix 1 2 Contents Page Governance arrangements to prevent Fraud and Corruption 1. Introduction & Scope 3 2. Key Issues 3-4 Detailed Report 3. Findings/Recommendations 5-10 4. Management Response 5-10 Appendices 1. Audit Terms of Reference and Definitions 2. Statement of Responsibility Page 88
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Appendix 1 3 1. Introduction and Audit Scope The Annual Audit Plan for 2024/25 provides for a review of the Council and the Moray Integration Joint Board (MIJB) governance arrangements to prevent fraud and corruption. The primary responsibility for preventing and detecting fraud and corruption rests with management who should ensure adequate systems of internal control, segregation of duties and proper authorisation procedures. However, the Internal Audit Section does have a role in supporting these arrangements by assessing the adequacy of these controls, and in accordance with the Council’s Financial Regulations for the Audit and Risk Manager to investigate in consultation with the Depute Chief Executive Education, Communities & Organisational Development irregularities concerning finances, property, services or policies of the Council. The audit also reviewed the arrangements for the investigation, preventing and detecting fraud and corruption within the MIJB. The Council’s Audit and Risk Manager is also the Chief Internal Auditor of the MIJB. The Cipfa Code of Practice on Managing the Risk of Fraud and Corruption was used as the template for developing an audit programme for this review. The audit was also undertaken as part of a joint working arrangement with the internal audit service providers of NHS Grampian, Aberdeen City and Aberdeenshire Councils. This has allowed the sharing of knowledge and agreement in the audit testing to ensure consistency and a more overarching review of the Integration Joint Boards (IJBs) counter fraud and corruption arrangements within the Grampian area. The IJBs deliver services through officers and systems of the Council and NHS Grampian. Officers from the Council and NHS Grampian will have access to the systems of both organisations. It is hoped these joint working arrangements with the internal audit service providers within Grampian will continue as it provides the opportunity for a more cross-organisational review of the IJB’s risk management, control and governance processes irrespective of NHS Grampian or Council systems are used in the delivery of services. The audit was carried out in accordance with Public Sector Internal Audit Standards (PSIAS). 2. Key Issues • The Public Sector Internal Audit Standards require the Chief Internal Auditor to provide an opinion on the overall adequacy and effectiveness of the MIJB risk management, control, and governance processes. MIJB delegated services are delivered by Council and NHS Grampian employed officers with access to systems of both organisations. Responsibility for investigating fraud within the Council Page 89
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Appendix 1 4 lies with the Audit and Risk Manager, but for NHS Grampian, it is the responsibility of the NHS Counter Fraud Authority. It is appreciated that the occurrence of fraud is rare, but consideration should be given to developing a protocol between the Audit and Risk Manager in consultation with the Chief Internal Auditor of Aberdeenshire/ Aberdeen City Councils and the NHS Counter Fraud Authority. This should assist in providing greater clarity and co-ordination of responsibility in the notification, investigation and reporting of alleged frauds within the MIJB, irrespective of whether the Council or NHS Grampian employs the officer delivering the delegated service. • The CIPFA Code of Practice on Managing the Risk of Fraud and Corruption requires that an “organisation should make arrangements for appropriate resources to support the counter fraud strategy”. This includes the need to detect fraud through data and intelligence analysis. The staff resources of the Internal Audit Section are limited, but consideration should be given to including a project within the Annual Internal Audit Plan to review Council systems and practices where fraud or irregularities have occurred in other organisations. The testing undertaken should make use of data evaluation software in the analysis of information, and a review of fraud cases and other irregularities reported within the media, Audit Scotland Technical Bulletins and participation in the Scottish Local Authority Investigator's Group. Page 90
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Appendix 1 5 Governance arrangements to prevent Fraud and Corruption - 2024/25 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 1. Medium A review of the Council’s policy framework which supports a counter fraud strategy, noted a range of policies to inform officers in their conduct and responsibilities as employees. These policies also protect officers from false allegations of fraud or corruption. However, the audit review noted that the Code of Conduct for Employees and the Policy on Outside Employment had not been reviewed for a number of years. It is appreciated that both the Code of Conduct for Employees and the Policy on Outside Employment detail best practices and are still relevant; however, both documents should be reviewed and if required updated. The Code of Conduct for Employees and the Policy on Outside Employment should be reviewed and if required updated. In addition, future dates of review should thereafter be agreed. . Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Organisational Development Manager Yes 31/03/2026 The employment policy framework is reviewed annually, resulting in agreement on the priorities for policy review according to a range of factors, such as changed legislation. The Code of Conduct for Employees and the Policy on Outside Employment remain appropriate and have not been identified as a priority for updating; however, they will be included in the annual plan for policies review for 2025/26. Page 91
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Appendix 1 6 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 2. Low It was noted that the Council’s website included details on reporting allegations of potential fraud to the Internal Audit Section. However, reference is made specifically to the reporting of Housing and Social Security Benefits fraud, as this used to be the most significant area of allegations received for investigation. A review of the wording used within the Council’s internet site should be undertaken, as a need to report a potential fraud may relate to any service area of the Council. In addition, research noted online fraud reporting function within other Local Authorities as an additional method for an individual to report an allegation of fraud. Current wording used within the Council’s internet site for reporting an allegation of fraud should be reviewed and updated. In addition, consideration should be given to the development of an online reporting function as an additional method for an individual to raise a concern of fraud to the Council. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Audit and Risk Manager Yes 31/03/2025 The information on the Council’s website for reporting fraud will be reviewed and updated. The timescale for implementation of this recommendation has been recorded as 31 March 2025 due to the need for updating web pages and the development of an online fraud reporting function which requires the support of the ICT Section. Page 92
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Appendix 1 7 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 3. Low As part of the audit planning of projects to be included within the Annual Audit Plan for 2023/24, a joint working arrangement was agreed with the internal audit service providers of NHS Grampian, Aberdeen City and Aberdeenshire Councils to review the Integration Joint Boards governance arrangements to prevent fraud and corruption. This has allowed for a more overarching review to be undertaken. As part of the joint audit working arrangement, this has also enabled the sharing of knowledge and information. The Financial Regulations of the MIJB were updated last year to include revised wording for reporting and investigating a suspected irregularity. However, it was noted that our neighbouring Councils had developed a “Counter Fraud Process” detailing best practices to follow in assessing a referral and investigating fraud. The occurrence of fraud is rare and the nature of each investigation can vary in nature, but consideration should be given to reviewing and if required, adapting this procedural document within Moray. Consideration should be given for the Internal Audit Section to develop a “Counter Fraud Process” procedure. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Audit and Risk Manager Yes 30/11/2024 The “Counter Fraud Process” already developed by a neighbouring Council will be used to prepare a similar procedural guidance document for the Moray Council. Page 93
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Appendix 1 8 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 4. Medium The Council’s Audit and Risk Manager is the appointed Chief Internal Auditor for delivering an internal audit service to the MIJB. MIJB delegated services are undertaken by Council and NHS Grampian officers and systems. Officers of both the Council and NHS Grampian are required to use the systems of each organisation to deliver services. The Audit and Risk Manager is responsible for investigating suspected irregularities within the Council, and the NHS Counter Fraud Authority investigates NHS Grampian's allegations of fraud. However, an issue may occur if an officer employed by the Council commits fraud involving an NHS system and vice-versa as to whether the allegation within the MIJB should be investigated by the Council’s Audit and Risk Manager or the NHS Counter Fraud Authority. The nature of the fraud may have a cross organisational implication regarding access to information and the individual officer's terms and conditions of employment from each organisation. Consideration should be given to the Audit and Risk Manager, in consultation with the Chief Internal Auditor of Aberdeenshire and Aberdeen City Councils, to discuss and if possible, agree on a protocol for the notification, investigation and reporting of alleged fraud within the Grampian IJBs with the NHS Counter Fraud Authority. This may require a “letter of understanding” detailing agreed arrangements for the fraud investigation. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Audit and Risk Manager Yes 30/11/2024 Contact will be made with the Chief Internal Auditor of Aberdeenshire and Aberdeen City Councils to discuss arranging a meeting with the NHS Counter Fraud Authority to agree a protocol for investigating fraud within the Grampian IJBs. Page 94
