Agenda Document Pack - Audit, Performance and Risk Committee - 27/03/2025
Moray Council · 27 March 2025
Back to Audit, Performance and Risk Committee — 27 March 2025 and its agenda
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Audit, Performance and Risk Committee Thursday, 27 March 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, 27 March 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 30 January 2025 5 - 8 4. Action Log of Meeting of 30 January 2025 9 - 10 5. Quarter 3 (October - December 2024) Performance Report - Adult Services 11 - 42 6. Quarter 3 Performance Report for Children and Families and Justice Social Work 43 - 76 7. Internal Audit Section - Update Report 77 - 94 8. Update on the Delivery of the Unpaid Carers Strategy 95 - 116 9. External Audit Plan for the Year Ending 2024-25 and Update on Recommendations from 2023-24 117 - 198 Page 1
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10. Internal Audit Plan Year Ending 31 March 2026 199 - 218 11. Moray Integrated Community Equipment Store Audit 219 - 224 Item(s) which the Committee may wish to consider with the Press and Public excluded 12. CONFIDENTIAL Internal Audit Section - Completed Projects - NHS Grampian Reviews • 9. Information on terms proposed or to be proposed by or to 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) Ms Sonya Duncan (Member) Ms Deborah O'Shea (Member) Ms Judith Proctor (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, 30 January 2025 Council Chambers, Council Office, High Street, Elgin, IV30 1BX PRESENT Mr Sean Coady, Councillor Scott Lawrence, Mr Derick Murray, Ms Deborah O'Shea, Ms Judith Proctor, Mr Sandy Riddell, Councillor Ben Williams APOLOGIES Ms Deirdre McIntyre, Mrs Jeanette Netherwood IN ATTENDANCE Corporate Manager; Angela Pieri, Engagement Lead, Grant Thornton; Interim Chief Social Work Officer/Head of Service; Chief Internal Auditor; Service Manager, Primary Care Contracts; Lizette Van Zyl, Social Work Service Manager and Caroline O'Connor, Committee Services Officer. 1. Chair The meeting was chaired by Mr Sandy Riddell. 2. Declaration of Member's Interests The Committee noted there were no declarations of member's interests. 3. Minute of meeting of 26 September 2024 The minute of the meeting of 26 September was submitted and approved. 4. Action Log of Meeting of 26 September 2024 The Action Log of the meeting of 26 September 2024 was discussed and updated accordingly. 5. Quarter 2 (July to September 2024) Performance Report Item 3. Page 5
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The meeting had before it a report by the Corporate Programme Manager updating the Committee on performance as at Quarter 2 2024 (July-September). With reference to the graphs contained in Emergency Admissions in Appendix 1, Mr Murray noted the significant increase in targets and asked whether the targets are set locally or nationally and if there was any specific reason for the increase. In response, the Chief Officer advised the figures are set nationally however suggested the red line may be a trend line rather than a target line as targets are not shifted routinely. She further stated it could be that they are targets and the trajectories have been adjusted based on understanding of the intelligence, and therefore agreed to provide Committee with an email update. The Chair expressed concern in relation to paragraph 5.2 which detailed recruitment in care had reached maximum number of hours available for provision and if care was not available, noting this would impact on other system pressures. In response, Mr Coady confirmed there required to be a system approach and while there have been difficulties recruiting internally to the care at home service, the recruitment situation was improving and by the end of March predicted the service will be 224 hours under 6,368 hours that they actually have. He advised this was mainly due to improved attrition as a result of improved terms and conditions and positive development and training of staff. External partners CQS have also provided assurances they will be able to increase their hours as a result of a block contract from January to end of February. Further work is being done in terms of the proportionate care programme to review those who have two carers, four times per day with a view to reducing where possible. In response to a question from Councillor Lawrence relating to the increase in National Insurance contributions which would affect the private providers more than internal employee, the Chief Financial Officer advised that this would be a budget pressure for next year and whilst more information is to come on the funding being provided by the Scottish Government, indications were that this would only cover half. Information from providers is being collated from providers to assess the implications. Following consideration the Committee unanimously agreed to:- (i) note the performance of local indicators for Quarter 2 (July to September 2024) as presented in the Performance Report at Appendix 1; and (ii) note 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. 6. Quarter 2 (July to September) Performance Report for Children and Families and Justice Social Work The meeting had before it a report by the Interim Chief Social Work Officer/Head of Service informing the Committee on Children and Families and Justice Social Work performance as at Quarter 2. In relation to Child Protection Activity referenced at paragraph 4.5(a), Mr Murray asked whether there were figures for August 2024 that could be compared rather than having to wait until after August 2025 when the national data was available. In response the Interim Chief Social Work Officer advised comparator and benchmark Page 6
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work is done on a regular basis and confirmed local comparator information could be shared should there be another report prior to release of the national information. Thanking the Interim Chief Social Work Officer for the work done by the team in preparing the report, the Chief Officer asked that future reports set out the key messages with how the information details what is being done well in terms of looking after children and young people and what the information details in terms of areas of concern where support or service change may be appropriate. Following consideration the Committee unanimously agreed to:- (i) note the performance of local indicators for Quarter 2 as presented in the Performance Report at Appendix 1; and (ii) note the analysis of the local indicators as detailed in Appendix 1. 7. Internal Audit Section - Update Report The meeting had before it a report by the Chief Internal Auditor providing Committee with an update on the work of the Internal Audit Section. The Chief Internal Auditor confirmed that an agreement has now been obtained for the reporting of internal audit reports from the NHS Grampian Internal Audit Provider, of interest to the MIJB, to future Audit, Performance and Risk Committees. Following consideration the Committee unanimously agreed to note the contents of the report. 8. Internal Audit Section Completed Projects Report 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. 9. Children’s Services Joint Inspection Improvement Plan 2024 The meeting had before it a report by the Interim Chief Social Work Officer/Head of Service providing 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. The Chair, recognising the extremely complex governance arrangements and the capacity required to support the groups, asked if there was any overview to ensure the structure is working effectively. In response the Interim Chief Social Work Officer advised he was unaware of issues of non-attendance however where there is a pattern of non-attendance, it is incumbent on chairs of groups to raise with the appropriate partners as well as the individuals. The Chief Officer advised she is a member of the Chief Officers Groups in relation to services she is responsible for and confirmed conversations are held at those meetings in terms of the ability of agencies to support and there is open challenge and commitment of all chief officers to ensure the correct people attend the group to provide assurance. Following consideration the Committee unanimously agreed to:- Page 7
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(i) 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. 10. Payment Verification The meeting had before it a report by the Head of Service / Deputy Chief Officer providing an update on the review of the Payment Verification Assurance Service provided by National Services Scotland Practitioner Services Divisions, on behalf of NHS Grampian. Following consideration the Committee unanimously agreed to:- (i) note the arrangements in place for 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. 11. Update on Improvement Plan for Adult Social Care Commissioning [Para 6.2.2] The meeting had before it a report by the Interim Head of Service / Chief Social Work Officer updating the Committee of progress on the Improvement Plan for Adult Social Care Commissioning. Following consideration the Committee unanimously agreed to:- (i) note the progress of the Improvement Plan attached as Appendix 1; (ii) note the progress within this report as at the end of November 2024 in relation to the recommendations detailed in the Improvement Plan; and (iii) approve the extension required to bring contracts into date to April 2025. Page 8
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MEETING OF MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE THURSDAY 30 JANUARY 2025 ACTION LOG Item No. Title of Report Action Required Due Date Action By Update for 27 March 2025 1. 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 Due to new template from Scottish Government, new HSCM H&S Delivery Plan and Workforce Delivery Plan now scheduled for later 2025. 2. 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 On today’s agenda 3. Q2 Performance Report Chief Officer to issue email update with information relating to the rise in targets detailed in Emergency Admissions graphs in Appendix 1. Chief Officer In Progress Item 4. Page 9
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 27 MARCH 2025 SUBJECT: QUARTER 3 (OCTOBER - DECEMBER 2024) PERFORMANCE REPORT – ADULT SERVICES BY: CORPORATE PROGRAMME MANAGER 1. REASON FOR REPORT 1.1 To update the Committee on adult services performance as at Quarter 3 2025 (October – December 2024). 2. RECOMMENDATION 2.1 It is recommended that the Committee consider, scrutinise and note: i) the performance of local indicators for Quarter 3 (October to December 2024) as presented in the Performance Report at Appendix 1; ii) the analysis of the highlighted local indicators and actions being undertaken to address performance that is outside of acceptable target ranges as detailed in Appendix 1; and iii) the initiatives and progress in reducing unmet need as outlined in paras 5.3, 5.4 and in Appendix 2. 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. Item 5. Page 11
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AMBER If Moray is performing worse than target but within agreed tolerance. RED If Moray is performing worse than target by more than agreed tolerance. 4.2 The detailed performance report for quarter 3 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 3 of the financial year 2024/25 are showing as improving. Six indicators are presenting as green and five are red. This represents an improved performance compared to quarter 2 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 - GREEN 4.5 There was a decrease in the rate per 1,000 this quarter to 19.7. This is below the numbers presenting in the last 3 quarters. This measure has been maintained around the target since October 2023. DELAYED DISCHARGES – RED 4.6 The number of delays at the December quarter 3 snapshot was down to 33, significantly higher than the target but it is a significant reduction from 40 in quarter 2 and down on the 37 recorded this time last year. 4.7 Bed days lost due to delayed discharges decreased to 981 this quarter, down from quarter 2 this year and the same period last year. Whilst this is positive, the figure does fluctuate. EMERGENCY ADMISSIONS – GREEN 4.8 Whilst there has been some small movement the indicators for Emergency Admissions all remain below target. The rate of emergency occupied bed days for over 65s has remained static at 2,604 this quarter, emergency admission rate per 1000 population for over 65s has increased this quarter to 183.6 but remains below target. Similarly, the number of people over 65 admitted to hospital in an emergency had hit a high of 133.2 in quarter 2 2023/24 but despite a small increase this quarter, remains below target at 127.5. HOSPITAL RE-ADMISSIONS - GREEN 4.9 The 7-day re-admissions have decreased to below target at 3.1%, and the 28- day re-admissions have decreased further to well below target at 7.9%. MENTAL HEALTH – RED 4.10 There has been a reduction in the percentage of patients commencing psychological therapy in Q3 to 44% at the end of quarter 3 2024/25 from 52% in the same quarter last year and is down on Quarters 1 and 2 this year. Page 12
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STAFF MANAGEMENT – RED 4.11 Sickness absence for NHS employed staff has remained high, with a slight increase to 7.0% at the end of quarter 3 2024/25. Council employed staff sickness has remained at 7.34%, which is well above target but it is an improvement on the levels experienced in 2023/24. Page 13
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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. Targets have been updated from Q1 2425 using average of activity for previous calendar year. *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) Page 14
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5. AREAS NOT MEETING TARGETS Delayed Discharge - Red 5.1 The number of delayed discharges at the census point in December 2024 was down to 33, which is a reduction from 40 in September 2024 and a decrease on the 37 recorded in December 2023. The target set by Scottish Government for Moray is 26. The number of bed days occupied by delayed discharges was 981, a reduction from 1,115 the previous quarter. These figures are reflective of the whole system challenges, which are being managed through a number of initiatives and there are signs that the work undertaken across many teams to address the delays, is beginning to have an impact. 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. As a result of outstanding infrastructure works there is currently a risk assessment in place in Turner Hospital which impacts on the acuity of patients that they can take. There are several reasons why people are delayed, with availability of care and support in the community remaining a key challenge, especially for people living in rural locations. 5.3 In the community, the level of unmet need continues to reduce slightly but at the end of December there were still 24 people waiting in hospital and 174 in the community awaiting care packages amounting to 1,298 hours of care. There are 5 measures of unmet need (people requiring a social care assessments and care at home services) that are provided to Public Health Scotland (PHS) on a weekly basis to give an overview of the number of people waiting for a social care assessment, or a package of care. Additionally, the number of hours of care not yet provided are also monitored. The information is published regularly on PHS website and a weekly summary of trends is provided for managers, attached to this report at Appendix 2. 5.4 There are many initiatives and ongoing project being undertaken by HSCM that are seeking to reduce the delays in hospitals and to meet unmet needs. For example, ensuring the provision of care at home is maximised within available budget is a key aspect of the Strategic Care at Home workstream. Research into the type of equipment, benefits and impacts is being undertaken by the Digital Health Institute as part of the Growth Deal which will inform our Technology Enabled Care and Digital strategy which will provide other options for supporting people to live independently in their own homes. The collaborative initiative Discharge Without Delays being undertaken by partners across NHS Grampian, is aiming to reduce delays currently experienced by people who are medically fit to return home and is being facilitated by Health Intelligence Scotland. Whole system outcomes have been determined which will be incorporated into the revised performance report to this committee for 2025/26. Mental Health - Red 5.5 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 Page 15
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treatment which, within the existing available capacity to meet need, results in the time spent on the waiting list being extended. 5.6 Primary care psychological therapies is a self-referral service in line with national and local strategy and operational procedures are as streamlined as possible to maximise available resources. The service is required to triage everyone that self-refers to them and demand vastly outstrips the current resource, with not everyone self-referring being suitable for this service. This position is unlikely to change without additional financial resources to increase staffing levels. However, the implementation of a new commissioned contract improves the local context for support and potentially with other community resources being developed it may help to prevent some of the inappropriate referrals being received. 5.7 Secondary care referral rates are relatively stable and adherence to the referral criteria has ensured that all referrals received are appropriate for the service. The development of a variety of groups to meet patient’s needs has significantly contributed to this position and it is anticipated that if referrals remain at this level, they will be able to meet the 18 week target going forward. Staff Management - Red 5.8 NHS employed staff sickness absences have slightly increased to 7% which was the same as quarter 1 and Council employed staff sickness has maintained at 7.3%. These figures remain well above the 4% target for both. 5.9 Over the past year, the total sickness absence rate of NHSG employed staff in HSCM has consistently exceeded that of NHSG with a peak occurring in Jul 2024 of 7.36%. The increase in December 2024 was primarily attributed to a rise in absences related to colds, coughs, and flu. 5.10 The most common causes of sickness absence continues 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. Historically there is usually a slight increase in short term absence during quarter 3 due to an increase in respiratory illness and episodes of gastrointestinal illness which are common winter illnesses. Staff are encouraged to take up available vaccinations for Covid and flu, which will not prevent illness but should potentially lessen the acuity, intended to reduce the time of absences for staff. Page 16
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5.11 A variety of approaches are 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. 5.12 Through ‘We Care’ there is a Covid Reflection listening service available due to the 5 year anniversary in March 2025 as it is recognised this is still traumatic for some staff and there are some excellent best practice examples to share. There is also Recovery in Mental Health, Relaxation workshops and stress awareness training available to all along with an active Menopausal awareness programme, which offers training, including men only sessions and tea and talk sessions. Once for Scotland policies have helped provide consistency and reduced interpretation and the policies due out this year will be very welcome. 5.13 Sickness and attendance is a standing item on our workforce, health and safety partnership meeting agenda. Recent discussions have focussed on how HSCM 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, and the next health and safety newsletter will reiterate this. Holiday periods still see to be a period of high absence rates. This is an area under review by service managers however for quarter 3, the winter illnesses were prevalent and it would be difficult to determine if this was exacerbated by the Christmas holidays. 5.14 Sickness absence for NHSG employed staff has reduced to 5.4% in January 2025, indicating that staff may be through the worst of the winter illnesses. 6. PERFORMANCE FRAMEWORK – DEVELOPMENT 6.1 The performance management framework is under review and will be implemented early in 2025/26. There will be a review of the performance indicators and reporting arrangement to align with the delivery of the outcomes identified in the Strategic Delivery Plan, once the Delivery Plan is approved. 7. 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. Page 17
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(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 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. 8. CONCLUSION 8.1 This report provides the Committee with an overview of the performance of specified Local and National 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 18
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Appendix 1 PERFORMANCE REPORT SUPPORTING CHARTS QUARTER 3 2024/25 (1 OCTOBER 2024 – 31 DECEMBER 2024) Item 5. Page 19
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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 – GREEN ................................................................................................... 8 AE-01: ED Attendance rates per 1,000 population (All Ages) ............................................................. 8 5. Hospital Re-admissions - GREEN ..................................................................................................... 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 20
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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 6 are Green and 5 are Red. 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. Targets have been updated from Q1 2024/25 using average of activity for previous calendar year. MH and SM are LDP Standard Indicators and targets are set nationally so remain unchanged. Page 21
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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 December quarter 3 snapshot was down to 33, which is a reduction from 40 in quarter 2 and down on the 37 recorded this time last year. Bed days lost due to delayed discharges decreased to 981 this quarter, down from quarter 2 but still up from 922 in June 2024. 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 While the number of delayed discharges at census date decreased over the last quarter there is still a slight increasing trend over the last 3 quarters. Source Public Health Scotland Page 22
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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 decreased over the last quarter there is still a slight increasing trend over the last 3 quarters. Source Public Health Scotland Page 23
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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 has remained static 2,604 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 this quarter to 183.6 which is still below target and well below the high in quarter 2 2023/24 of 189.9. 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 despite an increase this quarter is below target at 127.5 in quarter 3 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 24
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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 – Increasing After a steady but small decrease in previous quarters the last quarter saw a dramatic increase in this measure. Source Health Intelligence Page 25
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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 – Increasing After a steady but small decrease in previous quarters the last quarter saw a dramatic increase in this measure. Source Health Intelligence Page 26