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Appendix 1 9 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 5. Medium At a Special Meeting of the Moray Council on 28 February 2024, it was decided to reduce the Internal Audit Section staffing budget by replacing the Corporate Investigations Officer’s post with a 0.5 full- time equivalent. The remaining budget was used to appoint an Assistant Auditor, but this proved unsuccessful, with no suitable applicants. The CIPFA Code of Practice on Managing the Risk of Fraud and Corruption requires that an “organisation should make arrangements for appropriate resources to support the counter fraud strategy” of the Council. This includes the need to detect fraud through data and intelligence analysis. The limited staff resources of the Internal Audit Section are appreciated, but consideration should be given to including a project within the Annual Internal Audit Plan to review systems and practices where fraud or irregularities have been reported within other organisations. During this review, it was noted that a financial fraud was reported in the media of an officer in another Local Authority embezzling over £1 million in council tax refunds. Further to consultation with the Council’s Taxation Manager, additional controls have been introduced to current operating arrangements. The Audit and Risk Manager should consider including a project within the Annual Internal Audit Plan to review Councill systems and practices where fraud has occurred within other organisations. Identification of the scope and testing to be undertaken will be determined from a review of fraud cases reported in the media, Audit Scotland Technical Bulletins and participation in the Scottish Local Authority Investigator's Group. The use of information data evaluation software should also be used in the analysis of information and databases. Page 95
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Appendix 1 10 Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Audit and Risk Manager Yes 28/02/2025 A project will be included to support the Council’s and MIJB counter fraud and corruption arrangements in the Annual Internal Audit Plan. The scope of the audit and testing undertaken will be determined from frauds reported within other organisations. The use of IDEA® Data Analysis software will be further developed in the analysis of information used for audit testing. Page 96
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Appendix 1 11 Appendix 1 AUDIT TERMS OF REFERENCE AND DEFINITIONS 1. Audit Objectives 1.1 The overall audit objective is to provide an objective independent opinion on the adequacy and effectiveness of controls / processes. 1.2 The audit will for each controls / process being considered: • Walkthrough the processes to consider the key controls; • Conduct sample testing of the identified key controls, and • Report on these accordingly 1.3 All audit reviews are carried out in accordance with Public Sector Internal Audit Standards (PSIAS). 2. Definitions for Auditing Opinions and Findings 2.1 In order to assist management in using our reports: The Internal Auditor will categorise audit assurance opinion according to their overall assessment of the risk management system, effectiveness of the controls in place and the level of compliance with these controls and the action being taken to remedy significant findings or weaknesses. Assurance Level System and Testing Conclusion Full The controls tested are being consistently applied Substantial There is evidence that the level of noncompliance with some of the controls may put some of the system objectives at risk. Limited The level of non compliance puts the system objectives at risk. None Significant non-compliance with basic controls leaves the system open to error or abuse. 2.2 Risk ratings for each recommendation is based on the following criteria: High Fundamental control weaknesses that require immediate attention by management to action and mitigate significant exposure to risk Medium Less critically important controls absent, not being operated as designed or could be improved Low Lower level controls absent, not being operated as designed or could be improved. Page 97
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Appendix 1 12 Appendix 2 STATEMENT OF RESPONSIBILITY The responsibility for designing and maintaining a sound system of internal control to prevent and detect fraud and other irregularities rests with management, with internal audit providing a service to management to support them to achieve this objective. The Internal Audit Section will assess the adequacy and effectiveness of the system of internal control arrangements implemented by management and perform sample testing on those controls in the period under review with a view to providing an opinion on the extent to which risks in this area are managed. The Internal Audit Section will undertake testing with the objective of detecting significant control weaknesses. However, the audit approach alone should not be relied upon to identify all strengths and weaknesses in internal controls nor to find any fraud or irregularity. Even sound systems of internal control can only provide reasonable and not absolute assurance and may not be proof against collusive fraud. The matters raised in this report are only those that came to our attention during the course of the audit review and are not necessarily a comprehensive statement of all the weaknesses that exist or all improvements that might be made. Recommendations for improvements should be assessed by management for their full impact before they are implemented. The performance of the audit review undertaken should not be taken as a substitute for management’s responsibilities for the application of sound management practices. This report is confidential and must not be disclosed to any third party or reproduced in whole or in part without the written consent of the Moray Council’s Audit and Risk Manager. Page 98
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Appendix 2 1 Final Internal Audit Report Moray Growth Deal October 2024 Distribution: Acting Head of Economic Growth & Development Moray Growth Deal Programme Manager Chief Financial Officer Senior Communications Officer The Internal Audit Section provides Management with an opinion on the internal control environment and also categories risk ratings for recommendations as high, medium or low (detailed explanation provided in Appendix1). The audit recommendations for this review have been classified as follows Assurance Level Risk Ratings for Recommendations Priority 1 2 Substantial Priority 2 3 Priority 3 2 Confidentiality and Disclosure Clause This report (“Report”) was prepared by the Internal Audit Section of Moray Council. The matters raised in this Report are only those which came to our attention during our internal audit work. Whilst every care has been taken to ensure that the information provided in this Report is as accurate as possible, the Moray Council Internal Audit Section has only been able to base findings on the information and documentation provided and consequently, no complete guarantee can be given that this Report is necessarily a comprehensive statement of all the weaknesses that exist, or of all the improvements that may be required. This Report was prepared solely for the use and benefit of the Moray Council, Moray Integration Joint Board or the Grampian Valuation Joint Board. Moray Council's Internal Audit Section accepts no responsibility and disclaims all liability to any third party who purports to use or rely for any reason whatsoever on the Report, its contents, conclusions, any extract, reinterpretation, amendment and/or modification. Accordingly, any reliance placed on the Report, its contents, conclusions, any extract, reinterpretation, amendment and/or modification by any third party is entirely at their own risk. Please refer to the Statement of Responsibility in Appendix 2 of this report for further information about responsibilities, limitations and confidentiality. Item 8. Page 99
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Appendix 2 2 Contents Page Moray Growth Deal 1. Introduction & Scope 3 2. Key Issues 3-4 Detailed Report 3. Findings/Recommendations 5-11 4. Management Response 5-12 Appendices 1. Audit Terms of Reference and Definitions 2. Statement of Responsibility Page 100
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Appendix 2 3 1. Introduction and Audit Scope 2. The annual audit plan for 2024/25 provides for a review of the governance and administrative procedures for the management of the Moray Growth Deal (the Deal). The Moray Council’s Internal Audit Service will overview the Deal programme and project activities, but each partner organisation is separately responsible for allocating internal audit resources for its specific project. The Moray Growth Deal is a transformational programme, designed to drive economic growth across Moray over a ten year period and is supported by £100 million of investment with £65 million being invested by the UK and Scottish Governments. The Deal brings together the UK and Scottish Governments and Moray Council, together with Partners from across the public, third sector, and businesses, to work collaboratively in delivering the Deal's vision for the region. This year, the Deal entered its fourth year of the ten year programme with four of the eight approved projects now in the delivery phase and three of the four having already made grant claim submissions to draw down funding. At the time of the audit review, the funding claimed for the Moray Growth Deal amounted to £5.2 million. The scope of the audit included a review of the governance and administrative arrangements surrounding the Moray Growth Deal. It also considered how partnership working is operating, the financial management of the Deal and how success is being measured. It is pleasing to report that from the testing undertaken and within the scope of this review, effective arrangements are in place for the governance and administration of the Moray Growth Deal. However, the following areas were identified for management attention: The audit was carried out in accordance with Public Sector Internal Audit Standards (PSIAS). 2. Key Issues • The audit included testing on a sample of grant claims for projects currently in delivery and the expenditure claimed. The review found that in relation to one project, not all expenditure claimed had supporting documentation to evidence the payment. This concerned certain categories of expenditure relating to salary costs, overheads, travel/ subsistence and software related recharges. Page 101
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Appendix 2 4 • In accordance with the Moray Growth Deal Financial Plan, each Partner Organisation is separately responsible for allocating internal audit resources for Moray Growth Deal Activities. It was agreed within a previous audit report that each Partner Organisation should provide their Annual Audit Plans to the Moray Council for planned internal audit activity regarding the Moray Growth Deal. However, this requirement could be further supported with an annual meeting between the Internal Audit Services of the Council and Partner Organisation to review previous audits undertaken and to discuss and agree on the scope of future auditing activities. Page 102
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Appendix 2 5 Moray Growth Deal- 2024/25 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 1. Medium The Communications Protocol was developed by the Moray Council Communications Team before the signing of the Deal. This document sets out an agreed framework for communication and engagement protocols for both proactive and reactive activities in relation to the Moray Growth Deal. The Protocol details that effective use should be made of My Moray web and social media sites to ensure members of the public are kept up to date on Moray Growth Deal news and developments. The audit appreciates the limited staff resources, but it was noted that during the audit period, news releases had not been posted to the My Moray website and social media postings can be infrequent. Further use should be made to post information on My Moray website and social media sites to ensure effective communication of any developments concerning the Moray Growth Deal. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Senior Communications Officer/ MGD Programme Manager Yes 31/12/2024 A lack of dedicated comms and engagement resource was flagged as a risk before the deal was signed and has continued to be an issue with ensuring continuous comms activity. However, information is shared in-line with project comms plans. Social media posts are shared when there is a relevant update and appropriate content – best practice is to only share updates when there is newsworthy content, otherwise Page 103
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Appendix 2 6 engagement rates will be negatively impacted. A publishing error on the website has now been rectified to ensure all releases are shared timeously. As more projects enter delivery and there is more content available to share publicly this will be done. Quarterly full deal public updates will also be introduced. Page 104
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Appendix 2 7 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 2. Medium A Stakeholder Engagement Plan was developed in 2021 to detail the framework for engagement across all Moray Growth Deal projects with a key objective of promoting positive benefits for Moray and creating opportunities for stakeholders to influence the projects as they develop. The Plan details the need for regular review, however it was found there is no evidence of a formal review of this document. The audit also noted that the Stakeholder Engagement Plan requires engagement with targeted audiences to evidence the success of implementing Moray Growth Deal Projects. As more projects enter the delivery phase, it will become more important to obtain this data to evidence a success objective in supporting the realisation of benefits. The Stakeholder Engagement Plan should be reviewed and, if required, updated. Engagement should be undertaken with the targeted audiences for a project to evidence an established objective of the Moray Growth Deal. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment MGD Programme Manager / Senior Communications Officer Yes 31/03/2025 While engagement has been taking place at the appropriate stages of project development, the plan needs to be updated and have partner sign-off. Analytics, insights and evaluation are included in the comms tracker and will link to the updated engagement plan. Page 105
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Appendix 2 8 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 3. Low It was noted that a Communications Planner spreadsheet is used to organise and plan a communication strategy for all projects. The audit noted examples where fields within this spreadsheet regarding dates and explanatory information had not been completed. Better use could be made of the Communications Planner spreadsheet to support the management of the communication needs of the Moray Growth Deal more effectively. It was also found that not all communications related information is saved on the Moray Growth Deal Sharepoint site. In order to ensure consistency, all information concerning Deal activities should be saved on the Moray Growth Deal Sharepoint site. All fields within the Communications Planner spreadsheet should be completed to aid the communication management needs of the Moray Growth Deal. All communications related activities, where documented, e.g., press releases, should be saved on the Moray Growth Deal Sharepoint site. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Senior Communications Officer Senior Communications Officer Yes Yes Implemented Implemented The tracker has been refined to ensure all fields are relevant and information has been backdated where necessary to create a comprehensive record of comms actions undertaken. Now that the comms team has full access to the Sharepoint site, documentation can be kept updated through version controls. Page 106
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Appendix 2 9 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 4. High The audit reviewed a sample of grant claims for projects currently being delivered where expenditure has been claimed from Moray Growth Deal funding. It was noted that not all spending included in the claims from a partner organisation could be verified with supporting evidence. Invoices/receipts had been provided for some creditor payments, however, certain expenditure categories i.e. salary costs, overheads, travel/ subsistence and software application costs were not supported by claim forms or system back-up documentation. The audit also checked the type of payments included within the funding claimed by a partner organisation, as eligibility for reimbursement can depend on whether the expenditure is capital or revenue cost. It was noted that included within the claims are payments for subsistence, travelling and overheads, which are generally not considered as capital expenditure. However, it is appreciated the accounting rules detailing if expenditure can be capitalised are complex. All partner organisations should be informed that supporting evidence must be provided for all expenditure claimed from Moray Growth Deal funding. Further to the findings noted within the audit and discussions with the Chief Financial Officer, a review of the types of payments claimed by the partner organisation should be undertaken to ensure the correct classification of expenditure. Page 107
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Appendix 2 10 Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Chief Financial Officer Chief Financial Officer Yes Yes Immediate 31/12/2024 Partners are reminded of the requirement for audit evidence when claims are submitted and additional scrutiny given to the project in question A review of payment types will be undertaken to ensure compliance with the European System of Accounts 10 and in accordance with grant conditions. Page 108
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Appendix 2 11 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 5. Medium Further to an internal audit report issued in 2022, a recommendation detailed that 'Each Partner Organisation should provide their Annual Audit Plan to the Moray Council of planned internal audit activity regarding Moray Growth Deal activities. These plans should then be forwarded to the Audit and Risk Manager for Review'. At the time of this review, two partner organisations internal audit services have either delivered or are undertaking reviews regarding the delivery of Moray Growth Deal projects. Copies of each partner organisations annual audit plans had not been provided to the Moray Council Internal Audit Service. However, it is pleasing to note that one of the partner organisations internal audit services did forward details of the scope of a review to the Council’s Audit and Risk Manager, which does provide some assurance of the audit coverage undertaken of Moray Growth Deal project delivery. Partner organisations' internal audit services should be reminded to forward copies of their annual audit plans to the Moray Council regarding planned internal audit activity of Moray Growth Deal activities. This will allow the Moray Council, as the Accountable Body, to be consulted and contribute to the scope of the review. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment MGD Programme Manager / Senior Auditor Yes 31/03/2025 At the time of the audit 2 of the 4 Growth Deal projects led by partners were in delivery, with one having completed an internal audit at the end of 2023 (the details of which had been passed to the audit team) and the other project had only entered delivery in 2024. Page 109
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Appendix 2 12 Given different approaches to audit in the partner organisations, the PMO will work collaboratively with the Council’s Internal Audit Team to organise an annual meeting that seeks to: - Identify audit activity planned for the year ahead, securing audit plans ahead of the meeting when Moray Growth Deal activity is scheduled. - Review audit activity undertaken in the previous 12 months - Share learning and identify cross cutting issues that all partners should take account of when planning future activity It is expected that the first of these meetings will take place during Q4 24/25 FY and partners were briefed at the MGD Board on 26/09/24 of the need to support this. Page 110