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Emergency Department – GREEN Health and Social Care Moray - 8 - 2022-23 Quarter 1 Performance Report 4. EMERGENCY DEPARTMENT – GREEN Trend Analysis There was a decrease in the rate per 1,000 this quarter to 19.7. This is below the numbers presenting in the last 3 quarters. 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 – Decreasing During quarter 3 the attendance rate per 1,000 population has reduced, sitting just below the target level. Source Health Intelligence Page 27
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Hospital Re-admissions - GREEN Health and Social Care Moray - 9 - 2022-23 Quarter 1 Performance Report 5. HOSPITAL RE-ADMISSIONS - GREEN Trend Analysis The 7-day re-admissions have decreased to below target to 3.1%, and the 28-day re-admissions have decreased further to well below target at 7.9%. 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 28
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Hospital Re-admissions - GREEN 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 – Decreasing 28-day Hospital Re-admissions has decreased significantly over the last year despite a spike in quarter 2. Source Health Intelligence Page 29
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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 52% of patients being referred within 18 weeks at the end of quarter 3 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 30
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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 7.0% at the end of quarter 3 2024/25. Council employed staff sickness has remained high at 7.34% which is still low when compared 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 Page 31
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Staff Management - RED Health and Social Care Moray - 13 - 2022-23 Quarter 1 Performance Report National Health & Wellbeing Outcome 1, 2, 3, 5 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 32
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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 33
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Staff Management - RED Health and Social Care Moray - 15 - 2022-23 Quarter 1 Performance Report APPENDIX 2: STRATEGIC PRIORITIES Page 34
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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 35
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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 36
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APPENDIX 2 Unmet Need – Trends The numbers being reported represent people whose quality of life may be diminished, either through remaining in hospital longer than necessary, or from not receiving the care they have been assessed as requiring. The data suggests that the situation has started to improve, the long term project and initiatives, early intervention and prevention efforts all starting to have a positive impact in reducing the numbers of people experiencing delays in receiving support along their care journey. 1. Number of people waiting for a social care assessment (figure 1) The number of people waiting for a social care assessment overall has decreased from 57 in February 2024 to 36 at the end of February 2025. 2. Number of people assessed and waiting for a Care at Home package (figure 2) The number of people assessed and waiting for a package of care in the community has decreased from 211 at the end of February 2024 to 167 at the end of February 2025. This is a 20.9% reduction. The number of people assessed and waiting for a package of care in hospital has decreased from 42 at the end of February 2024 to 27 at the end of February 2025. This is a 35.7% reduction. 3. Number of hours of care yet to be provided for assessed individuals (figure 3) The number of hours not yet provided for people in hospital continues to vary weekly, but has gradually decreased over the past year from 462 hours in February 2024 to 410 hours in February 2025. Similarly, there has been a decrease for people in the community over the same period from 824 hours to over 663 hours. 4. Number of additional hours of care assessed as needed and not provided for those already in receipt of a care package (figure 4) For this measure we are looking at those people who already receive some Care at Home but not the full package they have been assessed as requiring. This can be because of a short term requirement after a period of ill health or a long term increase following a care review. At the end of February 2024 there were 506 additional hours required for those already in receipt of a package, at the end of February 2025 this figure has decreased to 284. Following consultation with other Health and Social Care Partnerships (HSCP) those being included in this measure have since been revised and the number continues to decrease. This was due to miscounting those in receipt of a reablement package or assistance from NHS teams as being in receipt of a care package. Item 5. Page 37
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APPENDIX 2 Page 38
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APPENDIX 2 Unmet need in Moray1 Figure 1 Figure 2 1 Dashboard - People requiring a social care assessment and care at home services 25 February 2025 - People requiring a social care assessment and care at home services - Publications - Public Health Scotland Page 39
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APPENDIX 2 Figure 3 Figure 4 Page 40
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APPENDIX 2 Notes on Data • Data within this release are provisional and may change as a result of data quality investigations. Each title is cited with ‘P’ to acknowledge the provisional nature of the data. • Following collaboration with various partners, the data definitions for this collection were revised and improved. The first submission of data using these new definitions was on 15 January 2024. This is illustrated by the black line in the graphs. Comparison of figures before and after this definition change should be done with caution and in conjunction with the data quality notes. • Where a partnership is unable to provide a hospital/community breakdown, an overall total is provided and presented under community. • Where a partnership is unable to provide a weekly snapshot figure, the previous submitted figure is used until the correct figures for the missing snapshot week are submitted. • Backfilled data is presented by a dotted line in the graph. • The number of hours of care at home assessed as needed for people requiring care at home (both new packages and alterations to ongoing packages) may fluctuate each week. Changes in this will reflect the variation in both the number of people waiting for a care at home package and the differing level of care packages required for each person Page 41
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 27 MARCH 2025 SUBJECT: QUARTER 3 (OCTOBER TO DECEMBER 2024) PERFORMANCE REPORT FOR CHILDREN & 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 3 (October to December 2024). 2. RECOMMENDATIONS 2.1 It is recommended Committee scrutinise and note: i) the performance of local indicators for Quarter 3 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 Moray Integration Joint Board (MIJB) 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 MIJB and the functions delegated by NHS Grampian and Moray Council for Children, Families and Justice Social Work services to allow wider scrutiny by the Board. 4. SUMMARY 4.1 Work is underway to develop and agree the refresh of Moray’s key performance indicators to enable recording of local data and measure set 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 43
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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 Q1 from page 1 to 11, Financial Q3 data is from page 12 to 30. Any trends of anomalies in this data are considered through the CPC Data Sub-group 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. Child Protection activity 4.5 At the end of this Child Protection (CP) Quarter 1, 69 children were registered on the North East Child Protection Register (NECPR) at a rate of 3.9 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 the data to be benchmarked at that point. Unfortunately, there is no reliable way comparisons can be tested before this information is officially published. The trends for Moray can be considered and interrogated in line with the questions this presents over previous years. Looked After Children 4.6 At the end of Financial (Fin) Quarter 3, 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 12.1 based on the most recent comparator statistics which date from 2022-23. This figure includes 9 New Scots (formally Unaccompanied Asylum Seeking Children (UASC)) and 6 children who are cared for on a part time basis (Short Breaks). 4.7 90% (47/52) 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. 4.8 The target for children living with kinship carers is adjusted annually to the median of comparator authorities which was 28% for 2022/23 (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 25% of looked after children in Moray are in approved Kinship care with family members. Moray is currently 3% below this median. Resultantly, work is being undertaken to strengthen practice, ensuring children, at the point of allocation, have a holistic extended family map produced, regularly updated, providing clear information on Kinship care options in the event short breaks or alternative care may be considered in the future. 4.9 17.1% (30/175) of 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 will be the preferred option when it is safe and appropriate, where possible) is adjusted annually to the median of comparator Page 44
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authorities (15% for 2022/23). This figure includes six 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 13.7% (24/175) which is 1.3% lower than the median of comparator authorities. However, in common with most of the comparator local authorities, Moray are higher than the Scotland national percentage of 10%. 4.10 89% of brothers and sisters remain together in care. The Maintaining Relationships Project is developing an approach and policy to ensure brothers and sisters are able to remain together as far as possible and where this is their assessed needs. Due to resource limitations, this is much more difficult to achieve when there is need to accommodate large family groups. 4.11 For New Scots, Moray has not adopted the residential homes model used by other local authorities. Moray’s model comprises of a combination of local authority housing and supported lodgings care and support. As such, the uncertainty regarding the future numbers of New Scots should not have an impact on residential care capacity for Moray. 4.12 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 New Scots and Short-term breaks are included within Looked After numbers. Not all comparator authorities do this so an exercise is being undertaken to consider what is being recorded by them. Justice and Youth Justice 4.13 At the end of Financial (Fin) Quarter 3, there were 532 people supported by Justice and Youth Justice Services of whom 44 are care experienced young people (CEYP) (Youth Justice 13 and Justice 31). 4.14 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 8.3% at the end of Fin Quarter 3. There has been a slight increase of 1.1% from Fin Quarter 2 and 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. 4.15 The majority of individuals supported by Youth Justice and Justice Social Work are male (86.4% Justice Social Work, 87.5% 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. 4.16 The Justice Social Work Service submitted 100% of reports to Court by their due date. This includes requests from Moray’s local Court and nationally. 5. KEY MATTERS RELEVANT TO RECOMMENDATION 5.1 Detailed charts and indicator data is attached in Appendix 1. 6. SUMMARY OF IMPLICATIONS Page 45
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(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, Families and Justice Social Work Senior Management Team, IJB Operational Management Team (OMT). 7. CONCLUSION 7.1 This report provides the MIJB 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 46
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APPENDIX 1 1 | P a g e CHILDREN & FAMILIES AND JUSTICE SOCIAL WORK - QUARTER 3 (OCT-DEC 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 CHILD PROTECTION (CP) QUARTER 1 WHICH IS LATEST AVAILABLE DATA (AUG TO OCT 2024). At the end of the CP Quarter 1, 687 referrals were made to the Access Team for 534 children (as per graph 1). Graph 1: CP Quarter 1 - 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. Number of referrals can be more than the number of children, as we can receive referrals from a range of sources about the same child. Pie chart 1: Sources of referral 233 267 187177 193 164 0 50 100 150 200 250 300 Aug-24 Sep-24 Oct-24 Referrals Referrals: No. in last month Referrals: No of children 286 112 115 89 85 Sources of Referral Police Education Health and Social Work Family & Community Other Agency Item 6. Page 47
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APPENDIX 1 2 | P a g e In CP Quarter 1, 41.6% of referrals were from the Police (286), followed by Health and Social Work 16.7% (115), Education 16.3% (112), Family and or Anonymous 12.9% (89), and 12.4% coming from other professionals (85) (as per pie chart 1). Where the number of referrals is 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. 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 1, 64 children were involved in 47 IRDs. Of the 64 children, 23 had been subject to two or more IRDs in the past (36%). 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 1 came from Social Work (44% [28]), followed by Police (19% [12]) and Education (19% [12]). 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 Northeast Child Protection Register (NECPR/CPR/Register). Pie chart 2: Main reasons for IRD 24 87 31 2 9 3 7 Reasons for IRD Physical Assault Sexual Assault Domestic Abuse Other reason Child Criminal Expl Child Sexual Expl Drugs Mental Health Neglect 66 65 63 47 47 125 105 89 84 64 0 20 40 60 80 100 120 140 Q1 Q2 Q3 Q4 Q1 No. of IRDs and Children involved No. of IRDs held No. of Children involved Page 48
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APPENDIX 1 3 | P a g e As per chart above, throughout CP Quarter 1, physical assault remains a consistent reason for an IRD being held (24, 37.5%), followed by drugs (9, 14%), sexual assault (8, 12.5%), neglect (7, 11%) and domestic abuse (7, 11%). Pie chart 3: Child protection concerns During CP Quarter 1, Neglect, Domestic Abuse, Parental Drug Use and Child affected by parent/carer mental ill health are the main child protection concerns. *Note there may be more than one concern documented for each child. Following the IRDs, 17 Child Protection Investigations were carried out, 12 Initial Child Protection Planning Meetings were convened, and 21 Joint Investigative Interviews were requested. Graph 3: Joint Investigative Interviewing Graph 3 shows the trend across the year 2023/24 for joint investigative interviews and Scottish Child Investigative Interviews. 18 2 22 12 24 8 12 22 3 6 CP Concerns as at 31 Oct 24 Child Affected by Parent/Carer Mental Ill-Health Child Criminal Exploitation Domestic Abuse Emotional Abuse Neglect Other Concern(s) Parental Alcohol Misuse Parental Drug Misuse Physical Abuse Services Finding It Hard to Engage 16 26 9 12 12 9 7 7 13 10 4 7 8 713 22 8 11 9 6 7 7 13 9 4 7 8 7 3 4 1 1 3 0 0 0 0 1 0 0 0 0 0 5 10 15 20 0 10 20 30 Aug-23 Sep-23 Oct-23 Nov-23 Dec-23 Jan-24 Mar-24 Apr-24 May-24 Jun-24 Jul-24 Aug-24 Sep-24 Oct-24 JIIs using Scottish Child Interview Model JII: No. of children subject to a JII as decision of IRD JII: No. of JII by SCIM as decision of IRD JII: No. of JII by 5 day process as decision of IRD JII: No. of children who declined/or did not complete JII Page 49
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APPENDIX 1 4 | P a g e Graph 4 – JII & SCIM Graph 4 shows the activity of Joint Investigative Interviewing across CP Quarter 1, during which 23 children were recommended for Joint Investigative Interview (JII); 17 interviews were completed and six children either declined or a different form of interview was carried out. 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. At the end of CP Quarter 1, 12 Initial and Pre-birth Child Protection Planning Meetings were held for 22 children of these, 22 children’s names were place on the register. 8 13 16 23 8 11 22 17 32 41 17 12 22 5 5 9 13 7 6 10 9 16 22 10 7 12 0 5 10 15 20 25 30 35 40 45 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 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 No. of Children and ICPPMs and Pre-Birth CPPMs Number of children subject to Initial and Pre-Birth CPPMs Number of Initial and Pre-Birth CPPMs Page 50
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APPENDIX 1 5 | P a g e Graph 6: Conversions from IRD to ICCPM Graph 6 above shows the trend from 2020 through to 2024 and specifically CP Quarter 1, where the conversion rate from ICPPM to Child Protection Registration was 100%. During CP Quarter 1, there were 18 Review Child Protection Planning Meetings (RCPPM) held for 37 children, where their circumstances were reviewed with their families, lead professionals and independent advocates, to assess if the identified risks had been sufficiently reduced to consider removing the child’s name from the register. 13 20 28 30 8 18 16 25 8 10 22 18 25 39 19 14 34 75 78 100 76 100 77 94 91 75 73 45 78 78 83 94 75 100 0 10 20 30 40 50 60 70 80 90 100 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 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 Aug- Oct 2020/21 2021/22 2022/23 2023/24 2024/25 Conversion Rates % IRD to Initial and Pre-Birth CPPMs % Initial and Pre-Birth CPPMs to Registration 687 referrals 47 IRDs 17 CPIs 12 ICPPMs The conversion rate from referral to IRD is 6.8% The conversion rate from IRD to CPI is 37% Conversion rate from CPI to ICPPM is 70.6% Page 51
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APPENDIX 1 6 | P a g e Graph 7: Child Protection Registration Trends The trend is depicted across Graph 7 from 2021-2024 and shows in CP Quarter 1, that 19 children were de-registered and 22 new children were registered. This meant at the end of CP Quarter 1, the number of children who were on the Child Protection Register (CPR) had increased by 3 (from 66 to 69). Graph 8: Child Protection Registration Comparator Authority Trends (up to 31 July 2023) 5 10 15 21 6 8 9 14 25 34 16 9 2231 35 44 50 42 37 27 32 50 79 70 66 69 9 6 6 15 14 13 20 9 9 5 25 13 19 0 10 20 30 40 50 60 70 80 90 100 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 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 2021/22 2022/23 2023/24 2024/25 Child Protection Register Number of Registrations Number on Register Number of De-registrations Page 52
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APPENDIX 1 7 | P a g e Graph 9: Number of Child Protection Registrations Comparator Authority Trends (1 August 2022 to 31 July 2023) Chart 10: Number of Child Protection Deregistration Comparator Authority Trends (1 August 2022 to 31 July 2023) Pie chart 4: CP Quarter 4 registration reasons Page 53
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APPENDIX 1 8 | P a g e Graph 11: Registration Categories Graph 11 above shows the trend in registration categories across the reporting period (from August 2023 to October 2024). There has been a rise in new registrations for the category Child affected by parental mental ill-health, with figures showing an increase from no new registrations in CP Quarter 4 (May-July 2024) to 5 in CP Quarter 1 (Aug-Oct 2024). 12.5% of IRDs were 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. 3 1 6 8 6 8 5 1 7 11 4 4 2 3 5 3 3 3 3 16 1 2 8 3 1 5 5 4 1 1 2 8 9 13 2 4 2 3 4 0 2 4 6 8 10 12 14 16 18 Q1 Q2 Q3 Q4 Q1 Registratration Categories Other Concern Neglect Criminal Exploitation Emotional Abuse Physical Abuse Parental Drug Use Parental Alcohol Use Domestic Abuse Child experiencing mental health problems Child Affected by Parent/Carer Mental Ill-Health Services find it hard to engage Page 54
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APPENDIX 1 9 | P a g e 37.5% 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 12: Family Groups As shown in Graph 12, at the end of CP Quarter 1, there were 15 family groups consisting of one child, five family groups with two children and 10 family groups of three or more children on the register. Graph 13: Previous Registrations At the end of the CP Quarter 1, there were 27 children on the register who had one previous registration and 14 with two or more previous registrations. Two children’s names were placed back on the register within 24 months of de-registration (as indicated in Graph 13). 12 5 15 9 8 14 10 7 12 0 2 4 6 8 10 12 14 16 CPR Family Group: 3 or more CPR Family Group: 2 CPR Family Group: Single child Family Groups on Moray CPR Aug-24 Sep-24 Oct-24 15 24 22 25 27 8 10 7 8 14 0 5 10 15 20 25 30 Q1 Q2 Q3 Q4 Q1 Previous Registrations on Moray CPR No. of children with 1 previous registration No. of children with more than 2 previous registration Page 55
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APPENDIX 1 10 | P a g e Graph 14: Time on Moray CPR Graph 15: Age of children on the register 1 5 9 26 31 1 5 14 21 24 1 5 9 23 24 0 5 10 15 20 25 30 35 > 2 years 18 mths < 2 years 1 year < 18 mths 6 mths < 1 year <6 months Time on Moray CPR Aug-24 Sep-24 Oct-24 1 1 1 1 1 1 1 4 12 15 18 25 29 37 36 26 22 22 21 22 20 21 1716 20 20 22 25 26 24 26 26 26 24 24 25 25 25 9 10 11 13 15 15 15 18 18 18 19 19 19 16 20 1 1 1 1 1 1 1 1 1 2 3 0 5 10 15 20 25 30 35 40 Age Bands on Moray CPR Unborn 0-4 5 - 10 11 - 15 16+ Page 56
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APPENDIX 1 11 | P a g e Graph 15 shows the trend for 2023/24 against CP Quarter 1 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 fluctuated since the end of the previous quarter (July 2024). Page 57
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APPENDIX 1 12 | P a g e THE FOLLOWING SECTIONS REPORT AGAINST THE FINANCIAL QUARTER (OCT-DEC 2024) Graph 16: Number of children looked after away from home and at home Graph 16 identifies that at the end of Financial (Fin) Quarter 3, there were 175 children who were looked after by Moray. This figure has remained relatively stable throughout the reporting period. Over the previous quarter there has been a steady decline in the numbers of Looked After Children. This reflects the wider approach of supporting children and their families without the need for them being Looked After either at home or in other care settings. Pie chart 5: Care setting categories At the end of Fin Quarter 3, 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, 89% of brothers and sisters remain together in a care setting. Brothers and sisters 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. 176 178 185 187 183 180 182 172 172 177 179 175 173 175 177 176 175 160 165 170 175 180 185 190 No. of Looked After Children 52 11 6 1246 37 1 9 1 Children in Care Settings Foster Care Residential in Moray Short Breaks /Shared Community Care Out of Area Kinship At Home Pros Adopters New Scots Secure Page 58
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APPENDIX 1 13 | P a g e Foster care (52) and kinship care (46) are the highest categories followed by children looked after at home (37). Our residential houses (11) remain at approximately the same level as the Out of Area residential category including Secure Care (13). The carer recruitment campaign has seen new 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 (145, 82.9%) rather than residential care (30, 17.1%). There remains the commitment to support young people in family-based care settings. This includes supporting families to identify and promote kinship care options via Family Group Decision Making processes. At the end of Fin Quarter 3, 13.7%, 24 of our looked after children were cared for on a full- time basis in residential care. If short breaks are included the figure increases to 17.1%. 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, highlighting our priority to support young people in family-based care, where possible, to provide a positive model of family life. One young person was remanded in secure care from November 2023 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 nine young people who are New Scots (formerly Unaccompanied Asylum Seeking Children) 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 or Supported Accommodation care settings. 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 17: Moray foster care households 35 36 37 37 36 35 36 27 27 25 25 28 31 31 0.00% 20.00% 40.00% 60.00% 80.00% 100.00% 0 5 10 15 20 25 30 35 40 Q1 Q2 Q3 Q4 Q1 Q2 Q3 2023/24 2024/25 Moray Foster Carers No. of Moray Council Fostering Households No. of Moray Council Foster Carers with 'Active' placements % of Foster Households who are 'active' Page 59
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APPENDIX 1 14 | P a g e At end of Fin Quarter 3 there were 52 children living in foster care, with 47 (90%) children living with Moray Council foster carers and 5 (10%) living with independent foster carers. Those young people living with independent foster carers are all in long-term care with Permanence Orders. Of our 36 fostering households, 86.1% are actively caring for a child. Not all fostering households have children living in their care. At the end of Fin Quarter 3 this comprises 5 (13.8%) 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. The Fostering Team is undertaking work to broaden the approvals capacity of Moray foster carers. This will enable them to care for a wider group of young people where they will be provided with additional support and advice. Graph 18: Children who live in foster care Graph 18 identifies the number of children cared for by Moray foster carers, 47 which is a slight increase from Fin Quarter 3 in 2023 which was 45. 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 accompanied by work to achieve greater retention rates. This is focused on supporting foster carers including improved 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. The reporting process for Children and Families and Justice Social Work is developing which includes reviewing its scope. An area which is currently not reported on is Young Carers. There are current discussions exploring what reporting is available and how this can be purposefully presented within this report. It is planned for reporting in relation to Young Carers to be available for Fin Quarter 4. 44 43 45 47 45 48 46 45 47 46 51 51 50 48 47 47 47 11 11 7 7 7 7 7 6 6 6 6 6 6 6 6 6 5 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 60
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APPENDIX 1 15 | P a g e Graph 19: 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. Moray is seeking to increase the numbers of kinship households. This is to ensure more children and young people can remain within their own communities and network of family and friends. It is envisaged that the numbers of kinship households will increase via the use of, for example, Family Group Decision Making processes. Graph 20: Residential care Residential care is divided into those in residential care in Moray and those out with Moray. Children cared for in 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 11. 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 12. 30 32 29 31 32 30 29 30 31 29 29 29 29 28 30 28 25 30 29 26 26 32 34 32 31 30 32 33 32 32 31 33 31 32 10 14 14 16 11 7 9 10 12 9 7 8 8 8 9 9 5 0 10 20 30 40 50 60 70 80 Kinship Care Settings Kinship: No. of Children in Pre-Approved Placements Kinship: No. of Children in Approved Placements Kinship: No. of households providing Kinship Placements 13 14 14 14 13 12 13 12 12 13 13 12 11 10 12 12 11 11 11 11 11 11 11 11 10 10 11 11 9 9 11 12 12 12 0 5 10 15 20 25 30 Residential Care Settings Residential Care Settings in Moray Residential Schools or Out of Area Care Settings Page 61
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APPENDIX 1 16 | P a g e Work is underway to reduce the number of young people in Out of Area care which is expensive and does not geographically support young people in maintaining relationship in Moray including health, education, family and friends. Residential care settings can be the correct care setting for some children and young people, often due to previous unsuccessful multiple family care arrangements. However, in most cases, a family-based setting is preferrable as it better prepares young people for adulthood as they have a positive model of family life. For those young people in residential care, there is significant preparation via independent living skills to support them in the transition to adulthood. Graph 21: Through care after care data As illustrated in Graph 21, as at 31 December 2024, there were 72 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 Council 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 given the opportunity to remain where they are living potentially until the age of 21. This is a key responsibility for the organisation and partners as corporate parents. The team is responsible for supporting New Scots (formerly Unaccompanied Asylum Seeking Children) via the National Transfer Scheme. This is an increasing workload for the team, 40 42 46 30 19 17 10 9 9 0 5 10 15 20 25 30 35 40 45 50 Oct-24 Nov-24 Dec-24 Through Care, After Care and Continuing Care TCAC: Open as Through Care TCAC: Open as Aftercare TCAC: Open as Continuing Care Page 62
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APPENDIX 1 17 | P a g e which is dependent, in part, on the numbers of young people arriving in Kent, making future forecasting a significant challenge. The team offers considerable support to young people after they leave care (After Care) up to the age of 26. There is a commitment to offer the same support birth families provide for young people who are transitioning into adulthood. This is a key element of Moray Council’s and Health and Social Care Moray’s responsibilities as Corporate Parents. Justice and Youth Justice. Graph 22: Care experienced young people supported by Justice Services Nationally, care experienced young people (CEYP) are overrepresented in the Scottish Justice Systems. At the end of Fin Quarter 3, 8.3% (44 of 532) were CEYP (up to age 26) within the Justice System (Youth Justice 13, Justice Social Work 31) depicted in graph 22, showing an increase of 1.1 percentage points from 7.2% at end of Fin Quarter 2. This figure has consistently remained below 12% throughout 2023/24 although the percentage has risen since June 2024. Work continues to identify CEYP and offer early assistance and support where possible. The aim is to address identified needs and risks to reduce re-offending rates and maximise support to reduce the length of time they are supported by justice services. Research informs that early entry or prolonged exposure to the criminal justice system can draw young people into the system rather than rehabilitate and divert from the system. 435 424 421 424 403 415 422 450 440 449 443 466 472 478 477 492 44 42 42 44 42 43 39 37 35 31 34 34 36 40 40 44 0 1 2 3 4 5 6 7 8 9 10 0 100 200 300 400 500 600 Care Experienced People in the Justice System Open to Justice Team Open to Youth Justice % CEYP open to both MYJ and JS Page 63
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APPENDIX 1 18 | P a g e Graph 23: Ages of young people in Youth Justice The average age of a young person receiving Youth Justice services is 15 years old which has remained consistent over the last two quarters. Most work undertaken is with children aged 11 to 15-years-old, highlighting the need for the service to work alongside education services to support young people to remain in education and meet their full potential. Whilst the team works with all schools throughout Moray, it has strong links with Moray Social, Emotion and Behavioural Needs Service (SEBN) where support is offered for social, emotional and behavioural needs. Young people aged over 18 years in the Justice Social Work Service, the Youth Justice Service usually has the most meaningful relationship with the young person to more effectively offer support and planned transitions between Youth Justice and Justice Social Work which can help minimise any impact on the young person. Pie chart 6: Gender of young people in Youth Justice Pie chart 7: Gender of individuals in Justice Services At the end of Fin Quarter 3, most individuals supported by Youth Justice were males accounting for 87% of young people supported by the service. There was a small increase from the previous Quarter which will continue to be monitored to ensure programmes and support offered are appropriate to address any emerging need from identified trends. 33 29 31 30 24 22 22 27 21 22 21 21 21 21 21 25 28 00000000000000000000 14 15 14 15 15 14 15 14 13 16 13 15 10 7 7 8 9 00000000000000000000 2 0 0 0 1 1 1 3 4 2 2 1 0 1 0 3 3 00000000000000000000 49 44 46 46 41 38 39 45 38 40 36 37 32 30 35 36 40 0 10 20 30 40 50 60 Age Bands - Youth Justice YJ: Age Band: 5-10 YJ: Age Band: 11-15 YJ: Age Band: 16-17 YJ: Age Band: 18+ YJ: No. open to Youth Justice 35 5 Gender: Youth Justice YJ Gender: Male YJ Gender: Female 425 67 Gender: Justice Service Justice: Male Justice: Female Page 64
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APPENDIX 1 19 | P a g e In Justice Social Work 13.6% of individuals supported by the service were females, which has remained relatively static over the past year. It is recognised women in the justice process 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 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. Work continues to capture the views of individuals to evaluate the impact of this service and shape its development. Graph 24: Justice social work reports (JSWR) Justice Social Work reports (JSWR) remain a priority to reduce any delays in sentencing and for Fin Quarter 3 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. Over the last year these figures have remained stable, except for an increase in Quarter 1, which was expected now Court business has returned to normal following Covid related delays. Completion of Court reports on time results in appropriate sentencing for individuals which addresses their current assessed risks and needs, and reduces time spent on remand where a community sentence is imposed. It also importantly supports a timely outcome for victims of offences. 104 104 106 103 130 107 107 96 96 90 94 121 95 95 100 100 100 100 100 100 100 0 20 40 60 80 100 120 0 20 40 60 80 100 120 140 Q1 Q2 Q3 Q4 Q1 Q2 Q3 2023-24 2024-25 Justice - SW Reports submitted on time No. Social Enquiry Reports submitted on Time No. of People % of Reports on time Page 65
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APPENDIX 1 20 | P a g e Pie chart 8: Justice Report Types 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. There has been an increase in the request for DTTO assessments during Fin Quarter 3. A DTTO is a disposal which focusses on drug treatment as the primary means of reducing offending behaviour and the assessment for this is an intense six-week period of involving support to stabilise an individual’s current situation, referrals to partner services where appropriate, and regular appointments where drug testing is carried out alongside therapeutic work. Graph 25: Structured deferred sentences (SDS) An SDS is a flexible provision with 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 supported 10, 9% 26, 25% 70, 66% Types of Report JSWR DTTO Assessment JSWR ROLO Assessment JSWR Standard 9 11 9 20 16 18 21 17 21 8 10 9 9 9 20 15 17 20 17 21 6 10 0 5 10 15 20 25 30 35 40 45 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 2022-23 2023-24 2024-25 Structured Deferred Sentences No. of Structured Deferred Sentences imposed No. of Individuals with SDS imposed Page 66
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APPENDIX 1 21 | P a g e by the service. The number of in SDS disposals in Fin Quarter 3 has risen very slightly and is comparable to Quarter 3 in the previous year. Graph 26: Bail supervision 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. Assessments are undertaken for all people where bail is being opposed by the Procurator Fiscal and are provided on the same day. There is a slight reduction in the number of assessments requested in Fin Quarter 3 and a slight increase in bail supervision orders imposed. There continues to be a significant number of assessments which do not result in bail being opposed and work is being undertaken nationally to understand trends, but data is not yet available to compare. The prison population in Scotland remains 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 27: CPO with supervision requirement Fin Quarter 3 has again seen an increase in the imposition of Community Payback Orders (CPO). Most individuals made subject to a CPO are seen on the day of sentencing, for those 1 2 4 4 17 33 34 38 59 62 50 1 0 3 4 5 2 7 15 14 13 17 1 0 3 4 5 2 7 15 14 12 17 0 10 20 30 40 50 60 70 80 90 100 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 2022-23 2022-23 2022-23 2022-23 2023-24 2023-24 2023-24 2023-24 2024-25 2024-25 2024-25 Bail Supervision No. of requests from Court for Bail Supervision No. of Bail Supervision cases commenced No. of individuals commenced with Bail Supervision 0 20 40 60 80 100 120 0 10 20 30 40 50 60 70 Q1 Q2 Q3 Q4 Q1 Q2 Q3 2023-24 2023-24 2023-24 2023-24 2024-25 2024-25 2024-25 CPOs with Supervision No. of new CPOs with Sup Req No. seen by Supervisor within 7 days % Target Met Page 67
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APPENDIX 1 22 | P a g e where this has not been possible, an appointment with their allocated social worker is made within seven days of an Order being imposed. There is a reduction in the target met during this Quarter related to individuals not attending appointments and some interruption in service in December which included a high level of staff sickness. Diversion from Prosecution Diversion from Prosecution (DfP) allows someone accused of offences to be dealt with outside of the formal justice system. 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. The Justice Social Work team undertakes all assessments of suitability; however, the Youth Justice team aids and supports 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. In Fin Quarter 3 the total numbers of assessments and cases commenced are smaller in comparison to the previous year, however, there is no clear reason for this at this stage and it will continue to be monitored. New guidance from the Scottish Government is due imminently for DfP which will provide an opportunity to review local practice in line with the new guidance. Graph 28: Diversion from prosecution: Female 6 5 8 5 2 1 3 4 1 0 0 4 0 1 2 1 0 1 2 3 8 2 2 5 2 3 3 1 1 0 0 4 4 01 2 3 8 2 2 5 2 1 2 1 0 0 0 2 4 0 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 Diversion from Prosecution: Female DFP Gender: Female DFP Commencing Gender: Female DFP Completed Gender: Female Page 68
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APPENDIX 1 23 | P a g e Graph 29: Diversion from prosecution: Male Policy, development, trauma-informed and commissioning. Staying Put- Moray’s Approach to Continuing Care Young people who are looked after and accommodated have the right to ‘stay put’ in their long-term home arranged by the local authority until they are ready to move on or reach their 21st birthday. This is called continuing care. The Children and Families Social Work Policy Team has been working with young people and professionals across the service to develop a procedure outlining local arrangements for continuing care. The consultation with young people who are currently in continuing care highlighted good practice as well as the need for a leaflet that explains the process. We worked with the Champions Board and PR colleagues to ensure that this need is met. The final draft of this procedure is now with the Chief Social Work Officer. Trauma-Informed Practice The Scottish Government’s vision for a trauma-informed nation includes a trauma-informed and responsive workforce in public services. To achieve this, an organisation must look at all its processes across several domains, both operationally and strategically, and assess them alongside the principles of trauma-informed practice, which are: Safety, Trust, Choice, 6 12 9 3 7 6 7 12 12 4 5 8 1 5 6 3 2 5 3 4 9 2 7 3 4 7 5 2 4 8 11 4 6 2 0 2 4 6 8 10 12 14 Diverson from Prosecution: Male DFP Gender: Male DFP Commencing Gender: Male DFP Completed Gender: Male “I did not notice any difference during the transition. My relationship with foster carers remained the same.” (Young person in continuing care) Page 69
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APPENDIX 1 24 | P a g e Collaboration, and Empowerment. The table below highlights the organisational domains and the key principles with which they align: Safety Trust Choice Collaboration Empowerment Physical environment Physical environment Screening, assessment and treatment services Training and workforce development Training and workforce development Progress monitoring and quality assurance Financing Financing Evaluation Engagement and involvement Cross sector collaboration Governance and leadership Policy The Scottish Government funded the role of the Trauma Informed Development Officer (also known as the Trauma Lead) to lead local authorities and their services through their own assessment, identify areas of change, and support future development. To further this work for Moray, the Trauma Lead developed a two-pronged approach. The first prong, focusing on awareness-raising, consists of an Introductory Brief which has been delivered to a variety of services, including Children’s Social Work, Human Resources and Organisational Development. The second prong, called a Walk-Through Lens of teams and services, consists of an interactive session to identify what is working well and what needs to be done to become trauma informed. Since October 2024, the Trauma Lead has been delivering these approaches, with engagement across 47 teams and services to date. The pie chart below indicates progress in this area. Pie chart 9: Introduction brief 72% 9% 19% INTRODUCTION BRIEF Delivered Arranged To be arranged Page 70
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APPENDIX 1 25 | P a g e Pie chart 10: Walk through lens Alongside the delivery of these sessions, the Trauma Informed Development Officer is leading on the review of available training on trauma-informed practice for staff across Moray Council and Health and Social Care Moray. The Q4 report shall cover the progress of this work. Training and Development During this quarter, there was no formal training activity within Children and Families Social Work, as the focus shifted towards end-of-year reflections and planning. However, key evaluation and improvement initiatives progressed. Self-evaluation and Continuous Improvement: Building on the initiation of the Children’s Services Self-Evaluation and Continuous Improvement approach, Social Work Services has begun exploring single-agency self- evaluation to identify areas for development and enhance practice as a starter for ten before a wider children’s services self-evaluative approach. Additionally, work commenced to evaluate the implementation of the Graded Care Profile 2 (GCP2), a structured assessment tool designed to measure the quality of care a child receives and identify neglect. An initial sense-check in the service suggested that GCP2 may not be widely used in practice, highlighting the need for a more detailed review of its implementation. This led to the development of a survey to gather practitioner insights, forming the basis for further analysis in the next quarter. Improvement initiative: As part of our work towards embedding a culture of continual learning and development, two Learning from Practice development sessions took place for Children and Families and Justice Services staff in November 2024. A total of 111 staff attended the sessions with good representation from all the teams. The sessions discussed the five key Social Work practice themes identified from a desktop review of historic complaints findings outlined in the figure immediately below: 15% 13% 72% WALK THROUGH LENS Delivered Arranged To be arranged Page 71
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APPENDIX 1 26 | P a g e The sessions employed a conversation café approach which ensured staff were able to discuss the learning from the themes and hear the views of colleagues from different teams. The tone of the day was positive and encouraged staff to think about what we do well and what we can do better. The sessions generated lots of ideas and suggestions for improvement. These were collated into an action plan, complete with arrangements for monitoring and evaluation, which will contribute to the plan for continual improvement and self-evaluation. The plan is in its final stages of development and shall be rolled out in the coming months. The learning and development report from the sessions, including feedback, has been distributed throughout the workforce. Commissioning The pie chart below identifies the seven main categories of the contracts held within the Children and Families and Justice Services Commissioning Team and their percentage of the budget. These categories will be further discussed below. Action plan Training and support newly qualified and qualified social workers Streamlined paperwork Creating a toolkit to engage the child’s voice Communication (with children, families and professionals) Timely actions and practices Processes (missing, outdated or not followed) The voice of children, young people and families Power imbalance and governance Page 72
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APPENDIX 1 27 | P a g e Pie chart 11: Contract categories Family support services The family support category covers three services commissioned for prevention and early intervention to avoid family breakdown and possible out of area care arrangements (Families Together, Functional Family Therapy, and Aberlour Youth Point Moray). Additionally, this category includes the independent advocacy contract. The three family support services have capacity for referrals which has been communicated across the social work teams. A total of 108 children, young people and their families have benefitted from these services during this quarter. This is broken down in the illustration below: =10815 •Functional Family Therapy 54 •Families Together 39 •Aberlour Youth Point Moray Page 73
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APPENDIX 1 28 | P a g e Functional Family Therapy Functional Family Therapy is a short term, strengths and family-based therapy programme designed to help families improve communication and relationships. The families receive therapy for a period up to six-months. This service is a prevention and early help intervention programme which aids in keeping families together. The quotation on the right demonstrated the changes one family faced in the service. Families Together This service delivers a restorative family service through a range of one to one and group sessions. It also offers a family focussed money advice service, the Family Group Decision Making approach and practical support including food parcels and school bank referrals amongst more. The service has 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 on the left breaks this area of work down to record the impact. The Family Group Decision Making process brings together a child or young person’s extended family and friends, providing a blame-free and future- focussed culture, the main aim is to repair relationships and improve the child or young person’s support network. The quote on the right illustrates the impact on one family. Aberlour Youth Point Moray Aberlour Youth Point Moray supports children and young people who struggle to remain positively engaged within their home, school or community and who require a targeted support service. It also provides support to the parents of the children and young people with whom they work. To enhance the contract monitoring and gain the views and voice of the young people and parents accessing the service, a Microsoft “I must confess we had little expectations before meeting you…we were so glad to have met you and follow the programme with all your support… to crack YP NAME and Dad, gaining their trust is quite the success…You have given us all hope for the future” Family Views on Functional Family Therapy “I feel listened to in the Family Group Decision Making process” A Parents view on Families Together “I don’t think she’d (daughter) be here if it wasn’t for YouthPoint” Parent Views on AYPM Page 74