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Appendix 2 13 Appendix 1 AUDIT TERMS OF REFERENCE AND DEFINITIONS 1. Audit Objectives 1.1 The overall audit objective is to provide an objective independent opinion on the adequacy and effectiveness of controls / processes. 1.2 The audit will for each controls / process being considered: • Walkthrough the processes to consider the key controls; • Conduct sample testing of the identified key controls, and • Report on these accordingly 1.3 All audit reviews are carried out in accordance with Public Sector Internal Audit Standards (PSIAS). 2. Definitions for Auditing Opinions and Findings 2.1 In order to assist management in using our reports: The Internal Auditor will categorise audit assurance opinion according to their overall assessment of the risk management system, effectiveness of the controls in place and the level of compliance with these controls and the action being taken to remedy significant findings or weaknesses. Assurance Level System and Testing Conclusion Full The controls tested are being consistently applied Substantial There is evidence that the level of noncompliance with some of the controls may put some of the system objectives at risk. Limited The level of non compliance puts the system objectives at risk. None Significant non-compliance with basic controls leaves the system open to error or abuse. 2.2 Risk ratings for each recommendation is based on the following criteria: High Fundamental control weaknesses that require immediate attention by management to action and mitigate significant exposure to risk Medium Less critically important controls absent, not being operated as designed or could be improved Low Lower level controls absent, not being operated as designed or could be improved. Page 111
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Appendix 2 14 Appendix 2 STATEMENT OF RESPONSIBILITY The responsibility for designing and maintaining a sound system of internal control to prevent and detect fraud and other irregularities rests with management, with internal audit providing a service to management to support them to achieve this objective. The Internal Audit Section will assess the adequacy and effectiveness of the system of internal control arrangements implemented by management and perform sample testing on those controls in the period under review with a view to providing an opinion on the extent to which risks in this area are managed. The Internal Audit Section will undertake testing with the objective of detecting significant control weaknesses. However, the audit approach alone should not be relied upon to identify all strengths and weaknesses in internal controls nor to find any fraud or irregularity. Even sound systems of internal control can only provide reasonable and not absolute assurance and may not be proof against collusive fraud. The matters raised in this report are only those that came to our attention during the course of the audit review and are not necessarily a comprehensive statement of all the weaknesses that exist or all improvements that might be made. Recommendations for improvements should be assessed by management for their full impact before they are implemented. The performance of the audit review undertaken should not be taken as a substitute for management’s responsibilities for the application of sound management practices. This report is confidential and must not be disclosed to any third party or reproduced in whole or in part without the written consent of the Moray Council’s Audit and Risk Manager. Page 112
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Appendix 3 1 Final Internal Audit Report Out of Area Placements December 2024 Distribution: Head of Adult Services Head of Children’s, Families & Justice Services Chief Financial Officer The Internal Audit Section provides Management with an opinion on the internal control environment and also categories risk ratings for recommendations as high, medium or low (detailed explanation provided in Appendix1). The audit recommendations for this review have been classified as follows Assurance Level Risk Ratings for Recommendations Priority 1 3 Limited Priority 2 3 Priority 3 0 Confidentiality and Disclosure Clause This report (“Report”) was prepared by the Internal Audit Section of Moray Council. The matters raised in this Report are only those which came to our attention during our internal audit work. Whilst every care has been taken to ensure that the information provided in this Report is as accurate as possible, the Moray Council Internal Audit Section has only been able to base findings on the information and documentation provided and consequently, no complete guarantee can be given that this Report is necessarily a comprehensive statement of all the weaknesses that exist, or of all the improvements that may be required. This Report was prepared solely for the use and benefit of the Moray Council, Moray Integration Joint Board or the Grampian Valuation Joint Board. Moray Council's Internal Audit Section accepts no responsibility and disclaims all liability to any third party who purports to use or rely for any reason whatsoever on the Report, its contents, conclusions, any extract, reinterpretation, amendment and/or modification. Accordingly, any reliance placed on the Report, its contents, conclusions, any extract, reinterpretation, amendment and/or modification by any third party is entirely at their own risk. Please refer to the Statement of Responsibility in Appendix 2 of this report for further information about responsibilities, limitations and confidentiality. Item 8. Page 113
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Appendix 3 2 Contents Page Out of Area Placements 1. Introduction & Scope 3 2. Key Issues 4 Detailed Report 3. Findings/Recommendations 5-11 4. Management Response 5-11 Appendices 1. Audit Terms of Reference and Definitions 2. Statement of Responsibility Page 114
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Appendix 3 3 1. Introduction and Audit Scope The Internal Audit Plan for the 2024/25 year provides for a review of the systems and procedures of people receiving adult care services who are Out of Area (OOA). The term “Out of Area” relates to an individual's care and support being delivered in a local authority area that is different from the local authority with the statutory responsibility for providing that care and support. The reasons for individuals to receive care out with the Moray Council local authority area may be a need to be closer to family or a requirement for more specialist care that cannot be provided locally. However, responsibility, including costs to ensure the care provided to the OOA placement meets outcomes agreed upon within their Care and Support Plan, remains with Health & Social Care Moray as ordinary residence remains in Moray. Guidance for determining Ordinary Residence status is provided by the Scottish Government and supplemented by best practice procedures developed by Social Work Scotland. In Health & Social Care Moray Adult Services, OOA placements are managed within Learning Disability, Mental Health, Physical and Sensory Disabilities and Older Persons Services. Analysis of the Financial Management System noted expenditure of approximately £5.8 million in 2023/24. In addition, it was also noted the Moray Integration Joint Board (MIJB) Annual Accounts include OOA placements managed by NHS Grampian costing £1.8 million in 2023/24. The audit randomly selected a sample of OOA placements to review the arrangements for the care delivery, ascertain the ordinary residence status and contract management agreements with care service providers. The sample for testing was chosen from Learning Disability, Mental Health Needs and Physical & Sensory Disability Services. Annual expenditure within these services was noted at approximately £4.3 million for 45 individual OOA placements. Older Persons are not part of this selected sample, as an audit of Residential Care for Older Persons has been included as a separate review topic within the Internal Audit Plan for 2024/25. In addition, testing of OOA placement costs charged to MIJB but managed by NHS Grampian is outside the scope of this review. Overall, a “limited opinion” has been detailed as the assurance level for this review; audit testing noted significant concerns regarding the progress undertaken in determining ordinary residence status for OOA placements and the contractual arrangements with care providers. The audit was carried out in accordance with Public Sector Internal Audit Standards (PSIAS). Page 115
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Appendix 3 4 2. Key Issues • Determination of “Ordinary Residence” for people receiving services is crucial in deciding which local authority is required to meet the needs of adults with care and support needs. Whether the person is ordinarily resident in the area of the local authority is a key test in determining where responsibilities lie between local authorities for the funding and provision of care and support. It is appreciated that the determination of ordinary residence is complex and involves questions of both fact and degree regarding time, intention and continuity, which have to be taken into account. From the sample checked of OOA placements, weekly care and support costs were up to £5,786 per week, and have been residing out of Moray for a number of years. The audit review found examples of OOA placements where it is considered that further escalation was required to determine ordinary residence status, which has not been pursued timeously. Proactive management to review and highlight changes in circumstances of ordinary residence status of people receiving services should be undertaken regularly to ensure the responsibility for care delivery is allocated to the appropriate Local Authority. • Analysis of the Financial Management System (FMS) found that separately identifying expenditure on OOA placements is not readily distinguishable or reported in totality. Moray Integration Joint Board (MIJB) financial reports (2023/24) only record the cost of OOA placements of £1.8 million managed by NHS Grampian and charged to the MIJB. Expenditure on OOA placements managed through the Council’s FMS of approximately £5.8 million per annum is not separately detailed but included within other reported budget headings. Consideration should be given to reporting the overall cost in the delivery of OOA placements by the MIJB, irrespective of budgetary responsibility. • From the sample checked, approximately a third of OOA placements managed by various social work teams had no formal contract with the service providers to deliver support and care to the person receiving the service. There is a need to ensure appropriate contract and performance monitoring arrangements are formalised for all OOA placements. Page 116