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APPENDIX 1 29 | P a g e Form was developed and issued on 9 December 2024. The survey will close on 6 January 2025, and results will be scrutinised and summarised in the next report. Independent Advocacy Moray’s Children’s Right Service delivered by Quarriers is available to all young people and their parents, carers, brothers and sisters. This quarter saw more referrals being received for the parents, carers, brothers and sisters for the first time since this contract started. Overall, 189 young people and 133 parents, carers, brothers and sisters benefitted from the service. These numbers include 60 children who are looked after and 39 children and young people in need of protection, as outlined on the right. Throughout this quarter, the provider has supported children, young and their families in 56 meetings. This is broken down below. Pie chart 12: LAC and CP on current caseload Graph 30: Number of meetings independent advocates have attended Children with a Disability - Support Following a successful commissioning and tender process, the Children with a Disability - Group Activities contract was awarded. This contract commenced on 1 November 2024. The service aims to provide support and a natural short break for families. Children with a Disability – Residential There are currently three young people living in a residential care in Alba Place, Elgin, delivered by Aberlour Child Care Trust. This is a new contract which commenced 1 September 2024 and the first quarterly contract monitoring will be due for the period 1 September 2024 – 31 December 2024 in January 2025. Page 75
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APPENDIX 1 30 | P a g e Moray Residential Services At present there are 8 young people living in care settings in Moray. The contract expires on 31 March 2025. Following the evaluation process in November 2024, the incumbent provider was successful in retaining the contract. Implementation will begin for the changes to the contract throughout Fin Quarter 4. The quote on the right was received from one young person. Out of Area Residential Services There are 21 young people living out with Moray. Fifteen of them are in residential homes and six are in foster homes or in continuing care with a variety of care providers across Scotland. These care settings form the 50% as described in the pie chart above. Support for Unpaid Carers Following discussions with the working group and evidence received through contract monitoring, the Unpaid Carers contract is in the process of being varied to enable the completion of Adut Carers Support Plans and Young Carers Statements to be brought in- house. As shared at the Operational Management Team (OMT) on 6 December 2024, this will allow Quarriers to develop more meaningful relationships with the unpaid carers through group work, deepen relationships with schools, develop and short-breaks model as well as assess and mitigate increasing unmet need. This will also decrease the number of services people interact with, whilst ensuring that their needs are met. This has all been done in full collaboration with Quarriers, and the letter of variation (LOV) is with them for final agreement and signature. “I feel safe and secure here” Young Person in Residential Home Page 76
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 27 MARCH 2025 SUBJECT: INTERNAL AUDIT SECTION - UPDATE REPORT BY: CHIEF INTERNAL AUDITOR 1. REASON FOR REPORT 1.1 Committee is asked to consider the contents of this report; seek clarification on any points noted and otherwise note the report. 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 Global Internal Audit Standards 4.1 The Local Authority Accounts (Scotland) Regulations 2014, paragraph 7 requires that a local authority must operate a professional and objective internal auditing service in accordance with recognised standards and practices in relation to internal auditing. The recognised standards adopted by all Scottish councils are the Public Sector Internal Audit Standards (PSIAS) developed by standard setters, including the Chartered Institute of Public Finance and Accountancy and the Chartered Institute of Internal Auditors. PSIAS requires a yearly quality assessment of internal audit systems and procedures against these standards. An external quality assessment of the Internal Audit Section was reported to this Committee on 26 September 2024 (para 10 of minute refers). 4.2 The Chartered Institute of Internal Auditors has recently released the Global Internal Audit Standards (GIAS). It is intended that the GIAS will be a Item 7. Page 77
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replacement for PSIAS and provide a single source to guide the worldwide professional practice of internal auditing and serve as a basis for evaluating and further elevating the quality of the internal audit function. At the centre of the GIAS are 15 guiding principles. These principles are supported by standards that contain requirements, considerations for implementation and examples of evidence to demonstrate conformance. It is intended that a gap analysis of current systems and procedures against these new standards will be undertaken to identify areas for further development of the Internal Audit Section. This has required additional time to be included within the Audit Plan for 2025/26. Follow Up Reviews 4.3 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: Payroll - Regularity Review 4.4 The Payroll system is one of the core financial systems of the Council. A follow-up review has been undertaken to evidence the implementation of recommendations reported in the audit undertaken of the payroll system. The scope of the audit included a review of the effectiveness of key controls in the management of the Payroll Service. This involved a review of systems and procedures and testing a random sample of starters, leavers and continuing employees to verify the accuracy of payments and to provide assurance that supporting documentation was in place to support the payments. The CIPFA Control Matrices were used to develop the audit programme. The follow up review found evidence to confirm the implementation of some of the recommendations, but a revised date for agreeing on a policy/procedure in the authorisation and administration of time off in lieu for officers was required. The Follow Up Report to review the implementation of the agreed recommendations is given in Appendix 1. Foster and Kinship Care Payments 4.5 A follow-up review was undertaken to evidence the implementation of recommendations from an audit has been undertaken of the administrative arrangements for Fostering and Kinship Care Payments. The reporting template for this review is in the new format developed in consultation with the Audit Management Software Supplier. It is intended to provide greater understanding and transparency in the reporting of the findings and the implementation of recommendations by services. There will be a period of transition between the previous and current reporting formats. 4.6 The audit reviewed that the processing of fostering and kinship payments of fees and allowances are administered in accordance with agreed policies and procedures. It is pleasing to report that within the scope of the audit, the management of fostering and kinship payments was well managed. However, some administrative control improvements were noted concerning the recording of information and the introduction of additional verification checks to confirm eligibility for ongoing kinship allowance payments. The follow up review found that implementation of the recommendations has progressed, but additional checking was required regarding the verification Page 78
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of the educational status of individuals who reside outwith Moray. The Follow Up Report to review the implementation of the agreed recommendations is given in Appendix 2. 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. (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 79
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APPENDIX 1 Moray Council Internal Audit Section 1 DEPARTMENT: Education, Communities & Organisational Development SUBJECT: Payroll – Regularity Review REPORT REF: 24'023 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: Key controls and processes are operating effectively in ensuring accurate salary payments to council employees that are accounted for correctly. 5.01 Notification of Appointment Forms should be completed for appointments of Newly Qualified Teachers. Medium Yes 31/08/2024 Implemented. Item 7. Page 81
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APPENDIX 1 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 budget managers should be reminded of the timely completion and submission of a ‘’Termination of Employment Form’’ as soon as it is known that an officer is leaving the employment of the Council High Yes 30/06/2024 Implemented. A reminder was included within the September Human Resources bulletin in relation to the complete, timely and accurate submission of documentation. A subsequent reminder is planned in 2025. 5.03 Procedures relating to Time Off In Lieu (TOIL) arrangements should be agreed. Medium Yes 31/10/2024 (Revised Implementation Date 30/04/2025) Part Implemented – A policy has been drafted and is currently progressing through the approval process. Page 82
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Appendix 2 1 Final Internal Audit Report (Follow-up Review) Fostering and Kinship Care Payments March 2025 Distribution: Chief Social Work Officer Children and Families Social Work Service 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 Substantial Priority 1 0 Priority 2 1 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 7. Page 83
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Appendix 2 2 Contents Page Fostering and Kinship Care Payments 1. Introduction & Scope 3 2. Key Issues 3-4 Detailed Report 3. Findings/Recommendations 5-9 4. Management Response 5-9 Appendices 1. Audit Terms of Reference and Definitions 2. Statement of Responsibility Page 84
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Appendix 2 3 1. Introduction and Audit Scope The 2024/25 Annual Audit Plan provides for a review of the administration of Fostering and Kinship Care Payments. Fostering occurs when a child cannot be cared for by their birth parents, or by their extended family or close friends, and need to be cared for by an approved foster family. Whereas kinship care is where a child is unable to live with their birth parent and resides instead with a relative or other individual with whom they have a pre-existing relationship, e.g., a sibling or close family friend. In August 2023, the Scottish Government and COSLA agreed on the Scottish Recommended Allowance for foster and kinship carers. In addition, foster carers are also paid a weekly fee depending on their skill levels and experience. A review of the Council’s Financial Management System noted that fostering and kinship payments made to carers in 2023/24 amounted to £1.2 million and £443,000 respectively. At the time of the audit, the Council financially supports 47 children in foster care and 80 children within kinship arrangements. The audit scope reviewed policies and procedures for the management of fostering and kinship payment of fees and allowances are administered in accordance with these policies and procedures and are operating within budgetary control. The audit was carried out in accordance with Public Sector Internal Audit Standards (PSIAS). 2. Key Issues The audit found that the management and processing of fostering and kinship payments were well managed. However, some systems and administrative control improvements were noted, including: • The audit noted the Service has detailed case recording procedures to assist officers in managing foster and kinship arrangements. However, audit testing of a sample of care arrangements noted that some documents, although found, had not been saved in the correct location in accordance with agreed procedures. In addition, it was also noted a need to update the Kinship Carer Agreement between the Council and carers to reflect current data protection legislation. • The scope of this audit included reviewing the controls in place to verify the ongoing entitlement of allowances and fees paid to carers. It was noted that a financial irregularity has occurred within another Scottish Local Authority concerning a significant overpayment of a kinship Page 85
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Appendix 2 4 payment made to a carer. The irregularity related to the ongoing payment when the child no longer stayed with the kinship carer. It is pleasing to note that the Service has controls in place to check carers eligibility to maintain continued allowance payments; however, further verification testing should also be considered. Page 86
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5 Findings/Recommendations - Fostering and Kinship Care Payments 2024/25 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 1. Low A requirement of the kinship care placement process for a child is for a carer to agree and sign a Kinship Carer Agreement with the Council. This document details the duties and obligations of both the Council and the carer regarding the ongoing care responsibility for the child. The audit found that on review of the Kinship Carer Agreement, reference is made to previous data protection legislation. The Kinship Carer Agreement template should be reviewed and updated with reference to the current data protection legislation. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Children and Families Social Work Service Manager Yes Implemented Kinship Carer Agreement template has been amended to reflect current data protection legislation. Follow Up Review Implementation Status Revised Implementation Date Internal Audit Review Outcome Implemented N/A Follow up review has confirmed that that Kinship Carer Agreement template has been updated to reflect current data protection legislation. Page 87
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6 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 2. Low In addition to a review of the arrangements for administering fostering and kinship payments, a check was also made to ensure that documentation retention of information and key documents for managing the relationship between the Council and the carer was saved in accordance with the Case Recording Procedures. Audit testing of a sample of care arrangements noted that some documents, although found, had not been saved within a location that was per these agreed procedures. All officers administering fostering and kinship arrangements with carers should be reminded that the recording and retention of documents should be in accordance with the Case Recording Procedures. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Children and Families Social Work Service Manager Yes 31/10/2024 Reminder will be issued by the Business Support Team to officers of the requirement to follow Case Recording Procedures around recording and retention of documents. Page 88
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7 Follow Up Review Implementation Status Revised Implementation Date Internal Audit Review Outcome Implemented N/A Business Support Team has issued a reminder to officers of the requirement to follow Case Recording Procedures regarding the recording and retention of documents. Page 89
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8 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 3. Medium As part of the research for this audit, it was noted that a financial irregularity had occurred within another Scottish Local Authority concerning a significant overpayment of a kinship payment made to a carer. The overpayment occurred due to ongoing payment when the child no longer stayed with the kinship carer. The Council concerned was contacted to gain a further understanding of the issues that have assisted in developing the audit programme of testing for this review. It is pleasing to note that the Service introduced a requirement a few years ago for carers to make a self-declaration of eligibility to maintain continued allowance payments. However, it is considered that further verification checks should also be considered. In accordance with the Children (Scotland) Act 1995, a carer is entitled to a kinship allowance payment until the young person is 18 if they remain in full time education. Further to discussions with the Service, consideration should be given to undertaking regular verification checks to confirm details of educational status and address for children within a kinship residence order arrangement with Education Services. Page 90
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9 Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Children and Families Social Work Service Manager Yes Implemented A new process has been implemented for residence carers to complete the details of the child’s school on their annual return. This information will be checked regularly with Education Services to ensure there is no change in circumstances. Follow Up Review Implementation Status Revised Implementation Date Internal Audit Review Outcome Implemented N/A The follow up review has found that processes have been amended to require residence carers to complete the details of the child’s school on their annual return. Testing confirmed that for locally resident carers, information is checked regularly with Education Services to ensure no change in circumstances. For out of area residence carers processes are now in place for residence details to be verified directly with the child’s school. Page 91
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10 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 non compliance 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 92
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11 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 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 93
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT PERFORMANCE & RISK COMMITTEE ON 27 MARCH 2025 SUBJECT: UPDATE ON THE DELIVERY OF THE UNPAID CARERS STRATEGY BY: SERVICE MANAGER PROVIDER SERVICES 1. REASON FOR REPORT 1.1 The purpose of this report is to inform Committee of the progress made towards achieving the objectives outlined in the Unpaid Carers Strategy. 2. RECOMMENDATION 2.1 It is recommended that Committee: i) acknowledge the progress made in meeting the objectives of the Strategy; ii) recognise the challenges faced regarding capacity in delivering key objectives to date outlined in paragraph 4.3; and iii) instruct the Lead Officer for Unpaid Carers to provide quarterly updates to this Committee to monitor ongoing progress in implementing the Strategy. 3. BACKGROUND 3.1 Unpaid carers provide vital support to Moray’s health and social care system, supporting family members, friends, or neighbours who are unable to manage independently. It is estimated that approximately 16,200 individuals in Moray provide some form of unpaid care. 3.2 The local Carer Strategy, launched on 1 April 2023, aligns with the national vision of "Valuing, Recognising, and Supporting Carers". The strategic outcomes for Scotland include: • Carers are recognized and their contributions are understood and valued by society. Item 8. Page 95
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• Carers' voices are heard, and their views are considered in decisions that impact them. 3.3 The three strategic priorities for Health and Social Care Moray’s (HSCM) Unpaid Carer Strategy are: • Recognition for Carers • Valuing Carers • Supporting Carers 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 The main areas of focus in the past 6 months have been on staff recruitment, improvements to service delivery, and new initiatives aimed at raising awareness and providing support to unpaid carers in the community. Staff Recruitment and Capacity 4.2 There are currently two key vacant posts critical to the successful delivery of the Carers Strategy which have impacted on the delivery of the Year 1 and 2 priorities outlined in the Strategy to date. The vacancies are: Social Worker – Unpaid Carers The post is actively being advertised, with a closing date of 7 March 2025. Young Carers Strategy Officer The recruitment process for this role is currently with Human Resources and is expected to be advertised soon. 4.3 Filling these vacancies will be crucial in maintaining progress on the Strategy’s objectives, with the impact of the vacancies being evident from the Strategy Implementation Plan (Appendix 1). Raising Awareness 4.4 Significant changes have been made to the specification of the Carers Commissioned Service. Assessments are now being brought in-house to the local authority, aiming to streamline service delivery and improve efficiency. This change will reduce delays and enhance the support carers receive in a timelier manner. This change will enable the commissioned service to focus on delivery relating to the Information, Advice and Support service. 4.5 Work continues with the Elgin Health Centre Project, which focuses on raising awareness of unpaid carers and identifying those who may be "hidden". Training has been developed by the HSCM Carers Team and issued to all practice staff. Feedback from staff will help refine our approach to supporting carers in healthcare settings (Implementation Plan Priority 1- 1.1.4). 4.6 Efforts to raise awareness of unpaid carers within hospital settings are underway. A recent Multi-Disciplinary Team (MDT) meeting in the Speyside locality was attended by the HSCM Carers Team where discussions around hospital discharge took place. It is planned to identify Carer Champions in each hospital setting to support awareness and identification of unpaid carers. A new project plan is in progress to ensure all hospital settings can recognise and Page 96