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Appendix 3 5 Out of Area Placements - 2024/25 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 1. High The audit found that payments for OOA Placements could not be readily identified from an analysis undertaken of the Financial Management System, either as a gross expenditure cost or within each social work team. Significant analysis was required as part of the audit to identify OOA Placement expenditure. Health & Social Care Moray OOA placement expenditure is allocated to each social work team budget for Learning Disabilities, Mental Health Needs, Older People, and Physical & Sensory Disabilities. Expenditure is included within the total spend per these sectors in the MIJB Joint Finance Report used for reporting budget monitoring to the Board. It was noted that the Joint Finance Report does have a separate line entitled OOA Placements; however, these only detail expenditures for OOA placements managed by NHS Grampian. For 2023/24, the Joint Finance Report details OOA placement expenditure of £1.8 million, but there is also an additional £5.8 million of OOA placement expenditure as part of social work teams budget headings. Health & Social Care Moray governance arrangements would benefit from greater transparency in the financial reporting arrangements to ensure more effective monitoring of OOA placement expenditure. Consideration should be given to further developing the financial monitoring and reporting arrangements to allow for improved monitoring and scrutiny of all OOA expenditures. Page 117
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Appendix 3 6 Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Chief Financial Officer Yes 30/06/2025 NHS Out of Area placements are all in one budget, council teams are split amongst many budgets. A dynamic register of placements being developed will allow for easy identification and the Care First system will need to be regularly updated by teams to ensure correct reporting. All Out of Area packages will be recoded to allow for easy identification on financial systems and Care First. Page 118
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Appendix 3 7 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 2. Medium For an audit review to select a sample for testing, there is a need to ensure that the total population can initially be identified. However, for this review, the Auditor was required to undertake considerable work within each social work team and analysis of the Financial Management System to compile a definitive listing of all OOA placements managed within Health and Social Care Moray. The separate identification of OOA Placements within data systems would assist in the monitoring and management of these commonly high-cost placements. From the sample checked, the audit noted that the weekly cost of care provided to OOA placements was up to £5,786 per week. Consideration should be given to developing OOA placement registers / listings within each social work team to ensure OOA placements are visible for management to review. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Head of Adult Services and Head of Children’s, Families & Justice Services Yes 31/01/2025 Dynamic Register of all Out of Area placements, collating all costings and review dates, has been compiled and is awaiting ratification. This register will be reviewed at regular fortnightly High Cost Packages board meetings. The register will allow for accurate reporting to the IJB Board. Page 119
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Appendix 3 8 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 3. High The audit randomly selected 12 OOA placements for testing. It was found that in a third of placements across various social work teams, no formal contracts were in place with the care and support service providers. While monitoring of the placements is undertaken by social work teams, without a contractual agreement, there is the risk of differing expectations, accompanied by a lack of formal monitoring of the engagement and overall service provider performance. The current contractual position of all OOA Placements should be reviewed. Where contracts with service providers are not in place for the delivery of care and support to people receiving the service, referrals should be made to the Adult Care Commissioning Section for appropriate contract and monitoring arrangements to be established. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Head of Adult Services and Head of Children’s, Families & Justice Services Yes 30/06/2026 All Out of Area placements to receive interim Service Level Agreement or contracts that impose regular review periods. Page 120
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Appendix 3 9 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 4. High The audit has checked a sample of OOA placements and reviewed the process for deciding ordinary residence status. The determination of ordinary residence is crucial in determining which local authority is required to meet the care needs of people receiving the service. The audit noted examples of OOA placements where further escalation is necessary to establish ordinary residence status, but this has not been pursued. In addition, it was also found that communication in the determination of ordinary residence had been entered into with other local authorities, which has resulted in protracted delays in progressing transfers of responsibilities. An example was noted where discussion with another local authority regarding agreement of Ordinary Residence Status for an OOA placement has been ongoing for approximately 5 years. An exercise should be undertaken to identify all OOA placements where ordinary residence status requires to be further clarified. This may require more proactive communication with other local authorities or, if necessary, through Scottish Ministerial involvement to determine responsibility. It is important to ensure not only the most effective supervision of care delivery is provided to the person receiving the service but also that the responsibility for the financial cost of the OOA placement care and support is regularly reviewed to ensure it is the responsibility of the appropriate local authority. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Head of Adult Services and Head of Children’s, Families & Justice Services Yes 31/03/2025 Regular ordinary residence meetings with legal support are being scheduled as part of an overall review schedule. All reviews will now go via the fortnightly High Cost Package group, with review dates set and monitored. A schedule of all reviews will be established and monitored with quarterly reporting to the Chief Financial Officer. Page 121
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Appendix 3 10 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 5. Medium Social work teams have different authorisation practices regarding the initial OOA placement approval and subsequent invoicing arrangements. Authorisation of placements can involve Team Resource Allocation Meetings, a recently formed High Cost Packages Meeting forum and a Resource Management Group. It was also noted that different procedures can be followed, for example, by Mental Health who are not subject to the same resource allocation processes due to generally not requiring places in the same establishments as the Area Teams dealing with Older Persons and Physical and Sensory Disabilities. The need to review and formalise authorisation practices regarding care packages was also included within a previous internal audit report of SDS Option 2 & 3 management. A review to agree consistent arrangements for authorising individual OOA placements should be undertaken. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Head of Adult Services and Head of Children’s, Families & Justice Services Yes 02/12/2024 All new placements, including mental health, are to be scrutinised via High Cost Packages group which sits every two weeks. Resource Management Group (RMG) then make decision whether to accept placement. Appeals are in the first instance to RMG, then to senior management team if necessary. The review schedule identified will form a regular agenda item for High Cost Packages meetings. Page 122
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Appendix 3 11 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 6. Medium Care and Support Plans are developed for each OOA placement detailing agreed outcomes. Procedures detail that Care and Support Plans should be reviewed annually to ensure the agreed care is being provided and continues to meet the supported person's assessed needs. Audit testing of a random sample of 12 OOA placements found that 5 had not received annual reviews. This is an audit finding that has already been highlighted in a number of other social care audits where the requirement to review the Care and Support Plans of people receiving services was noted. Care and Support Plans for people receiving services should be reviewed annually in accordance with agreed procedures. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Head of Adult Services and Head of Children’s, Families & Justice Services Yes 31/12/2025 A review schedule to be established with care and support plans being part of this. SDS and care package reviews as part of efficiencies strategies will be considered alongside the out of area package reviews. A full register with review dates will be available by end January 2025. Page 123