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support unpaid carers effectively (Implementation Plan Priority 1- 1.2.3, Priority 2- 2.2.3). Providing Support to Unpaid Carers in the Community 4.7 Early progress is being made in launching the Carer Aware Moray Campaign, designed to raise public awareness of unpaid carers and available support services. Prototypes for the campaign branding have been developed, which will help visually identify carers within healthcare settings and the wider community. It is planned to engage unpaid carers for feedback on the branding (see Appendix 2 for prototypes). 4.8 As part of the Carer Aware Moray Campaign, we will review the existing Carer Aware Card (currently used as an emergency contact card). The goal is to increase its use and incorporate new benefits, such as collaborating with local businesses to offer discounts to carers. Partnerships with Business Gateway are underway to engage local businesses and raise awareness about the value of supporting unpaid carers. Further engagement will take place with unpaid carers to ascertain their views as the remit of the card develops. (Implementation Plan Priority 1- 1.5.1, 1.5.2, 1.5.3). 4.9 The Carer Aware Moray initiative will be promoted in healthcare settings as a key tool for raising awareness and ensuring healthcare professionals are equipped to recognise unpaid carers and involve them in the discharge planning for the individual they are caring for. Training around the identification and awareness of unpaid carers is currently on TURAS (online learning platform developed by NHS Education for Scotland (NES)), with this training being promoted. Once all staff within ward/departmental setting have completed the training the team will receive a Carer Aware Certificate. (Implementation Plan Priority 1- 1.2.1, 1.2.2) 4.10 While positive progress has been made towards achieving strategic outcomes, a review has been undertaken of the original timescales to ensure they are achievable, however it will be essential to have a full complement of staff to deliver the actions on schedule. 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” Supporting carers aligns with the ambitions outlined in the Moray IJB Strategic Plan, Corporate Plan, and LOIP. It will contribute to Outcome 6 of the National Health and Wellbeing Outcomes by improving health, wellbeing, and outcomes for both carers and the people they care for. Involving unpaid carers, the person they care for, and workers from health and social care services work together as partners they increase the chances of better outcomes for all involved, this aligns with Realistic Medicine, putting people at the centre of decision about care and support, alongside the key priorities highlighted through the work of EPiC. (b) Policy and Legal Page 97
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The local Carer Strategy meets the legal requirements set out in the Carers (Scotland) Act 2016, ensuring that carers have access to: • Information and advice services • Hospital discharge involvement • Adult Carer Support Plans or Young Carer Statements • Support for eligible needs (c) Financial implications Funding through the annual Carers Act allocation supports the delivery of the Strategy. Actions outlined in the Strategy and Action Plan, including the commissioning of local information and advice services, must be managed within the existing resources and additional funding streams where possible. (d) Risk Implications and Mitigation Demand for support is likely to increase as more carers are identified. A local eligibility criteria is in place to ensure appropriate support is provided. Current risks and mitigations, where possible, are evidenced in Appendix 1 within the risk log. The significant number of outstanding Adult Carer Support Plans and Young Carer Statements to be actioned by the Social Worker for unpaid carers currently stands at circa 300. (e) Staffing Implications The delivery of the Strategy relies on a collaborative workforce, including unpaid carers, the public, third-party organisations, and the wider community. The impact of vacant posts has slowed progress towards Year 1 and 2 priorities, and the details of the posts are outlined in paragraph 4.3. (f) Property No direct implications from this report. (g) Equalities/Socio Economic Impact Carers are more likely to experience inequality of outcome and poor health. The Strategy aims to enhance opportunities for all carers, ensuring equitable access to support. (h) Climate Change and Biodiversity Impacts None arising directly from this report. (i) Directions To support the potential for the extension of the current Carers Strategy by an additional 2 years, until March 2028 to enable the strategic outcomes to be embedded. This will also enable sufficient time to effectively review the current Strategy and the development of the next. (j) Consultations Consultations have taken place with the Carer Representative on the Board, Assistant SDS & Carers Officer, Provider Service Manager, Carers Strategy Implementation Group, Strategic Planning & Commissioning Group (SPCG). Page 98
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6. CONCLUSION 6.1 Progress continues to be made in supporting unpaid carers in Moray, through improvements in recruitment, service delivery, collaboration with health and the development of the carer aware campaign. Continued efforts are needed to maintain this momentum and ensure carers receive the recognition and support they deserve. 6.2 This report outlines key updates to the Strategy and highlights ongoing developments that will contribute to improved support and recognition for unpaid carers in Moray. Author of Report: Michelle Fleming, Self-Directed Support & Unpaid Carers Team Manager (SDS & Carers Lead Officer) Appendix 1: Implementation Plan Carers Strategy 2023-2026 Appendix 2: Carer Aware Moray Branding Prototypes (Attached: Preview of branding prototypes for the Carer Aware Moray campaign, with feedback from stakeholders forthcoming.) Background Papers: Ref: Page 99
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Date Version No Amendments/Notes Completed By 27/04/2023 V0 DRAFT submitted to IJB Michelle Fleming Michelle Fleming SDS & Unpaid Carers Team Manager (Carers Lead) 25/05/2023 V1 DRAFT Approved by MIJB and finalised MIJB Penny Southall Assistant SDS/Unpaid Carers Officer 21/07/2023 V2 Progress Notes Added Michelle Fleming John Campbell Service Manager 27/05/2024 V3 Progress Notes Added, Addition of Column for "Responsible Person", Lead Person/s amended, Job Titles for Adult Carers Officer amended to SDS & Unpaid Carers Team Manager (Carers Lead), Full title amended for Assistant Adult Carer Officer to Assistant SDS/Unpaid Carers Officer. Addition of 3.8.8 and 3.3.9 in connection with GDPR, data sharing and consent. Addition of 3.8.10 to reflect the action to establish a unique identifying code for unpaid carers on Carefirst. Risk Log reviewed and updated. Actions reviewed and completed actions moved to the "Completed Actions" tab. Michelle Fleming/Penny Southall 08/07/24 & 09/07/2024 V4 Review of Implementation Plan - Progress updates added for 1.4.1, 3.5.1 and 3.8.9. John Campbell/Penny Southall 07/03/2025 V5 Progress updates added. Risk Log reviewed and updated Michelle Fleming/Penny Southall APPENDIX 1 Item 8. Page 101
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Objectives from Moray Carers Strategy 2023 - 2026 Ref Activities Ref Actions Target Achievement Date Reference To Separate Project Plan Associated Risks (see Risk Log for detail on Med and High Risks) Low , Medium, High Lead Person(S) Supported by/Additional Resources Required Progress Notes Status - (Completed, In Progress, Not Started) Reference to Carers (Scotland) Act 2016 Reference to National Carers Strategy Reference to Strategic Plan Health & Social Care Moray “Moray Partners in Care 2022- 2032" 1.1.1 Provide a programme of information/awareness to Social Work Teams and Home Care Teams in Adult Services, highlighting carer issues, the referral process to the commissioned service, and the supports available, as well as the statutory requirements under the Carers (Scotland) Act 2016 Year 1 SDS & Unpaid Carers Team Manager (Carers Lead) Assistant SDS & Unpaid Carers Officer, Commissioned Carers Service, Staffing Information, materials, Online Campaigns, Promotion & Marketing Need to refine current processes as they are not currently working, and cumbersome. Discussions commenced with Quarriers regarding the contract. Contract Variation in place from 1/1/25 Not Started 1.1.2 Provide a programme of information to MIDAS and MADP members, highlighting carer issues, the referral process to commissioned services, and the support available, as well as statutory requirements under the Carers (Scotland) Act 2016 Year 1 SDS & Unpaid Carers Team Manager (Carers Lead) Assistant SDS & Unpaid Carers Officer, Commissioned Carers Service, Staffing Information, materials Need to refine current processes as they are not currently working, and cumbersome. Discussions commenced with Quarriers regarding the contract. Contract Variation in place from 1/1/25 Not Started 1.1.3 Provide a programme of information to Social Work Teams in Children’s Services, highlighting carer issues, the referral process to the commissioned service, and the supports available, as well as the statutory requirements under the Carers (Scotland) Act 2016 Year 1 Young Carers Strategy Officer Commissioned Carers Service, staffing information and associated materials Vacant YCS Officer post impacting progress Not Started 1.1.4 Provide a programme of information/awareness to GP practice staff, highlighting carer issues, the referral process to the commissioned service, and the supports available, as well as the statutory requirements under the Carers (Scotland) Act 2016 Year 1 SDS & Unpaid Carers Team Manager (Carers Lead) /Young Carers Strategy Officer Assistant SDS & Unpaid Carers Officer, Commissioned Carers Service, Staffing information and associated materials Pilot project agreed to with Maryhill Group (Elgin Health Centre). Project brief developed, proposed carer pathway, TURAS training, SSSC badges, participation at whole practice team meetings. Separate action plan in place. January 2025 update - training/awareness training in progress at Maryhill - awaiting feedback. In Progress 1.1.5 Provide a programme of information/awareness to colleges/universities highlighting carer issues, the referral process to the commissioned service, and the supports available. Year 2 SDS & Unpaid Carers Team Manager (Carers Lead)/Young Carers Strategy Officer Assistant SDS & Unpaid Carers Officer Commissioned Carers Service, Contacts within college/university, information and awareness materials Vacant YCS Officer post impacting progress Not Started 1.1.6 Support and promote the creation of Carer Champions in colleges/universities Year 2 SDS & Unpaid Carers Team Manager (Carers Lead)/Young Carers Strategy Officer Assistant SDS & Unpaid Carers Officer, Commissioned Carers Service, resources within colleges/universities, Carer Champion Role Documentation, Support Materials Vacant YCS Officer post impacting progress Not Started 1.1.7 Include Young Carer Awareness sessions in PSE lessons in schools 50% of schools within Year 2, 100% of schools by end Year 3 Young Carers Strategy Officer Commissioned Carers Service, Young Carer awareness resources/pack for school use Vacant YCS Officer post impacting progress Not Started 1.1.8 Promote and encourage, with a view to establish Carer Champions in schools in Moray 50% of schools within Year 2, 100% of schools by end Year 3 Young Carers Strategy Officer Commissioned Carers Service, Young Carer awareness resources/pack for school use Vacant YCS Officer post impacting progress Not Started 1.1.9 Facilitate a programme of carer awareness for third sector and business/community providers in Moray, highlighting the needs of carers, the referral process to the commissioned service, and the supports available Year 1 and 2 SDS & Unpaid Carers Team Manager (Carers Lead)/Young Carers v Officer Assistant SDS & Unpaid Carers Officer, Commissioned Carers Service, Third Sector Provider contacts, appropriate information and awareness materials. Need to refine current processes as they are not currently working, and cumbersome. Discussions commenced with Quarriers regarding the contract. Contract Variation in place from 1/1/25 Not Started 1.1.10 Consider and research the introduction of a Carer Passport scheme to support awareness, understanding and recognition of carers across our communities in Moray Year 3 To be developed Adult Carers Officer/Young Carers Strategy Officer Assistant SDS & Unpaid Carers Officer, Commissioned Carers Service, Development of a working group to progress. Use learning from implementation of Hospital Carer Passport Not Started 1.2.1 Include online Carer Aware training in induction for all new NHS staff Year 1 Hospital Project SDS & Unpaid Carers Team Manager (Carers Lead) Requirement to identify hospital lead - 7/3/25 - Lead now identified linked to Carer Aware Campaign In Progress 1.2.2 Include online Carer Aware training in ongoing professional development programmes for all existing NHS staff Year 2 Hospital Project SDS & Unpaid Carers Team Manager (Carers Lead) Requirement to identify hospital lead - 7/3/25 - Lead now identified linked to Carer Aware Campaign In Progress We want carers to be able to say, ‘I can identify as a carer. I am able to access the information and advice I need as a carer and I know and understand my rights’. 1.1 1.2 Priority 1 – Recognition for carers - To raise the profile of all carers of all ages in Moray, and support individuals to both recognise carers, and be recognised as carers, as early as possible in their caring role as the first step to support. Theme 1 - Building Resilience, Objective 2 - Value and Support Unpaid Carers Develop and deliver an awareness raising programme to NHS staff, Adult Social Care, Children’s Social Care, Schools and UHI, wider Moray Council and NHS staff, third sector and other community/business providers across Moray Embed Turas Carer Aware training in the core skills requirement for all NHS staff Page 102
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1.2.3 Establish Carer Champions in NHS public facilities: hospital wards, out-patient clinics, A&E, to enable regular circulation of carer aware information for staff, patients and carers Year 2 Hospital Project SDS & Unpaid Carers Team Manager (Carers Lead) Carer Champion previously identified in Stephen Hospital. 7/3/25 - Early work via MDT to work to re-establish links In Progress 1.3.1 Identify a lead to progress Carer Positive within Moray Council Year 1 Carer Positive Project SDS & Unpaid Carers Team Manager (Carers Lead) Lead (to be determined) Current policy needs to be changed to reflect the Carers Leave Act, liaison with HR Not Started 1.3.2 Achieve Level 2 Carer Positive in Moray Council Year 3 Carer Positive Project SDS & Unpaid Carers Team Manager (Carers Lead) Carer Positive Lead, Assistant SDS & Unpaid Carers Officer, HR, promotional materials, Not Started 1.3.3 Identify a lead within HSCM to support the progress of Carer Positive in all hospitals in Moray Year 1 Carer Positive Project SDS & Unpaid Carers Team Manager (Carers Lead) Lead (to be determined) Requirement to identify hospital lead Not Started 1.3.4 Complete - see "completed actions" Completed 1.3.5 Complete - see "completed actions" Completed 1.3.6 Carers Team (Moray Council) to support NHS Grampian in achieving Level 2 (established) Carer Positive Award in hospitals within Moray Year 3 Carer Positive Project HSCM Hospital Carer Positive Lead (to be determined) To be determined Requirement to identify hospital lead Not Started 1.4.1 Review and enable online, in-person and paper- based referral processes within the commissioned Carer Support Service Year 1 and 2 N/A SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Commissioned Carer Service, Unpaid Carers Social Worker, Assistant SDS & Unpaid Carers Officer, IT Currently in progress in line with work to ensure GDPR compliance following the award of the new carers contract in January 2024. Completed GDPR updated documentation. Work will commence to ensure easier access into the commissioned Carer Support Service in line with the contract variation 1/1/25. In Progress 1.4.2 Promote commissioned Carer Support Service referral processes widely across Moray and all stakeholders Year 2 N/A SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Commissioned Carer Service, Unpaid Carer Social Worker, Assistant SDS & Unpaid Carers Officer, IT, Communications, PR The current contract is being evaluated as we come to the end of the first year. Current process feel cumbersome and query over what has been delivered under the contract in the first year. 1/1/25 contract variation in place In Progress 1.5.1 Establish an application, recording and issuing process for carer ID cards in Moray Year 2 To be developed SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Commissioned Carer Service, Assistant SDS & Unpaid Carers Officer, Carers Voice Group, Card machine Blank cards Staffing/admin Work incorporated into the Carer Aware Campaign In Progress 1.5.2 Promote the Carer ID card initiative widely across Moray, to carers, communities, businesses and service providers Year 2 To be developed SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Commissioned Carer Service, Unpaid Carer Social Worker, Assistant SDS & Unpaid Carers Officer, PR, Comms, Social Care Teams Not Started 1.5.3 Secure discounts and other benefits for carers in Moray linked to the Carer ID card Year 3 To be developed SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Assistant SDS & Unpaid Carers Officer, PR, Comms, 7/3/25 Early work around this linked to the Carer Aware Campain In Progress 1.5.4 Support carers to obtain a Carer ID card Year 3 To be developed SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Commissioned Carer Service, Unpaid Carer Social Worker, HSCM Social Care Teams Not Started 1.6.1 Enable early identification and support for YC transitioning from Secondary School to higher/further education Year 2 To be developed Young Carers Strategy Officer To be determined Vacant YCS Officer post impacting progress Not Started 1.6.2 Enable early identification and support for YC making choices about employment – link to Developing the Young Workforce and other initiatives able to provide targeted support Year 3 To be developed Young Carers Strategy Officer To be determined Vacant YCS Officer post impacting progress Not Started 1.6.3 Review and enable early identification and support for carers of someone moving, or considering moving, into residential or nursing care Year 2 To be developed SDS & Unpaid Carers Team Manager (Carers Lead) Assistant SDS & Unpaid Carers Officer, Unpaid Carer Social Worker, Commissioned Carer Service, HSCM Social Care Teams Not Started 1.6.4 Enable early identification and support for carers in work, to support decisions in relation to balancing work and caring, and the potential for reducing or ceasing work Year 2 To be developed SDS & Unpaid Carers Team Manager (Carers Lead) Assistant SDS & Unpaid Carers Officer, Unpaid Carer Social Worker, Commissioned Carer Service, HSCM Social Care Teams To link in with the new legislation- Carer's Leave Act which came into force on 6th April 2024 Not Started 1.6.5 Review and enable early identification and support for carers wishing to return to work, to support decisions in relation to balancing work and caring Year 2 To be developed SDS & Unpaid Carers Team Manager (Carers Lead) Assistant SDS & Unpaid Carers Officer, Commissioned Carer Service, Unpaid Carer Social Worker Requirement to clarify commissioned contract with Quarriers as it is currently not an efficient process for carers. This is in progress . Not Started 1.6.6 Enable early identification and support for parent carers of disabled children approaching adulthood/independent living Year 2 To be developed SDS & Unpaid Carers Team Manager (Carers Lead) Assistant SDS & Unpaid Carers Officer, Commissioned Carer Service, Unpaid Carer Social Worker, HSCM Social Care Teams Requirement to clarify commissioned contract with Quarriers as it is currently not an efficient process for carers. This is in progress . Not Started 1.6.7 Review and enable early identification and support for former carers on the death of the person they care for or if their caring role reduces suddenly because the cared-for has moved into long term care. Year 2 To be developed SDS & Unpaid Carers Team Manager (Carers Lead) Assistant SDS & Unpaid Carers Officer, Commissioned Carer Service, Unpaid Carer Social Worker, HSCM Social Care Teams Requirement to clarify commissioned contract with Quarriers as it is currently not an efficient process for carers. This is in progress . Not Started 1.6.8 Research, develop & facilitate peer support groups for carers whose caring role has ended or significantly reduced for different reasons. Year 2 To be developed SDS & Unpaid Carers Team Manager (Carers Lead) Assistant SDS & Unpaid Carers Officer, Commissioned Carer Service, Carers Voice Group. Requirement to clarify commissioned contract with Quarriers as it is currently not an efficient process for carers. This is in progress . 1/1/25 contract variation to enable carer support groups. In Progress 1.3 1.6 Support carers during periods of transition: age and circumstance related We want carers to be able to say, ‘I can identify as a carer. I am able to access the information and advice I need as a carer and I know and understand my rights’. 1.2 1.4 1.5 Theme 1 - Building Resilience, Objective 2 - Value and Support Unpaid Carers Embed Turas Carer Aware training in the core skills requirement for all NHS staff Enable easy referral and registration for carers to the commissioned Carer Support service, including online, in- person and paper processes Develop and make easily available a carers ID card, recognised across Moray Support take-up of the Carer Positive award in HSCM, Moray Council and NHS Grampian provision in Moray Page 103