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Appendix 3 12 Appendix 1 AUDIT TERMS OF REFERENCE AND DEFINITIONS 1. Audit Objectives 1.1 The overall audit objective is to provide an objective independent opinion on the adequacy and effectiveness of controls / processes. 1.2 The audit will for each controls / process being considered: • Walkthrough the processes to consider the key controls; • Conduct sample testing of the identified key controls, and • Report on these accordingly 1.3 All audit reviews are carried out in accordance with Public Sector Internal Audit Standards (PSIAS). 2. Definitions for Auditing Opinions and Findings 2.1 In order to assist management in using our reports: The Internal Auditor will categorise audit assurance opinion according to their overall assessment of the risk management system, effectiveness of the controls in place and the level of compliance with these controls and the action being taken to remedy significant findings or weaknesses. Assurance Level System and Testing Conclusion Full The controls tested are being consistently applied Substantial There is evidence that the level of noncompliance with some of the controls may put some of the system objectives at risk. Limited The level of non compliance puts the system objectives at risk. None Significant non-compliance with basic controls leaves the system open to error or abuse. 2.2 Risk ratings for each recommendation is based on the following criteria: High Fundamental control weaknesses that require immediate attention by management to action and mitigate significant exposure to risk Medium Less critically important controls absent, not being operated as designed or could be improved Low Lower level controls absent, not being operated as designed or could be improved. Page 124
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Appendix 3 13 Appendix 2 STATEMENT OF RESPONSIBILITY The responsibility for designing and maintaining a sound system of internal control to prevent and detect fraud and other irregularities rests with management, with internal audit providing a service to management to support them to achieve this objective. The Internal Audit Section will assess the adequacy and effectiveness of the system of internal control arrangements implemented by management and perform sample testing on those controls in the period under review with a view to providing an opinion on the extent to which risks in this area are managed. The Internal Audit Section will undertake testing with the objective of detecting significant control weaknesses. However, the audit approach alone should not be relied upon to identify all strengths and weaknesses in internal controls nor to find any fraud or irregularity. Even sound systems of internal control can only provide reasonable and not absolute assurance and may not be proof against collusive fraud. The matters raised in this report are only those that came to our attention during the course of the audit review and are not necessarily a comprehensive statement of all the weaknesses that exist or all improvements that might be made. Recommendations for improvements should be assessed by management for their full impact before they are implemented. The performance of the audit review undertaken should not be taken as a substitute for management’s responsibilities for the application of sound management practices. This report is confidential and must not be disclosed to any third party or reproduced in whole or in part without the written consent of the Moray Council’s Audit and Risk Manager. Page 125
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 30 JANUARY 2025 SUBJECT: CHILDRENS SERVICES JOINT INSPECTION IMPROVEMENT PLAN 2024 BY: INTERIM CHIEF SOCIAL WORK OFFICER/HEAD OF SERVICE 1. REASON FOR REPORT 1.1 To provide the Committee with an overview of the governance arrangements for the joint inspection improvement plan which was submitted to the Care Inspectorate on 5 March 2024. 2. RECOMMENDATION 2.1 It is recommended that Committee: i) scrutinise and note the content of the improvement plan produced in response to the joint inspection, attached as Appendix 1; and ii) note the governance arrangements in place for child protection in Moray, attached as Appendix 2. 3. BACKGROUND 3.1 On 10 July 2023 Moray received notification of Joint Inspection of Services for Children at Risk of Harm in Moray, which was conducted in 3 phases to 29 November 2023. 3.2 The findings from the joint inspection were previously reported to this committee on 29 February 2024 (para 13 of minute refers). 4. INSPECTION IMPROVEMENT PLAN 4.1 The improvement plan in Appendix 1 covers three main areas of improvement: • Children and young people at risk of harm influencing service planning and improvement • Children and young people at risk of harm benefit from independent advocacy Item 9. Page 127
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• Young people at risk of harm from themselves or to others, or from risk in the community 4.2 Partnership approval for the improvement plan was secured via Moray Child Protection Committee and Moray Public Protection Chief Officers Group prior to final submission to inspectors on the 5 March 2024. 4.3 The Independent Chair of Moray Child and Adult Protection Committees will report progress of the improvement plan to Moray Public Protection Chief Officers Group. 5. PARTNERSHIP GOVERNANCE ARRANGEMENTS 5.1 Chief Officers are ultimately responsible and accountable for improving the experience and outcomes for children who may need protection as noted within Scottish Government 2019 guidance Protecting children and young people: Child Protection Committee and Chief Officer responsibilities. 5.2 Working within the accountability structures of their respective organisations, Chief Officers work collectively to identify and commission inter-agency activity for the protection of children and young people. Moray Child Protection Committee is the inter-agency mechanism to take this work forward. 5.3 The improvement plan is broader than child protection and activity also sits within the context of Moray Community Planning Partnership Childrens Services Plan 2023-26. 5.4 The Moray Getting it Right for Every Child (GIRFEC) leadership group is the strategic planning group for children’s services with remit to oversee the development and implementation of the Childrens Services Plan 2023-26 on behalf of Moray Community Planning Board. 5.5 To support alignment between governance for child protection and wider children’s services strategic planning, Moray Child Protection Committee also provides quarterly progress reports to the GIRFEC Leadership Group. 5.6 Appendix 2 further outlines the governance arrangements for Moray’s Children’s Services Partnership and the role and remit of groups responsible for child protection. 6. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” This report notes that the improvement plan is aligned with key priority areas across the Children’s Services partnership. (b) Policy and Legal None arising as a direct result of this report. (c) Financial implications None arising as a direct result of this report. Page 128
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(d) Risk Implications and Mitigation None arising as a direct result of this report. (e) Staffing Implications There are no proposed changes to the staffing or reporting relationships (f) Property None arising as a direct result of this report. (g) Equalities/Socio Economic Impact None arising as a direct result of this report. (h) Climate Change and Biodiversity Impacts None arising as a direct result of this report. (i) Directions None arising as a direct result of this report. (j) Consultations HSCM Senior Management Team. 7. CONCLUSION 7.1 On 5 March 2024 an improvement plan was submitted to the care Inspectorate in response to the Joint Inspection of Services for Children at Risk of Harm in Moray. 7.2 Progress against the improvement plan is monitored by the Moray Child Protection Committee. 7.3 The Independent Chair of the Moray Child Protection Committee provides updates to both the Moray Public Protection Chief Officers Group and the Moray GIRFEC Leadership Group. Author of Report: Emma Johnston, Public Protection Lead Officer Background Papers: Report of a joint inspection of services for children and young people at risk of harm in Moray Page 129
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Approved by Moray Public Protection Chief Officers Group on 12/04/24. Submitted to Care Inspectorate on 05/03/2024. Improvement plan Moray joint inspection of services for children and young people at risk of harm Introduction This improvement plan identifies and commits to improvements centred on the findings of the 2024 joint inspection of services for children at risk of harm in Moray. These improvement’s, some of which are already underway, also sit within a context of a partnership Children’s Services Plan which incorporates Moray’s Promise plan. The leads indicated within the plan form part of the Moray structure which sits below the Child Protection Committee and GIRFEC Leadership Group and it will be the responsibility of these subgroups to create the detail of the activity necessary to achieve these improvements and RAG rate them accordingly. A more detailed action plan will therefore sit alongside this document. The Child Protection Committee will oversee the activity related to this plan and report progress to Moray Public Protection Chief Officers Group. The Improvement Plan covers three main areas of improvement, namely; • Children and young people at risk of harm influencing service planning and improvement • Children and young people at risk of harm benefit from independent advocacy • Young people at risk of harm from themselves or to others, or from risk in the community There is a need for improvement in how the partnership self-evaluate and understand the impact their services are making and this is key to the improvement activity noted in this plan. APPENDIX 1 Item 9. Page 131
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2 | All children and young people in Moray grow up loved, safe, respected and equal, because our services and workforce put people first and support families with the right help at the right time Children and young people at risk of harm, influencing service planning and improvement. Joint Inspection Findings: Information about children and young people’s experience of services was not routinely sought, analysed and used to inform service planning. Development area What do we need to do? Action How Will We Do It? Lead Timescale Evidence Produce a Children and Young Person’s Rights and Participation Strategy ensuring a focus on children at risk of harm. Develop a participation strategy which includes specific objectives relating to children in need of care and protection and those at risk of harm. Children’s Rights and Participation Group TBC Children’s Rights and Participation strategy is co- produced with children and young people and approved through governance structures. Ensure that children, young people, and their families have involvement in strategic planning Provide opportunities for children, young people and where appropriate, parents and/or carers to contribute to strategic planning Children’s Rights and Participation Group March 2025 Self-evaluation activity undertaken with children and young people at risk of harm evidences that their voice is influencing strategic planning. (included in annual self-evaluation calendar) Increase awareness of the role and function of the Child Protection Committee Develop a communication and engagement strategy with children, young people and frontline practitioners to increase awareness of the role and contribution of the Child Protection Committee Child Protection Committee and Child Protection Improvement Officer September 2024 Workforce report increased awareness through quality assurance activity (included in annual self-evaluation calendar) Develop and launch Public Protection website Child Protection Improvement Officer September 2024 Public Protection website is live. Analysis of website hits Moray Childrens Services Plan 2023-26 Priority High Level Outcome Hearing Children and Young People’s voices The voice of children and young people is evident in all things that impact on them. Page 132
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3 | All children and young people in Moray grow up loved, safe, respected and equal, because our services and workforce put people first and support families with the right help at the right time Children and young people at risk of harm benefit from independent advocacy Joint Inspection Findings: Children and young people and parents and carers were contributing to decisions about their lives, though not all had access yet to independent advocacy. Development area What do we need to do? Action How Will We Do It? Lead Timescale Evidence Improve how we ensure children’s views are central to decision making Children and young people at risk of harm are consistently encouraged by all staff to take up independent advocacy Children’s Rights and Participation Group September 2024 Analysis of record of offer of independent advocacy support Develop mechanisms to establish and record whether young people have been offered advocacy services and their reasons, where appropriate, for not taking this up Children’s Rights and Participation Group September 2024 Identify and address the barriers to children and young people engaging with independent advocacy services March 2025 Increase uptake of advocacy service Evidence the impact of independent advocacy Social Work Commissioning Team March 2025 Commissioned service contract monitoring processes Quality Assurance included in file auditing activity within annual self-evaluation calendar Moray Childrens Services Plan 2023-26 Priority High Level Outcome Keeping Children and Young People Safe Children & young people are empowered to participate in child protection processes Page 133
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4 | All children and young people in Moray grow up loved, safe, respected and equal, because our services and workforce put people first and support families with the right help at the right time Young people at risk of harm from themselves or to others, or from risk in the community Joint Inspection Findings: A multi-agency co-ordinated approach to risk was not yet in place for young people at risk of harm from themselves, to others or from risk in the community. Planning and support for young people at risk of harm from themselves, or to others or at risk in the community, was less effective than support for children and young people at risk of abuse and neglect. Development area What do we need to do? Action How Will We Do It? Lead Timescale Evidence Introduce a multi-agency framework for vulnerable young people, who are a risk to themselves, to others or are at risk in the community Co-produce a Protection from Serious Harm procedure and guidance with all partners including young people and their families. Child Protection Implementation Group September 2024 Procedure and guidance produced and approved. Quality assurance of procedure included in annual self-evaluation calendar Implementation of vulnerable young person procedure, including training for staff Child Protection Implementation Group March 2025 Audit activity undertaken (included in annual self-evaluation calendar) Moray Childrens Services Plan 2023-26 Priority High Level Outcome Keeping Children and Young People Safe Children and young people are safer because risks have been identified early and responded to effectively. Children and young people at risk of or who come into conflict with the law are supported with compassion and care. Page 134
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5 | All children and young people in Moray grow up loved, safe, respected and equal, because our services and workforce put people first and support families with the right help at the right time Measuring Impact Joint Inspection Findings: The child protection committee had not yet fully developed the mechanisms necessary to understand and communicate the difference that services were making to the lives of children and young people at risk of harm. The partnership’s agenda for improvement and change was not yet underpinned by a cohesive approach to service review and self-evaluation. Development area What do we need to do? Action How Will We Do It? Lead Timescale Evidence Ensure our agenda for improvement and change is underpinned by a cohesive approach to service review and self- evaluation Develop a robust performance management and quality improvement framework Child Protection Committee /GIRFEC Leadership Group March 2025 Quality Improvement Framework launched Establish and implement annual multi-agency self-evaluation calendar to ensure self-evaluation activity is undertaken in key areas. This includes capturing voice /views of children and young people at risk of harm. Child Protection Committee September 2024 Calendar developed and operational. Annual quality and standards report produced to inform ongoing improvement activity Include the voice of children, young people, and their parents/ carers in all quality assurance activity Children’s Rights and Participation Group March 2025 Moray Childrens Services Plan 2023-26 Priority High Level Outcome Working In Partnership We more consistently and effectively measure impact of the actions we are taking to improve outcomes for children, young people, and families. Improved co-ordination of continuous improvement activity. Page 135
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6 | All children and young people in Moray grow up loved, safe, respected and equal, because our services and workforce put people first and support families with the right help at the right time Planning and Support Joint Inspection Findings: The quality of chronologies, assessments and plans was variable. While some single agency audit activity had taken place, the partnership had not yet developed a comprehensive multi-agency approach to quality assurance to support improvement. Development area What do we need to do? Action How Will We Do It? Lead Timescale Evidence Ensure the multi-agency GIRFEC integrated assessment and planning framework leads to improved/consistent high-quality practice. Develop a GIRFEC Integrated Assessment Framework for Moray (IAF) Child Planning Group September 2024 IAF developed and operational Deliver training and development on the Moray GIRFEC IAF Learning and Development Group March 2025 Training in place Evaluation of impact of training undertaken with participants Implement self-evaluation activity to monitor standards of practice and inform improvement activity. Data and Evaluation Group September 2025 Self-evaluation activity operational (incorporated within annual self-evaluation calendar) % Increase in quality of files audited, using inspection information as baseline. Produce multi agency chronologies to a consistently high standard and are utilised as a tool of analysis to inform SMART action planning Child Planning Group March 2025 Quality assurance activity demonstrates improvement in quality of multi-agency chronologies (incorporated within annual self-evaluation calendar) Finalise revision of multi-agency child’s planning process and roll out associated training Child’s Planning Group September 2024 Test of change completed, and process finalised based on learning. Audit activity included within annual self- evaluation calendar. Moray Childrens Services Plan 2023-26 Priority High Level Outcome Strengthening Family Support Children and family's needs are addressed early through the implementation of effective child’s planning processes Supporting Our Workforce Integrated working practice is enhanced through joint development opportunities that supports our shared vision, core principles and values. Page 136
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7 | All children and young people in Moray grow up loved, safe, respected and equal, because our services and workforce put people first and support families with the right help at the right time Relationships with Staff Joint Inspection Findings: Not all children and young people felt that their worker spent time with them or gave them the help they needed. This was linked to a lack of consistency of staff members and some families experienced frequent changes in staff. Development area What do we need to do? Action How Will We Do It? Lead Timescale Evidence Explore ways to improve workforce planning to support children and young people at risk of harm having consistent support from key workers Scope current position in relation to workforce pressures and provide analysis of gaps, recruitment, and retention challenges Child Protection Committee September 2024 Analysis of current position completed Exploration of potential solutions with key stakeholders drawing on local and national best practice Child Protection Committee with Child Protection Improvement Officer September 2024 Potential solutions and recommendations collated, agreed, and actioned Implementation of agreed solutions Child Protection Committee with Child Protection Improvement Officer September 2024 Quality assurance activity In partnership with third sector maximise their services to meet the needs of children, young people, and families. Child Protection Committee March 2025 Third sector performance reports demonstrate improved uptake and impact (as evidenced through outcome measurement tools used by third sector) Moray Childrens Services Plan 2023-26 Priority High Level Outcome Supporting Our Workforce Staff facilitate and enable the relationships, networks and connections that support our children, young people, and families. Page 137