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1.7.1 Enable and encourage family members to explore their role and its impact on them, in the context of the Carers (Scotland) Act 2016 and their rights to support as a carer Year 1 To be developed SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer, Assistant SDS & Unpaid Carers Officer, Commissioned Carer Service, Unpaid Carer Social Worker, Specialist Service Providers, Not Started 1.7.2 Involve carers of people who have an alcohol and/or drug dependency in the review of the ACSP template and process, to ensure relevance and accessibility for their circumstances Year 2 To be developed SDS & Unpaid Carers Team Manager (Carers Lead) Assistant SDS & Unpaid Carers Officer, Commissioned Carer Service, Specialist Service Providers, Working Group consisting of Carers with experience. Not Started 1.7.3 Enable early identification and support for children of those with an alcohol and/or drug dependence, who may be taking on a caring role that isn’t recognised or acknowledged within the family Year 2 To be developed Young Carer Strategy Officer Commissioned Carer Service, Specialist Service Providers, Education, GP's Vacant YCS Officer post impacting progress Not Started 1.7.4 Create targeted materials for use with carers and family members of people who have an alcohol and/or drug dependence, to help improve understanding of the caring role Year 2 To be developed SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Commissioned Carer Service, Specialist Service Providers, Education, GP's, PR, Comms Not Started 2.1.1 Establish a Carers Voice Group enabling engagement by adult carers in regular discussion and decision making linked to implementation of the Carers Strategy and ongoing identification and prioritising of carer unmet needs Year 1 N/A SDS & Unpaid Carers Team Manager (Carers Lead) Assistant SDS & Unpaid Carers Officer, Commissioned Carers Service, HSCM Carer Team, PR, Comms Promotion and Invitations to join first meeting taking place in and around Carers Week in June. Initial meeting August 2023. Terms of Reference developed. Meetings chaired by IJB Carers rep. Further discussion to take place regarding attendance of the Carers Team with Comms Officer. Due to capacity within the team this has not been achievable. Work needs to progress in Year 3 to re-establish the group along with role and remit. In Progress 2.1.2 Support and promote the developing Young Carer Reference Group initiated by the commissioned service, enabling young carer engagement in regular discussion and decision making linked to the implementation of the Carers Strategy and ongoing identification and prioritising of carer unmet need Year 2 N/A Young Carer Strategy Officer Commissioned Carers Service, Young Carers, Education, PR, Comms Vacant YCS Officer post impacting progress In Progress 2.1.3 Enable targeted feedback opportunities for all carers, with specific focus on parent carers, Young Adult Carers, older carers, carers of adults in recovery from/dependence of alcohol and/or drugs, carers of Long Term Conditions, carers of adults in residential/nursing care, and other such groups as may be identified by carers themselves, enabling ongoing identification and prioritising of carer unmet need Year 3 but commencing from Year 1 N/A SDS & Unpaid Carers Team Manager (Carers Lead) Assistant SDS & Unpaid Carers Officer, Commissioned Carers Service, PR, Comms, Carer Voice Groups. Not Started 2.1.4 Provide admin/co-ordination to enable effective two- way communication between Carer Voice activity and appropriate platforms – e.g. IJB, Carers Steering Group, and others that may be developed during the lifetime of this strategy Year 1 N/A SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Assistant SDS & Unpaid Carers Officer Carers Voice Group links into the Carers Strategy Group which feeds into PGB, into AP&R quarterly, IJB annually and SMT as required. In Progress 2.2.1 Identify a Lead for the hospital project, as well as resources and support required. Year 1 Hospital Project SDS & Unpaid Carers Team Manager (Carers Lead) Lead has been identified. In Progress Section 28 2.2.2 Establish a dedicated staff presence in all hospitals in Moray, enabling early identification of carers and easy access to the full range of supports available. Commencing Year 1 Hospital Project Commissioned Carer Service Action needs to be reviewed in line with the changes to the commissioned service contract Not Started Section 28 2.2.3 Develop and support a network of Carer Champions in hospitals, able to promote carer awareness amongst staff, and maintain information displays for carers in wards and clinics Year 2 Hospital Project Commissioned Carer Service Carer Champion identified in Stephen Hospital. 7/3/25 Carer Champion previously identified - early work In Progress Section 28 2.2.4 Offer regular staff information sessions in hospitals, to maintain carer awareness and support early identification and referral Year 1, 2 and 3 Hospital Project Commissioned Carer Service Not Started Section 28 2.2.5 Develop carer information packs for wards and clinics, ensuring carers are able to access relevant and timely information as easily and quickly as possible Year 1 Hospital Project commissioned Carer Service Information Pack in progress of being pulled together In Progress Section 28 2.3 Introduce the Carer Passport process in Moray hospitals, to aid carer access and information when the cared for is admitted 2.3.1 Initiate a Carer Passport scheme in Moray hospitals Year 2 Hospital Project Passport work commenced 2022. Draft prepared - currently under further review and amendment. To be picked up in year 3. In Progress Section 28 2.4.1 Consider extending the Carer Passport scheme to other areas of life in Moray, including employment and education Year 3 Hospital Project Not Started 2.4.2 Deliver Triangle of Care awareness sessions to NHS and HSCM staff involved in the care and support of people with poor mental health Year 2 Hospital Project Need to ascertain current position as Triangle of Care approach apparent in Muirton Ward, Buckie. In Progress 2.4.3 Seek endorsement of the Triangle of Care principles within mental health support providers in Moray Year 3 Hospital Project As above In Progress 2.4.4 Consider the role of a Carer Passport scheme in improving carer awareness and engagement in support for people with poor mental health Year 3 Hospital Project In Progress Priority 2 – Valuing carers - To involve, respect and listen to carers in planning the care and support of the person they care for, and themselves Theme 1 - Building Resilience, Objective 2 - Value and Support Unpaid Carers Support the development of appropriate Carer Voice opportunities for carers of all ages, enabling effective feedback on strategic outcomes progress and carer experience in Moray 2.1 Build on the Test of Change work in hospitals in Moray, to seek Carer Champions on wards and easy links to the commissioned Carers Support Service 2.2 Adopt the Triangle of Care to support carers of people with poor mental health 2.4 We want carers to be able to say, ‘I am listened to and valued as an equal and expert partner by people working in health and social care. I am involved in the planning and delivery of services and support for myself and for the person/s I am caring for’. Improve identification and support for carers of family members who have an alcohol and/or drug dependence, recognising the sensitivities around identifying as a carer and the impact of cared for non-engagement. We want carers to be able to say, ‘I can identify as a carer. I am able to access the information and advice I need as a carer and I know and understand my rights’. Theme 1 - Building Resilience, Objective 2 - Value and Support Unpaid Carers 1.7 Page 104
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2.5.1 Collate data from ACSPs and YCSs to inform carer access to condition-specific awareness sessions to help increase understanding and confidence Year 2 To be developed SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Social Worker Unpaid Carers, Assistant SDS & Unpaid Carers Officer, Commissioned Carers Service Not Started 2.5.2 Engage a wide range of condition-specific providers in awareness raising opportunities for carers of all ages Year 2 To be developed SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Assistant SDS & Unpaid Carers Officer, Commissioned Carers Service, Relevant Providers across Moray Not Started 2.5.3 Evaluate provision and access to training/awareness linked to conditions of the cared for person to inform future development and commissioning needs Year 3 To be developed SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Assistant SDS & Unpaid Carers Officer, Commissioned Carers Service, Social Worker Unpaid Carers Not Started 2.6 Improve carer access to self- management support in their role 2.6.1 Provide skills development and information opportunities to carers of all ages that meet the self- management needs identified via ACSP/YCS Year 2 To be developed SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Assistant SDS & Unpaid Carers Officer, Commissioned Carers Service, Social Worker Unpaid Carers Not Started 3.1.1 Complete see 'completed actions' tab 3.1.2 Ensure relevant, timely and accessible information is available to carers of all ages in a variety of formats, and is widely promoted Year 2 SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Commissioned Carers Service, Assistant SDS & Unpaid Carers Officer See Risk Log 3.1.3 Maintain social media and online communications that are flexible and responsive, to ensure carers have easy access to the most up-to-date information Year 2 SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Commissioned Carers Service, Assistant SDS & Unpaid Carers Officer See Risk Log 3.1.4 Enable face to face information and advice sessions for carers, in response to direct enquiry or collation of unmet need via ACSP/YCS Year 1 SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Commissioned Carers Service, Assistant SDS & Unpaid Carers Officer See Risk Log 3.1.5 Create effective referral pathways to Welfare Rights support and other financial management/life event services Year 1 SDS & Unpaid Carers Team Manager (Carers Lead) Commissioned Carers Service, Assistant SDS & Unpaid Carers Officer See Risk Log 3.2.1 Complete a desktop review of a sample group of ACSPs completed in the last 12 months, the support enabled as a result, and any review monitoring, to establish the accuracy of ACSP data gathering in relation to outcomes sought and achieved Year 2 To be developed SDS & Unpaid Carers Team Manager (Carers Lead) Assistant SDS & Unpaid Carers Officer, Social Worker Unpaid Carers, Commissioned Carers Service Currently in progress In Progress 3.2.2 Engage adult carers from a variety of caring circumstances and demographics in a review process to identify areas for improvement/change in the ACSP template and process Year 2 To be developed SDS & Unpaid Carers Team Manager (Carers Lead) Assistant SDS & Unpaid Carers Officer, Social Worker Unpaid Carers, Commissioned Carers Service Short term working group to be established with unpaid carers to collate their views s part of the self evaluation work being undertaken Not Started 3.2.3 Refresh the ACSP template and process, and test with a sample group of adult carers, seeking feedback on the experience to inform the final model Year 2 To be developed SDS & Unpaid Carers Team Manager (Carers Lead) Assistant SDS & Unpaid Carers Officer, Social Worker Unpaid Carers, Commissioned Carers Service Proposed inline with action 1.4.1. 7/3/25 Further work to be undertaken in year 3, in line with assessments being brought into HSCM In Progress 3.2.4 Implement any revised ACSP template and process, ensuring appropriate data recording and reporting for local stats and Carers Census input Year 2 To be developed SDS & Unpaid Carers Team Manager (Carers Lead) Assistant SDS & Unpaid Carers Officer, Social Worker Unpaid Carers, Commissioned Carers Service Not Started 3.3.1 Provide counselling for adult carers Year 2 SDS & Unpaid Carers Team Manager (Carers Lead) Commissioned Carer Service See Risk Log. Some short term counselling can be accessed via commissioned carer service. 3.3.2 Enable peer support for carers of all ages and circumstances Year 1 SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Commissioned Carer Service See Risk Log. 7/3/25 Commissioned service to increase peer support groups in year 3 in line with contract variation. 3.3.3 Provide targeted support to Young Adult Carers Year 2 SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Commissioned Carer Service See Risk Log - 7/3/25 Commissioned service to increase peer support groups in year 3 in line with contract variation. 3.3.4 Provide targeted support to Parent Carers Year 2 SDS & Unpaid Carers Team Manager (Carers Lead) Commissioned Carer Service See Risk Log. 7/3/25 Commissioned service to increase peer support groups in year 3 in line with contract variation. 3.3.5 Provide targeted support to carers in specific circumstances/roles as indicated by unmet need in ACSP/YCS Year 1 Adult Carer Officer, Young Carer Strategy Officer Commissioned Carer Service See Risk Log 7/3/25 Commissioned service to increase peer support groups in year 3 in line with contract variation. Further impacted by the vacany for Young Carer Strategy Officer. 3.3.6 Provide Young Carer Groups in schools Year 2 Young Carer Strategy Officer Commissioned Carer Service See Risk Log 7/3/25 Commissioned service to increase peer support groups in year 3 in line with contract variation. Further impacted by the vacany for Young Carer Strategy Officer.3.3.7 Provide easy access to breaks that help prevent the breakdown of the caring relationship Year 1 SDS & Unpaid Carers Team Manager (Carers Lead) Commissioned Carer Service, Social Worker Unpaid Carers See Risk Log 3.4.1 Support carers to plan for emergencies Year 1 SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer commissioned Carer Service, Social Worker Unpaid Carers See Risk Log 3.4.2 Provide support for working carers, to help them stay in work and, where necessary, make informed decisions about their employment Year 2 SDS & Unpaid Carers Team Manager (Carers Lead) Commissioned Carer Service, Social Worker Unpaid Carers See Risk Log 7/3/25 Commissioned service to increase peer support groups in year 3 in line with contract variation. 3.4.3 Support for employers to understand the needs of working carers – flexible working, communication while at work, time off for dependents Year 3 SDS & Unpaid Carers Team Manager (Carers Lead) Commissioned Carer Service, Social Worker Unpaid Carers, Assistant SDS & Unpaid Carers Officer Not Started Review and develop the current Short Breaks Service Statement 3.5.1 Review and refresh the current short breaks service statement in line with the strategy and current short breaks available Year 2 SDS & Unpaid Carers Team Manager (Carers Lead) Assistant SDS & Unpaid Carers Officer SBSS obtained from other HSCP's to support the review of the local SBSS. 7/3/25 HSCM short breaks statement will need to be reviewed following release of national SBS. In Progress Theme 1 - Building Resilience, Objective 2 - Value and Support Unpaid Carers Priority 3 - empower carers to manage their caring role, to enable them to look after their own health and wellbeing, and maintain a life of their own alongside caring. For young carers, provide support to learn, develop and thrive, and where appropriate maintain an appropriate caring role Theme 1 - Building Resilience, Objective 2 - Value and Support Unpaid Carers We want carers to be able to say, ‘I am able to manage my caring role and reduce any negative impact on my health and wellbeing. I can access the support and services which are right for me. I am able to take a break from my caring role when I need to. I am not disadvantaged because I am a carer. I am able to achieve my own goals and maintain my education and/or employment’. 3.2 3.3 3.4 Review and improve the Adult Carer Support Plan and Young Carer Statement templates and process to best support identification of carer support needs and services/support required to achieve personal outcomes Provide practical support to help carers manage the impact of their caring role Ensure carers of all ages are supported to plan for the future (their own and that of the person they care for), by identifying them and working together to consider long term needs and preferences 3.5 Provide a fully accessible Information and Advice service for carers of all ages 3.1 We want carers to be able to say, ‘I am listened to and valued as an equal and expert partner by people working in health and social care. I am involved in the planning and delivery of services and support for myself and for the person/s I am caring for’. Ensure carers have access to skills development and training/awareness opportunities linked to the condition of the person they care for, to help them best support their care 2.5 Page 105
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Develop targeted Carer Short Breaks and Respite policies, for adult, parent and young carers 3.5.2 Engage carers in discussions about how short breaks and respite could look for them, and what’s needed to make that happen Year 2 SDS & Unpaid Carers Team Manager (Carers Lead) Commissioned Carer Service, Social Worker Unpaid Carers, Assistant SDS & Unpaid Carers Officer, Carer Voice Group Feedback obtained from Carers Voice Group. Further engagement is required to explore how we provide short breaks. In Progress 3.6.1 Provide regular peer support opportunities, offering short breaks from the caring role Year 2 SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Commissioned Carer Service, Assistant SDS & Unpaid Carers Officer, Social Worker Unpaid Carers See Risk Log 3.6.2 Enable relationship building with local activity and break providers to increase the opportunities for carers to benefit from a range of local breaks Year 2 To be developed SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Commissioned Carer Service, Assistant SDS & Unpaid Carers Officer, Social Worker Unpaid Carers Vacant YCS Officer post impacting progress Not Started 3.6.3 Enable Moray’s participation in the Respitality programme to increase Moray carers’ opportunities to access breaks in Moray and beyond Year 1 To be developed SDS & Unpaid Carers Team Manager (Carers Lead) Commissioned Carer Service, Assistant SDS & Unpaid Carers Officer, Social Worker Unpaid Carers Vacant YCS Officer post impacting progress Not Started 3.6.4 Offer small grants opportunities to enable carer breaks from their role as part of an agreed personalised action plan arising from ACSP/YCS Year 3 To be developed SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Commissioned Carer Service, Assistant SDS & Unpaid Carers Officer, Social Worker Unpaid Carers Vacant YCS Officer post impacting progress Not Started 3.6.5 Ascertain a true budget for Carers SDS Year 1 To be developed SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Assistant SDS & Unpaid Carers Officer, Social Worker Unpaid Carers, Social Care Teams, CareFirst, Finance Currently in progress through the testing of the SDS Self-Evaluation Framework for improvement In Progress 3.6.6 Review and develop Carer SDS provision inline with SDS Legislation Year 1 To be developed SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Assistant SDS & Unpaid Carers Officer, Social Worker unpaid Carers, Social Care Teams, CareFirst, Finance Currently in progress through the testing of the SDS Self-Evaluation Framework for improvement In Progress 3.7.1 Include young carer awareness in induction and professional development programmes for school staff Year 2 To be developed Young Carer Strategy Officer Commissioned Carer Service, Assistant SDS & Unpaid Carers Officer, Moray School Contacts Vacant YCS Officer post impacting progress Not Started 3.7.2 Conduct annual surveys of school staff to measure awareness of young carers and the impact of their caring role on their lives and education Year 3 To be developed Young Carer Strategy Officer Commissioned Carer Service, Assistant SDS & Unpaid Carers Officer, Moray School Contacts Vacant YCS Officer post impacting progress Not Started 3.8.1 Complete see 'completed actions' tab Completed 3.8.2 Carers Voice Groups’ to report to Carers Strategy Group Year 1, Year 2, Year 3 N/A SDS & Unpaid Carers Team Manager (Carers Lead) Assistant SDS & Unpaid Carers Officer, Carer Voice Group In Progress 3.8.3 Carers Strategy Group to report monthly as required to Practice Governance Board (PGB) Year 1, Year 2, Year 3 Service Manager SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer, Assistant SDS & Unpaid Carers Officer 3.8.4 Carers Strategy Group to report progression of activities to the AP&R Quarterly Year 1, Year 2, Year 3 N/A Service Manager Strategy Implementation Group members Quarterly reports now provided to AP&R, previously provided to CCGC In Progress 3.8.5 Carers Strategy Group to report progression of activities and actions detailed on the Strategy Implementation Plan to the IJB, initially 6 monthly, then annually thereafter Year 1, Year 2, Year, 3 N/A Service Manager Strategy Implementation Group members Annual reports presented to MIJB In Progress 3.8.6 Commissioned Carers Service reporting processes evidence carer support needs and trends, support provided, unmet needs, outcomes and carer satisfaction Year 1 N/A Commissioning Officer Commissioned Carer Service, Commissioning Team, SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer, Social Worker for Unpaid Carers This is being reported and collaborative work is underway to ensure this is capturing the data required In Progress 3.8.7 Annual evaluation of carer experience in Moray, analysis and outcomes to be reported to the Strategy Implementation Group to determine and identify unmet need and how this will be met. Year 2/Year 3 N/A SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Assistant SDS & Unpaid Carers Officer, Carers Voice Group, Marketing/Comms, PR, Unpaid Carers Due to commence Not Started 3.8.8 Complete Carers Census submissions accurately and within required timescales As per Census Schedule N/A SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Commissioned Carer Service. Commissioning Team (HSCM) See Risk Log. No submission required for 2024/2025 due to national work being undertaken to review reporting template. In Progress 3.8.9 Identify the resources currently in place and match those against those necessary to deliver the actions from the Carers Strategy. Identify and address any imbalances, taking into account funding from the Scottish Govt for the Carers Act. August 2023 N/A Service Manager SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Currently being discussed In Progress 3.8.10 Complete see 'completed actions' tab Completed Theme 1 - Building Resilience, Objective 2 - Value and Support Unpaid Carers We want carers to be able to say, ‘I am able to manage my caring role and reduce any negative impact on my health and wellbeing. I can access the support and services which are right for me. I am able to take a break from my caring role when I need to. I am not disadvantaged because I am a carer. I am able to achieve my own goals and maintain my education and/or employment’. Adopt a continuous improvement approach to monitoring and evaluating carer experience in Moray, aiding consistent reporting to the Scottish Carers Census and informing commissioning and development activity to improve outcomes for carers 3.8 3.7 3.5 Facilitate carer breaks through a variety of models, including participation in the national Respitality programme 3.6 Participate in national programmes to improve schools’ awareness of, and support for, young carers in education Page 106
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3.8.11 Review and refresh Moray Carers Strategy 2023- 2026 on an annual basis January 2024, January 2025, January 2026, Service Manager Carers Voice Group, Carer Strategy Review Group, Strategy Implementation Group members, Social Worker for Unpaid Carers, Commissioned Carers Service, IJB Currently started early conversations to extend the strategy by 2 years Not Started 3.8.12 Establish a process and actions for the development and consultation of the Moray Carers Strategy 2026 - ? To Commence July 2025. Completion date March 2026 for launch April 2026 To be developed SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer Carers Voice Group, Carer Strategy Review Group, Service Manager, Strategy Implementation Group members, Commissioned Carer Service, IJB, Currently started early conversations to extend the strategy by 2 years Not Started Theme 1 - Building Resilience, Objective 2 - Value and Support Unpaid Carers We want carers to be able to say, ‘I am able to manage my caring role and reduce any negative impact on my health and wellbeing. I can access the support and services which are right for me. I am able to take a break from my caring role when I need to. I am not disadvantaged because I am a carer. I am able to achieve my own goals and maintain my education and/or employment’. Adopt a continuous improvement approach to monitoring and evaluating carer experience in Moray, aiding consistent reporting to the Scottish Carers Census and informing commissioning and development activity to improve outcomes for carers 3.8 Page 107
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1.1.1, 1.1.2, 1.1.5, 1.1.6, 1.1.9, 1.4.1, 1.4.2, 1.6.1, 1.6.2, 1.6.3, 1.6.4, 1.6.5, 1.6.6, 1.6.7, 1.6.8, 1.7.1, 1.7.2, 1.7.3, 1.7.4, 2.1.2, 2.2.2, 2.2.5, 2.5.2, 2.5.3, 2.6.1, 3.1.2, 3.1.3, 3.1.4, 3.1.5, 3.3.1, 3.3.2, 3.3.3, 3.3.4, 3.3.5, 3.3.6, 3.3.7, 3.4.1, 3.4.2, 3.6.1, 3.6.2, 3.6.3, 3.6.4, 3.8.7, 3.8.10, 3.8.11 Commissioned Unpaid Carer Support Service Contract from January 2024 Carer service provision does not deliver Carer support that is required or compliant. HSCM failure to meet legislative requirements. Increase of Carers in "crisis". Increase in Carer unmet need. Unable to meet increases in referrals or demand for services. Inability to contribute to the progression of Carer Strategy outcomes. Unable to recruit within carer service. Satisfaction with Carer support decreases. Increase in complaints. Reduced ability to provide early help and intervention. High High Variation of Contract issued January 2025 to remove ACSP/YCS from the remit of the commissioned unpaid carer service and in-source. Currently in transition period until the successful recruitment of an unpaid carer social worker. Comprehensive and robust contract monitoring in place with regular monitoring meetings to ensure quality and continued service provision. Updates provided to the Strategy Oversight Group. Deadline Owner Action Ref No. Risk Description Impact Countermeasures Status Overall Im pact Overall Probability Page 108
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Ongoing Social Care crisis More unpaid carers requiring practical and emotional support. Increase in carers reaching "crisis". Increase in referrals to Commissioned Carer Support Service. Increase in urgent referrals to Social Work for emergency respite. Decrease in available respite or long term care provision. January 2025 variation to contract will allow time to focus on early help and crisis prevention. Actively recruiting to unpaid carers social work post. 1.1.1, 1.1.2, 1.1.5, 1.1.6, 1.1.9, 1.4.1, 1.4.2, 1.6.1, 1.6.2, 1.6.3, 1.6.4, 1.6.5, 1.6.6, 1.6.7, 1.6.8, 1.7.1, 1.7.2, 1.7.3, 1.7.4, 2.1.2, 2.2.2, 2.2.5, 2.5.2, 2.5.3, 2.6.1, 3.1.2, 3.1.3, 3.1.4, 3.1.5, 3.3.1, 3.3.2, 3.3.3, 3.3.4, 3.3.5, 3.3.6, 3.3.7, 3.4.1, 3.4.2, 3.6.1, 3.6.2, 3.6.3, 3.6.4, 3.8.7, 3.8.10, 3.8.11 Commissioned Unpaid Carer Support ServiceContract fromJanuary 2024 Carer serviceprovision does not deliver Carer support that is required or compliant. HSCM failuretomeet legislativerequirements. Increase ofCarers in "crisis". Increasein Carer unmet need. Unabletomeet increases in referrals or demand for services. Inability tocontributeto theprogression ofCarer Strategy outcomes. Unabletorecruit within carer service. Satisfaction with Carer support decreases. Increasein complaints. Reduced ability to provideearly help and intervention. High High Variation ofContract issued January 2025 toremove ACSP/YCS fromtheremit ofthe commissioned unpaid carer serviceand in-source. Currently in transition period untilthe successfulrecruitment ofan unpaid carer socialworker. Comprehensiveand robust contract monitoring in placewith regular monitoring meetings to ensurequality and continued serviceprovision. Updates provided totheStrategy Oversight Group. Page 109
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High1.1.3, 1.1.5, 1.1.6, 1.1.7, 1.1.8, 1.1.9, 1.4.1, 1.4.2, 1.5.1, 1.5.2, 1.5.3, 1.5.4, 1.6.1, 1.6.2, 1.7.1, 1.7.3, 1.7.4, 2.1.2, 2.1.4, 2.5.1, 2.5.2, 2.5.3, 2.6.1, 3.1.2, 3.1.3, 3.1.4, 3.3.2, 3.3.3, 3.3.5, 3.3.6, 3.6.1, 3.6.2, 3.6.3, 3.6.4, 3.6.5, 3.6.6, 3.7.1, 3.7.2, Young Carers Strategy Officer post currently vacant. Impact of the caring role may lead to young carers not achieving their full potential at school, entering further education or work. Aims to embed Young Carer Statements into both adult and children's services have ceased. Activities and actions identified in the Carer Strategy will not be completed. Strong links with Health and Education have ceased to be explored and progressed. Awareness raising for the support and identification of hidden young Carers is unable to progress within Moray and within HSCM. Non compliance with the young Carer aspects of the Carer legislation. Young Carers will not be represented in the review and development of the Carer Strategy or Carer Support Service contract. Development for Young Carer breaks, Young Carer transition support is not achieved. High DAR and VFM approved, currently with HR. Awaiting recruitment. Page 110
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3.8.8, 2.5.1, HSCM significant backlog (circa 300 to date) in processing ACSPs and YCSs due to Unpaid Carer Social Worker vacancy. Unable to meet our legislative duties under the Carers (Scotland) Act 2016. Carer increased stress and burnout, decreased mental and physical health, delayed access to necessary support and services, carer isolation, compromised care provided to the cared-for, impact on family relationships, difficulty in maintaining a work and caring balance, deterioration in carer/cared-for relationships, loss of autonomy and control and increased risk of carer crisis. High High Currently recruiting for the unpaid carer Social Worker. Monitoring referrals as early indications are that the volumes require additional resource. Review processes and structure of the unpaid carers team within HSCM via the Strategy Oversight Group. 1.1.3, 1.1.5, 1.1.6, 1.1.7, 1.1.8, 1.1.9, 1.4.1, 1.4.2, 1.5.1, 1.5.2, 1.5.3, 1.5.4, 1.6.1, 1.6.2, 1.7.1, 1.7.3, 1.7.4, 2.1.2, 2.1.4, 2.5.1, 2.5.2, 2.5.3, 2.6.1, 3.1.2, 3.1.3, 3.1.4, 3.3.2, 3.3.3, 3.3.5, 3.3.6, 3.6.1, 3.6.2, 3.6.3, 3.6.4, 3.6.5, 3.6.6, 3.7.1, 3.7.2, Young Carers Strategy Officer post currently vacant. Impact ofthecaring rolemay leadtoyoung carers not achieving their fullpotentialatschool, entering further education or work. Aims to embed Young Carer Statements intoboth adult and children's services haveceased. Activities and actions identified in theCarer Strategy will not becompleted. Strong links with Health and Education haveceased tobeexplored and progressed. Awareness raising for thesupport and identification ofhidden young Carers is unabletoprogress within Moray and within HSCM. Non compliancewith theyoung Carer aspects oftheCarer legislation. Young Carers will not berepresented in thereview and development oftheCarer Strategy or Carer Support Servicecontract. Development for Young Carer breaks, Young Carer transition support is not achieved. High DARand VFM approved, currently with HR. Awaiting recruitment. Page 111
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3.6.5, 3.6.6 SDS budget allocation of £300 for those eligible for further support is not in line with the SDS legislation HSCM are not meeting their legal duties under the act to identify a personal budget. Not able to fully deliver on the SDS legislation or offer all 4 options of SDS High High Ascertain a true SDS Carers Budget. Review and develop Carer SDS provision in line with SDS Legislation. Carers of people who are Palliative patients are to have assessments and plans all processed in 14 days. Unknown carer status if not triaged. Failure to meet Carers Act legislation. High High Mitigation - to look at each case as the referral is received. Referral disseminated to relevant SW team as applicable (during unpaid carer social worker post vacancy) 1.3.1, 1.3.2, 1.3.3, 1.3.6 Carer Positive Award progression to Level 2 within Moray Council. No lead identified. Actions to progress to level 2 Carer Positive award will not be achieved without a Carer Positive Lead within the Council. Moray Council will fail to demonstrate how it is committed to valuing and supporting staff who have an unpaid caring role outside of work. Retention and recruitment of staff may be negatively affected. Medium Medium 3.2.4 Application of the carer support pathway detailed within the Carers (Scotland) Act is not always followed and/or evidenced. Carer outcomes not fully met/evidenced. Eligibility criteria not applied correctly. Non compliance with legislation. Documentation (Part 2 ACSP/YCS) would not show details of any increase in support arranged for the cared-for or access to universal services. Insufficient information recorded to inform annual reviews of ACSP/YCS. Unable to accurately identify true cost of spend for unpaid carers.. High High Reviewing pathways and documentation and recruiting to the unpaid carer social work post. Page 112
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3.8.8, 1.2.1, 1.2.3, 1.3.1, 1.3.3, 2.4.2, 2.5.1, 3.2.2, 3.2.3, 3.2.4, 3.6.5, 3.6.6, 3.98.10, 3.8.11, 3.8.12 Insufficient resources to successfully implement the Carers Strategy Unable to meet legislative requirements. Unable to implement the actions from the Carer Strategy. Unable to effectively support carers in Moray in their caring role. High High Review processes and capacity of the unpaid carers team. Page 113
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Ref Actions Target Achievement Date Reference To Separate Project Plan Associated Risks (see Risk Log for detail on Med and High Risks) Low , Medium, High Lead Person(S) Supported by/Additional Resources Required Progress Notes Status - (Completed, In Progress, Not Started) Reference to Carers (Scotland) Act 2016 Reference to National Carers Strategy 1.3.4 Agree a programme of Carer Positive take-up in all hospitals in Moray Year 1 Carer Positive Project Hospital Carer Positive Lead (to be determined) To be determined Level 1 (engaged) achieved by NHS Grampian Complete 1.3.5 Achieve Level 1 Carer Positive in all hospitals in Moray (will need to be broken down to specific hospitals/years once commitment secured) Year 3 Carer Positive Project Hospital Carer Positive Lead (to be determined) To be determined Level 1 (engaged) achieved by NHS Grampian Complete 3.1.1 Establish the parameters and arrangements for the Adult and Young Carers Contract from April 2023 and subsequent contract tendering process which is responsive to local need/risks and statutory requirements. April 2023 N/A Carers Service Commissioning Officer, Service Manager Assistant SDS & Unpaid Carers Officer, Social Worker Unpaid Carers, Assistant Adult and Young Carer Officers, Commissioned Carers Service The current commissioned service has a letter of commitment running until September 2023 to enable a robust service specification can be developed, out to tender and contract awarded towards the end of 2023 Complete 3.8.1 Re-establish a Strategy Implementation Group - review membership and Terms of Reference. Set meeting dates for Strategy term. May 2023 N/A Service Manager SDS & Unpaid Carers Team Manager (Carers Lead), Young Carer Strategy Officer, Assistant SDS & Unpaid Carers Officer Complete 3.8.10 Establish membership and Terms of Reference for a Carer Strategy Review Group October 2023 N/A Service Manager Carers Voice Group, Strategy Implementation Group members, Social Worker for Unpaid Carers, Commissioned Carers Service, Complete Page 114
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APPENDIX 2 Carer Aware Branding Prototypes Item 8. Page 115
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 27 MARCH 2025 SUBJECT: EXTERNAL AUDIT PLAN FOR THE YEAR ENDING 2024/25 AND UPDATE ON RECOMMENDATIONS FROM 2023/24 BY: CHIEF FINANCIAL OFFICER 1. REASON FOR REPORT 1.1 To inform the Committee of the Auditor’s Annual Plan for 2024/25 and update on the recommendations following last years’ audit. 2. RECOMMENDATION 2.1 It is recommended that Committee scrutinises and notes the contents of the External Auditor’s Annual Plan for 2024/25 attached as Appendix 1 and update on audit recommendations from 2023/24 attached as Appendix 3. 3. BACKGROUND 3.1 In September 2022, Grant Thornton was confirmed as the external auditor of the Moray Integration Joint Board (MIJB). The appointment was for financial years 2022/23 to 2026/27 inclusive. 3.2 Grant Thornton were appointed by the Accounts Commission to deliver the public audit for Moray, they will provide independent assurance to the people of Scotland that public money is spent appropriately and provides value. Audit work is carried out in accordance with International Standards on Auditing, the Code of Audit Practice https://www.audit-scotland.gov.uk/publications/code-of- audit-practice-2021 and any other relevant guidance. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 An Annual Audit Plan for 2024/25 has been received from Grant Thornton and is attached at Appendix 1 to this report. The Plan sets out the scope of the audit work and the auditors approach to the audit. The Plan details the initial risks identified by Grant Thornton and planned work to be undertaken for the audit of the financial statements for the year ending 2024/25. Grant Thornton also aim to add value to the MIJB through its work. Item 9. Page 117
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4.2 The Audit Plan identifies the main risks for the MIJB which will be the focus of audit testing and are outlined in page 10 of the Plan. In order to assist with the assessment of risk, an Informing the Audit Risk Assessment was completed by senior managers and is attached at Appendix 2. 4.3 On page 8 of the Audit Plan, Grant Thornton has shown the External Audit fee for 2024/25 as being £36,500. This is made up of a base fee £34,000 plus £2,500 for additional work on the wider scope, due to the significant financial sustainability issues impacting the MIJB (£35,860 for 2023/24, which also included an additional fee of £2,500). 4.4 The annual accounts timetable, including key deadlines are shown on page 28 of the audit plan and requires the MIJB to submit the Unaudited Annual Accounts along with supporting working papers to Grant Thornton by 30 June 2025 following consideration by those charged with governance at the meeting of the MIJB on 19 June 2025. The MIJB will be asked to approve the audited annual accounts and to consider the Annual Audit Report at its special meeting on 30 October 2025. 4.5 As part of the audit on 2023/24 accounts Grant Thornton produced the Annual Audit Report on 26 September 2024 (para 6 of the minute refers), within which there were a number of recommendations following the work on the Wider Scope audit. Attached at Appendix 3 is the latest update on the recommendations, all of which have been actioned. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and MIJB Strategic Commissioning Plan ‘Partners in Care’ 2022 – 2032 The work undertaken by External Audit seeks to provide assurance to the MIJB on the financial governance and resource management. It will express a view on the key risks to be managed in order to secure operational efficiency in line with the Strategic Plan 2022 - 32. (b) Policy and Legal The external audit is conducted in terms of statutory powers afforded to the appointed External Auditor and in accordance with Grant Thorntons Code of Practice. (c) Financial implications The annual audit fee set for 2024/25 by Grant Thornton and paid by the MIJB is £36,500. (d) Risk Implications and Mitigation The risks associated with the Audit Plan have been identified and categorised within the Plan on page 10. (e) Staffing Implications Preparation of the MIJB’s financial statements will require input and coordination from the MIJB Chief Financial Officer and the finance teams Page 118
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of both Moray Council and NHS Grampian which forms part of the scheduled work. (f) Property None arising directly from this report. (g) Equalities/Socio Economic Impact None arising directly from this report as there has been no change to policy. (h) Climate Change and Biodiversity Impacts None arising directly from this report. (i) Directions None arising directly from this report. (j) Consultations The content of the Plan has been discussed with the Chief Officer, Chief Internal Auditor and Senior Managers prior to production and their comments have been incorporated where appropriate. 6. CONCLUSION 6.1 The Annual Audit Plan informs the MIJB, its Committees and officers of the work to be undertaken by External Audit (Grant Thornton) in the year ahead. 6.2 The Audit recommendations from 2023/24 audit have been considered and progress has been made on them all. Author of Report: Deborah O’Shea Background Papers: with author Ref: Page 119
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Moray Integration Joint Board External Audit Plan Financial year ending 31 March 2025 Prepared for those Charged with Governance, the Controller of Audit and the Accounts Commission 17 March 2025 APPENDIX 1 Item 9. Page 121
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Contents Section Page 1. Key developments impacting our audit approach 03 2. Introduction and Headlines 05 3. Identified risks 09 4. Our approach to materiality 14 5. IT audit strategy 18 6. Wider scope and best value arrangements 20 7. Logistics 27 8. Fees and related matters 31 8. Independence considerations 34 9. Communication of audit matters with those charged with governance 36 10. Delivering audit quality 38 11. Appendices 42 Moray Integration Joint Board External Audit Plan 2024/25 2 Page 122
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Key developments impacting our audit approach 01 Moray Integration Joint Board External Audit Plan 2024/25 3 Page 123
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|© 2025 Grant Thornton UK LLP Commercial in Confidence 4Moray Integration Joint Board External Audit Plan 2024/25 4 Key developments impacting our audit approach Our commitments • As a firm, we are absolutely committed to audit quality and financial reporting in the local government sector. • To ensure close work with audited bodies and an efficient audit process, our preference as a firm is either for our staff to work on site with you and your staff or to develop a hybrid approach of on-site and remote working. • We would like to offer a formal meeting with the Chief Officer twice a year as part of our commitment to keep you fully informed on the progress of the audit. • We will consider your arrangements for managing and reporting your financial resources as part of our audit in completing our wider scope work in relation to financial management and financial sustainability. • Our wider scope work will also consider your arrangements relating to vision, leadership and governance and use of resources to improve outcomes. • We hold annual financial reporting workshops for our audit bodies to access the latest technical guidance and interpretation, discuss issues with experts and create networking links with other client to support consistent and accurate financial reporting across the sector. Page 124
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Introduction and Headlines02 Moray Integration Joint Board External Audit Plan 2024/25 5 Page 125
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Introduction and headlines (1) Purpose • This document provides an overview of the planned scope and timing of the external audit of Moray Integration Joint Board (the IJB) for those charged with governance. • We are appointed by The Accounts Commission as the external auditors of the IJB for the five-year period 2022/23 to 2026/27. Respective responsibilities • The Code of Audit Practice (the Code) summarises where the responsibilities of auditors begin and end and what is expected from the audited body. Our respective responsibilities, and that of the IJB are summarised in the Appendix of this Audit Plan. We draw your attention to this and the Code. Scope of our Audit • The scope of our audit is set in accordance with the Code and International Standards on Auditing (ISAs) (UK). We are responsible for forming and expressing an opinion on the IJB’s financial statements, which have been prepared by management with the oversight of those charged with governance (the Audit, Performance and Risk Committee). Our audit of the financial statements does not relieve management or the IJB Board of your responsibilities. It is your responsibility to ensure that proper arrangements are in place for the conduct of your business, and that public money is safeguarded and properly accounted for. As part of our wider scope work, we will consider how you are fulfilling these responsibilities. Our audit approach is based on a thorough understanding of the IJB and is risk based. Other Audit Matters We summarise other audit matters for the IJB Audit, Performance and Risk Committee awareness. This includes: • Consideration of going concern in accordance with Practice Note 10. • In accordance with the Code and planning guidance we also required to complete and submit a number of information returns and other deliverables to Audit Scotland during the year. Moray Integration Joint Board External Audit Plan 2024/25 6 Page 126
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Introduction and headlines (2) Significant risks Those risks requiring special audit consideration and procedures to address the likelihood of a material financial statement error have been identified as: • Management override of controls (ISA (UK) 240); We will communicate significant findings on this area as well as any other significant matters arising from the audit to you in our Audit Findings (ISA 260) Report. Moray Integration Joint Board External Audit Plan 2024/25 7 Wider Scope and Best Value Audit In accordance with the Code, our planning considers the Wider Scope and Best Value areas of audit. We have identified the following wider scope significant risk and will conclude on this during the audit: • Financial sustainability – future financial plans for 2025/26 and beyond As part of our integrated wider-scope work, we also use a risk-based approach to assess and report on whether the IJB has made proper arrangements for securing Best Value and is complying with its community planning duties. The audit plan sets out our risk-based audit approach for the IJB. This plan outlines our initial risk assessment and is reported to those charged with governance (the Audit, Performance and Risk Committee) and will be shared with Audit Scotland. Materiality We have calculated our planning materiality to be £5.070 million (PY: £3.376 million) for the IJB, which equates to 2.5% (PY: 2%) of your prior year gross expenditure as per the audited accounts. This gives us a PM of £3.802 million (PY: £2.532 million) and is based on 75% (PY: 75%) of planning materiality. We are obliged to report uncorrected omissions or misstatements other than those which are ‘clearly trivial’ to those charged with governance. Clearly trivial has been calculated at 5% of materiality being £0.254 million (PY: £0.169 million). A lower materiality threshold will of £25,000 will be used on salary and pension (CETV) tables for senior management and board members. We will revisit our materiality throughout our audit including updating to reflect the draft unaudited financial statements for 2024/25. Adding value through the audit Our overall approach to adding value through the audit is clear and upfront communication, founded on our public sector credentials. We use our LEAP audit methodology and data analytics to ensure delivery of a quality audit. We have also invited members of your financial reporting team to our annual Local Government Chief Accountants workshop, which is led by our internal financial reporting technical team. Page 127
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Introduction and headlines (3) Audit Fees Audit fees were shared by Audit Scotland with the IJB in January 2025. The baseline audit fee for the IJB is £34,000. This fee includes: • Auditor remuneration £36,450 • Pooled costs £920 • Contribution to Performance Audit and Best Value costs £7,000 • Sectoral cap adjustment of -£10,370 Audit fees are paid to Audit Scotland who in turn pay Grant Thornton UK LLP. The baseline audit fee has been agreed with the audited body. Due to the significant financial sustainability issues impacting the IJB, we expect to complete additional wider scope work around this key theme. Although the full extent of our procedures are not yet known it is expected the additional time, will be at least £2,500. This would mean the baseline fee would be £36,500. We reserve the right to review our fee during the audit should significant delays be encountered and/or new technical matters arise. Moray Integration Joint Board External Audit Plan 2024/25 8 Other Matters We summarise other audit matters for the Audit; Performance and Risk Committee’s awareness. This includes: • Consideration of going concern in accordance with Practice Note 10. • In accordance with the Code and planning guidance we also required to complete and submit a number of information returns and other deliverables to Audit Scotland during the year. Page 128
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Identified risks03 Moray Integration Joint Board External Audit Plan 2024/25 9 Page 129