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APPENDIX 2 Children’s Services Governance Arrangements in Moray The Moray GIRFEC Leadership Group (GLG) works on behalf of the Moray Community Planning Partnership to deliver on the Moray Childrens Services Plan 2023-26. Keeping children & young people safe is one of the five priorities of the Childrens Services Plan. This priority is overseen by the Moray Child Protection Committee which sits within a wider infrastructure for public protection within the partnership. Protecting People in Moray The Public Protection Chief Officers Group provides leadership, direction and scrutiny of the respective Child Protection and Adult Support & Protection Committees, and related strategic partnerships which include the Alcohol and Drug Partnership, Violence Against Women and Girls Partnership and Moray Community Justice Partnership. The Moray Public Protection Chief Officers Group meet quarterly to review the delivery of services and improvement plans across the public protection partnership. The Independent chair of the Moray Child Protection Committee attends the Public Protection Chief Officers Group as does the Chief Social Work Officer who is also chair of the GIRFEC Leadership Group. To support alignment between governance for child protection and wider children’s services strategic planning, the Moray Child Protection Committee also provide quarterly progress reports to the GIRFEC Leadership Group. Item 9. Page 139
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Moray Child Protection Committee Chair Independent Chair Support Team Public Protection Lead Officer Child Protection Improvement Officer Business Support Public Protection Contact mcpc@moray.gov.uk Purpose The Moray Child Protection Committee (CPC) is the inter-agency body that drives forward the work on behalf of the Moray Public Protection Chief Officers Groups to protect children from neglect, abuse and harm. CPC Objectives are to: • jointly identify and manage risk to children and young people • improve the experience of and outcomes for children who may need protection Membership Voting Members • Detective Chief Inspector Public Protection Unit, Police Scotland • SCRA Regional Manager • Lead Nurse for Child Protection • Childrens Hearings Scotland Area Convener • Chief Social Work Officer/ Head of Service Health & Social Care Moray • Independent Chair of Child Protection Committee • Third Sector Representative • Ministry of Defence Representative • Service Manager, Children & Families and Justice Social Work • Chief Education Officer, Moray Council Attendees • Housing Services Representative • Care Inspectorate Strategic Link Inspector • Public Protection Lead Officer • Specialist Nurse Child Protection • Mental Health Service Manager • Children & Families Health Services Lead • Getting it Right for Every Child (GIRFEC) Lead Officer • Quality Improvement Officer Education Remit The CPC must perform a number of crucial functions in order to jointly identify and manage risk to children and young people and improve the experience of and outcomes for children who may need protection. These functions are: continuous improvement; publicity and promotion; strategic planning and annual reporting. Moray CPC Substructure Moray Public Protection Introduction Pack (Child Protection) Page 140
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National Publications and Website(s) National guidance for child protection in Scotland 2021 Protecting children and young people: Child Protection Committee and Chief Officer responsibilities (2019) Moray Public Protection Chief Officers Group Vision We are here to serve the communities of the Moray and will do this with fairness, integrity and respect. We will challenge each other constructively when necessary to ensure we deliver beyond expectations for these communities. Purpose The Moray Public Protection Chief Officers Group provides strategic leadership and scrutiny to the public protection work of their respective agencies and to inter-agency work. Chief Officers in Moray are individually and collectively responsible for the leadership, direction and scrutiny of their respective Child Protection and Adult Support & Protection Committees and are linked to public protection partnerships and groups, which include the Alcohol and Drug Partnership, Violence Against Woman and Girls Partnership and Community Justice Partnership. Membership • Moray Council, Chief Executive • NHS Grampian, Chief Executive • Police Scotland, Chief Superintendent • Health & Social Care Moray, Chief Officers • Moray Council, Chief Social Work Officer • Independent Chair, Adult Protection Committee & Child Protection Committee • Scottish Fire & Rescue Services Remit In relation to public protection, Chief Officers will: • identify and commission inter-agency activity for protection of children and adults • be responsible and accountable for improving the experience of and outcomes for children and adults who may need protection • consider issues that have an impact on wider public protection arrangements and development • agree Annual/Biennial Reports and Improvement/Business Plans • consider performance reports and findings from case reviews Page 141
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National guidance for child protection committees undertaking learning reviews (2021) Child Protection Scotland (Link to publications page here) Page 142
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE & RISK COMMITTEE ON 30 JANUARY 2025 SUBJECT: PAYMENT VERIFICATION BY: HEAD OF SERVICE / DEPUTY CHIEF OFFICER 1. REASON FOR REPORT 1.1 The purpose of this report is to provide an update on the review of the Payment Verification (PV) Assurance Service provided by National Services Scotland (NSS) Practitioner Services Divisions (PSD), on behalf of NHS Grampian. 2. RECOMMENDATION 2.1 It is recommended that Committee: i) scrutinise and note the arrangements in place in Grampian for the management of the payment verification process; ii) note that the payment verification process has now fully restarted after pausing during COVID-19; and iii) note the actions already taken to address the outstanding issues, with plans for future action to include an update on progress to this committee in 2025. 3. BACKGROUND 3.1 A report was presented to this Committee on 26 September 2024 (para 11 of minute refers) providing a general update on the PV process when it was agreed that the report was to be shared with Aberdeen City and Aberdeenshire (Integration Joint Boards (IJBs) (complete) and a progress update was to come back to this committee in January 2025. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 Difficulties were experienced in receiving updates on progress for the improvement of PSD/PV outcomes prior to the COVID-19 pandemic. Item 10. Page 143
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4.2 Since COVID-19 the process has caught up, and there are no longer significant delays in the system. 4.3 NHS Grampian has now obtained sessional GP clinical input for the virtual General Medical Services (GMS) visits. Two GPs are now available which provides resilience. 4.3 NHS Grampian has identified lack of consultation on the process in general plus clear governance channels, particularly with respect to NSS PV Reference Groups. This has been escalated via both the national Family Health Services (FHS) Finance Execs and Primary Care Management Lead groups. 4.4 The above is progressing with dialogue ongoing at a national level, and some progress has been made. The FHS Finance Execs are reviewing and plan to discuss again early in 2025. 4.5 Until this is resolved the Partnership Agreement between NSS and NHS Grampian referred to in DL 2923 (24) remains unsigned. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” The Moray Integration Joint Board requires effective governance arrangements for those services and functions delegated to it. Such governance arrangements include systems for managing risks. (b) Policy and Legal There are no legal implications arising from this report. (c) Financial implications There are no financial implications arising directly from this report. (d) Risk Implications and Mitigation There is a risk that assurance cannot be provided to NHS Grampian that Payment Verification is being carried out appropriately. (e) Staffing Implications There are no staffing matters arising directly as a result of this report. (f) Property There are no implications in terms of Council or NHS property directly arising from this report. (g) Equalities/Socio Economic Impact An Equality Impact Assessment is not required because there are no service, policy or organisational changes proposed in this report. (h) Climate Change and Biodiversity Impacts There are no matters arising directly as a result of this report. (i) Directions Page 144
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There are no directions directly as a result of this report. (j) Consultations Consultation has taken place with the Head of Service, Service Manager Primary Care Contracts and Finance Manager regarding this report. 6. CONCLUSION 6.1 It is encouraging to note the PV process has now fully resumed. 6.2 However, there are still further updates required as to governance of service provided, especially to do with PV specification. 6.3 Updates will be brought back to future meetings of this Committee. Author of Report: Peter Maclean, Service Manager, Primary Care Contracts Background Papers: DL (2023) 24 - Revised Payment Verification Protocols Ref: Page 145
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