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Significant risks identified (1) Significant risks are defined by ISAs (UK) as risks that, in the judgement of the auditor, require special audit consideration. In identifying risks, audit teams consider the nature of the risk, the potential magnitude of misstatement, and its likelihood. Significant risks are those risks that have a higher risk of material misstatement. “In determining significant risks, the auditor may first identify those assessed risks of material misstatement that have been assessed higher on the spectrum of inherent risk to form the basis for considering which risks may be close to the upper end. Being close to the upper end of the spectrum of inherent risk will differ from entity to entity and will not necessarily be the same for an entity period on period. It may depend on the nature and circumstances of the entity for which the risk is being assessed. The determination of which of the assessed risks of material misstatement are close to the upper end of the spectrum of inherent risk, and are therefore significant risks, is a matter of professional judgment, unless the risk is of a type specified to be treated as a significant risk in accordance with the requirements of another ISA (UK).” (ISA (UK) 315). In making the review of unusual significant transactions “the auditor shall treat identified significant related party transactions outside the entity’s normal course of business as giving rise to significant risks.” (ISA (UK) 550). Significant risk Description Management override of controls Under ISA (UK) 240 there is a non-rebuttable presumed risk that the risk of management override of controls is present in all entities. Our risk focuses on the areas of the financial statements where there is potential for management to use their judgement to influence the financial statements alongside the potential to override the entity’s internal controls, related to individual transactions. We have therefore identified management override of controls as a significant risk of material misstatement. This relates to the elements involving consolidation, after the information is extracted from partner ledgers, to produce the financial statements for Moray IJB. We will: • Confirm our understanding over the agreement of balances and transactions to the year end submissions from Moray Council and NHS Grampian. • Document our understanding of and evaluate the design effectiveness of management’s key controls over journals at the partner authorities; • Gain an understanding of the critical judgements applied by management in the preparation of the financial statements and consider their reasonableness; • Evaluate the rationale for any changes in accounting policies, estimates or significant unusual transactions. Management should expect engagement teams to challenge management in areas that are complex, significant or highly judgmental which may be the case for accounting estimates, going concern, related parties and similar areas. Management should also expect to provide to engagement teams with sufficient evidence to support their judgments and the approach they have adopted for key accounting policies referenced to accounting standards or changesthereto. Where estimates are used in the preparation of the financial statements management should expect teams to challenge management’s assumptions and request evidence to support those assumptions. Moray Integration Joint Board External Audit Plan 2024/25 10 Page 130
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Significant risks identified (2) Significant Risk Description Fraud in Expenditure Recognition As set out in practice note 10 (Revised 2020) ‘The Audit of Public sector Financial Statements’, issued by the Public Audit Forum, which applies to all public sector entities, we consider there to be an inherent risk of fraud in expenditure recognition. The IJB delegates services to Moray Council and NHS Grampian. A budget is agreed by all parties in advance of the financial year. It is up to the Council and the NHS Board to spend the delegated budget, as agreed with the IJB. (rebutted) Having considered the risk factors set out in PN 10 and the nature of the expenditure streams at the IJB, we have determined that the risk of fraud arising from revenue recognition can be rebutted, because: • opportunities to manipulate expenditure recognition are very limited. Therefore, we do not consider this to be a significant risk for IJB Fraud in Revenue Recognition Under ISA (UK) 240 there is a rebuttable presumed risk that revenue may be misstated due to the improper recognition of revenue. This presumption can be rebutted if the auditor concludes that there is no risk of material misstatement due to fraud relating to revenue recognition. (rebutted) Having considered the risk factors set out in ISA 240 and the nature of the revenue streams at the IJB, we have determined that the risk of fraud arising from revenue recognition can be rebutted, because: • there is little incentive to manipulate revenue recognition; and • opportunities to manipulate revenue recognition are very limited. Therefore, we do not consider this to be a significant risk for the IJB. Moray Integration Joint Board External Audit Plan 2024/25 11 Page 131
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Other matters (1) Other work In addition to our expected responsibilities under the Code of Practice, we have a number of other audit responsibilities, as follows: • We audit parts of your Remuneration Report, as required under the Code, and check whether these sections have been properly prepared (opinion). These procedures are performed to a lower materiality. • We read the sections of your Statement of Accounts which are not subject to audit and check that they are consistent with the financial statements on which we give an opinion (opinion). • We carry out work to satisfy ourselves that disclosures made in your Annual Governance Statement are in line with requirements set out in Delivering Good Governance in Local Government: Framework (2016) (opinion). • We consider our other duties under the Code and planning guidance (2024/25), as and when required, including: • Supporting Audit Scotland’s reporting to the Accounts Commission. • Contributing to Audit Scotland Performance Reports and providing regular updates to Audit Scotland to share awareness of current issues. • Contributing to the National Fraud Initiative (NFI) report. • Notifying the Controller of the Audit when circumstances indicate a statutory report may be required. • Completing mandated information requests and returns and notifying Audit Scotland of any cases of money laundering or fraud. • Review of Technical guidance prior to issue by Audit Scotland. Moray Integration Joint Board External Audit Plan 2024/25 12 Other material balances and transactions Under International Standards on Auditing, "irrespective of the assessed risks of material misstatement, the auditor shall design and perform substantive procedures for each material class of transactions, account balance and disclosure". All other material balances and transaction streams will therefore be audited. However, the procedures will not be as extensive as the procedures adopted for the risks identified in this report. Internal control environment During our initial audit planning we will develop our understanding of your control environment (design and implementation) as it relates to the preparation of your financial statements. In particular we will: • Consider key business processes and related controls. • Assess the design of key controls over all significant risks we have identified. This will include key controls over: • Journal entries and other key entity level controls. • The completeness and accuracy of information provided to the actuary to perform the valuation of the net pension fund liability. • The review of actuarial outputs including key assumptions made by the actuary and significant movements impacting the net pension liability. Our focus is on design and implementation of controls only. We do not intend to assess or place any reliance on the operating effectiveness of your controls during our audit. Page 132
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Other matters (2) Going concern assessment As auditors, we are required to obtain sufficient appropriate audit evidence regarding, and conclude on: • whether a material uncertainty related to going concern exists; and • the appropriateness of management’s use of the going concern basis of accounting in the preparation of the financial statements. The Public Audit Forum has been designated by the Financial Reporting Council as a “SORP-making body” for the purposes of maintaining and updating Practice Note 10: Audit of financial statements and regularity of public sector bodies in the United Kingdom (PN 10). It is intended that auditors of public sector bodies read PN 10 in conjunction with (ISAs) (UK). PN 10 was updated in 2020 to take account of revisions to ISAs (UK), including ISA (UK) 570 (Revised September 2019) on going concern. PN 10 allows auditors to apply a ‘continued provision of service approach’ when auditing going concern in the public sector, where appropriate. Audit Scotland’s also issued further guidance in a Going Concern publication in December 2020). Within our wider scope work we will conclude on the IJB’s arrangements to ensure financial sustainability. Internal Audit We read and understand the work of Internal Audit during the year, and how this work feeds into management’s governance processes and inclusion within the Annual Governance Statement. We do not rely directly upon the work of Internal Audit, and our approach is fully substantive. Moray Integration Joint Board External Audit Plan 2024/25 13 Financial reporting developments During our audit we will actively discuss emerging financial reporting developments with you. We invited members of your finance team to our LG technical audit workshops earlier this year. Progress against prior year audit recommendation As part of our final account's procedures, we will follow up on the implementation of prior year audit recommendations and report on progress against the recommendations in full within our Annual Audit Report. IFRS 16 – Right of Use Assets In line with the Code of Audit Practice for Local Authority Accounting in the UK, 2024/25 is the first year local government bodies are required to adopt IFRS 16 Leases. Under IFRS 16 a lessee is required to recognise right-of-use assets and associated lease liabilities in its Statement of Financial Position. Integration Joint Board’s are unable to hold assets, however we will consider whether the new accounting standard has any relevance to the IJB and whether any associated disclosures are required in the annual accounts. Page 133
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Our approach to materiality04 14Moray Integration Joint Board External Audit Plan 2024/25 Page 134
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Our approach to materiality (1) The concept of materiality is fundamental to the preparation of the financial statements and the audit process and applies not only to the monetary misstatements but also to disclosure requirements and adherence to acceptable accounting practice and applicable law. Matter Description Planned audit procedures Determination We have determined planning materiality (financial statement materiality determined at the planning stage of the audit) based on professional judgement in the context of our knowledge of the business, including consideration of factors such as shareholder expectations, industry developments, financial stability and reporting requirements for the financial statements. We have determined financial statement materiality based on a proportion of the gross expenditure of the IJB for the financial year. Materiality at the planning stage of our audit is £5.070 million (PY: £3.376 million), which equates to 2.5% of your prior year gross expenditure for the year. Performance materiality for the IJB has been set at £3.802 million (PY: £2.532 million) which is based upon 75% of materiality. • We determine planning materiality in order to: – establish what level of misstatement could reasonably be expected to influence the economic decisions of users taken on the basis of the financial statements; – assist in establishing the scope of our audit engagement and audit tests; – determine sample sizes; – assist in evaluating the effect of known and likely misstatements in the financial statements. Other factors An item does not necessarily have to be large to be considered to have a material effect on the financial statements • An item may be considered to be material by nature when it relates to: – instances where greater precision is required (e.g. the Senior Management and Board Member Remuneration and Pension CETV Tables). Reassessment of materiality Our assessment of materiality is kept under review throughout the audit process • We reconsider planning materiality if, during the course of our audit engagement, we become aware of facts and circumstances that would have caused us to make a different determination of planning materiality. 01 02 Moray Integration Joint Board External Audit Plan 2024/25 15 03 Page 135
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Our approach to materiality (2) Matter Description Planned audit procedures Matters we will report to the Audit, Performance and Risk Committee Whilst our audit procedures are designed to identify misstatements which are material to our opinion on the financial statements as a whole, we nevertheless report to the Audit, Performance and Risk Committee any unadjusted misstatements of lesser amounts to the extent that these are identified by our audit work. Under ISA 260 (UK) ‘Communication with those charged with governance’, we are obliged to report uncorrected omissions or misstatements other than those which are ‘clearly trivial’ to those charged with governance. ISA 260 (UK) defines ‘clearly trivial’ as matters that are clearly inconsequential, whether taken individually or in aggregate and whether judged by any quantitative or qualitative criteria. • We report to the Audit, Performance and Risk Committee any unadjusted misstatements of lesser amounts to the extent that these are identified by our audit work. • In the context of the IJB, we propose that an individual difference could normally be considered to be clearly trivial if it is less than £0.254 million (PY: £0.169 million). If management have corrected material misstatements identified during the course of the audit, we will consider whether those corrections should be communicated to the Audit, Performance and Risk Committee to assist it in fulfilling its governance responsibilities. Misstatements, including omissions, are considered to be material if they, individually or in the aggregate, could reasonably be expected to influence the economic decisions of users taken on the basis of the financial statements; Judgments about materiality are made in light of surrounding circumstances, and are affected by the size or nature of a misstatement, or a combination of both; and Judgments about matters that are material to users of the financial statements are based on a consideration of the common financial information needs of users as a group. The possible effect of misstatements on specific individual users, whose needs may vary widely, is not considered. (ISA (UK) 320) Moray Integration Joint Board External Audit Plan 2024/25 16 04 Page 136
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Our approach to materiality (3) Amount (£) Qualitative factors considered Materiality for the IJB’s financial statements £5.070 million Our materiality has been set at 2.5% of prior year gross expenditure of the IJB as per the 2023/24 financial statements. In setting this threshold, the following factors have been considered: • There were no significant findings in the 2023/24 audit report. • No significant deficiencies have been identified with the IJB’s control environment. • The level of public interest in the IJB for Scotland by the public and the Scottish Government. Materiality for specific transactions, balances or disclosures – Remuneration Report £25,000 Due to the sensitivity of the disclosures to the users of the financial statements, a lower materiality threshold has been applied to the salary and pension (CETV) disclosures for senior management and board members. All other remuneration disclosures will be audited at headline materiality. 17Moray Integration Joint Board External Audit Plan 2024/25 17 Page 137
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|© 2025 Grant Thornton UK LLP Commercial in Confidence IT audit strategy05 Moray Integration Joint Board External Audit Plan 2024/25 18 Page 138
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|© 2025 Grant Thornton UK LLP Commercial in Confidence IT audit strategy In accordance with ISA (UK) 315, we are required to obtain an understanding of the IT environment related to all key business processes, identify all risks from the use of IT related to those business process controls judged relevant to our audit and assess the relevant IT general controls (ITGCs) in place to mitigate them. Our audit will include completing an assessment of the design and implementation of ITGCs related to security management; technology acquisition, development and maintenance; and technology infrastructure. IT application Audit area Planned level IT audit assessment Advance Business Solutions e5 System Financial Reporting – Moray Council • ITGC assessment (design and implementation effectiveness only) eFinancials Financial Reporting – NHS Grampian • Review of Service Auditor Reports • ITGC assessment (design and implementation effectiveness only) The following IT applications are in scope for IT controls assessment based on the planned financial statement audit approach, we will perform the indicated level of assessment: Moray Integration Joint Board External Audit Plan 2024/25 19 Page 139
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Wider scope and best value arrangements 06 Moray Integration Joint Board External Audit Plan 2024/25 20 Page 140
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Wider scope and best value arrangements (1) Our responsibilities under the Code extend beyond the audit of the financial statements. The Code sets out four wider scope areas that constitute the wider scope of public audit in Scotland. We consider each of these areas through our audit planning process and have set out below the identified areas of risk for our wider scope work. From our initial planning work, we have identified one significant risk in relation to Financial Sustainability. We have not identified significant risks in relation to Financial Management; Vision, Leadership and Governance; and Use of Resources. We will continue to review your arrangements before we issue our Annual Report. 21Moray Integration Joint Board External Audit Plan 2024/25 2021 Code of Audit Practice Wider Scope Areas Meaning Financial Sustainability Financial sustainability looks forward to the medium and longer term to consider whether the body is planning effectively to continue to deliver its services or the way in which they should be delivered. Financial Management Financial management is concerned with financial capacity, sound budgetary processes and whether the control environment and internal controls are operating effectively. Vison, Leadership and Governance Vision, Leadership and Governance is concerned with the effectiveness of scrutiny and governance arrangements, leadership and decision making, and transparent reporting of financial and performance information. Use of Resources to Improve Outcomes Bodies need to make best use of their resources to meet stated outcomes and improvement objectives, through effective planning and working with strategic partners and communities. This includes demonstrating economy, efficiency, and effectiveness through the use of financial and other resources and reporting performance against outcomes. Page 141
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Wider scope and best value arrangements (2) 22 No significant weaknesses in arrangements identified or improvement recommendation made. No significant weaknesses in arrangements identified, but improvement recommendations made. Significant weaknesses in arrangements identified and key recommendations made. Moray Integration Joint Board External Audit Plan 2024/25 This section of our report documents our conclusions from audit work on the wider scope areas set out in the Code. We take a risk-based audit approach to wider scope work. We will continue to review your arrangements before we issue our Annual Audit Report. Financial Management Appropriate arrangements were in place, with only minor improvement recommendations being made. No significant risks has been identified. We reviewed the financial management processes in place at Moray IJB, including budget setting and preparation of monitoring reports taken to the Board during the year Financial Sustainability Significant risk identified. The IJB had a significant funding gap over the medium term and minimal reserves in place to manage projected deficits. The Medium- Term plan was also out of date and needed to be refreshed. Significant risk identified in relation to financial sustainability. We have confirmed the Medium-Term Financial Strategy will be updated as part of the 2025/26 budget setting process. The IJB are expected to have a significant budget shortfall over the medium term which will need to be addressed through a programme of efficiency savings. For 2024/25, the IJB are predicting a £5.6m overspend which will need to be addressed through additional funding from the partner bodies. Use of Resources to Improve Outcomes Appropriate arrangements were in place with the Board provided updates on the IJBs performance on an ongoing basis No significant risk has been identified We reviewed the 2023/24 Annual Performance Report and quarterly performance reports taken to Audit, Performance & Risk Committee meetings to gain an understanding of the IJB’s in year performance. Vison, Leadership and Governance The governance arrangements are effective; however, several improvement recommendations were made. No significant risk has been identified. We reviewed the governance arrangements in place and confirmed they continue to be effective. We also liaised with Internal Audit to confirm the result of their reviews to date and the impact of any issues identified to date. Page 142
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Wider scope and best value arrangements (3) 23Moray Integration Joint Board External Audit Plan 2024/25 Financial Sustainability The draft Revenue Budget for 2024/25 was £200.641 million, which included £14.665 million set aside services, representing Moray’s share of the Large Hospital Services. The total funding provided from the partner authorities and Scottish Government was £191.088 million, resulting in a budget gap of £9.553 million. To manage the funding deficit, the IJB identified efficiency savings totalling £8.207 million, resulting in a projected budget deficit of £1.346 million. The Quarter 2 revenue monitoring report presented to the Board in November 2024 identified that the IJB are projecting a total overspend of £5.580 million for 2024/25. If this deficit cannot be reduced by year end, partner authorities will require to provide additional funding contributions to manage the overspend. The IJB has a Medium-Term Financial Framework 2023/24 - 2027/28 which has not been subject to update since the 2023/24 budget was agreed and is now considered to be out of date. The funding deficit identified in the MTFF shows a budget gap of approximately £26 million from 2025/26 - 2027/28. The IJB is preparing an updated Medium Term Financial Framework which will presented to the Board in March 2025, alongside the 2025/26 budget. Significant risk identified: There is a risk that transformation and savings plans to address financial pressures for medium to longer term are not sufficient to address future funding gaps and increasing deficits. Response to significant risk: We will: • will seek to understand the future financial forecasts and plans for the IJB for 2025/26 and beyond, including key assumptions used, scenario planning, sensitivity analysis, risk analysis and the extent of any budget pressures any impact upon reserves • consider the actions the IJB is taking to address identified funding gaps and associated savings plans. • follow-up the prior year recommendations in respect of the financial sustainability risk highlighted last year. Page 143
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Wider scope and best value arrangements (4) 24Moray Integration Joint Board External Audit Plan 2024/25 Financial management Revenue budget monitoring reports are presented to the Board at the end of each quarter and provide clear and concise detail on the financial performance of the IJB. The monitoring reports provide the provisional forecast outturn to the end of the financial year and present detailed explanations around areas of overspend or underspend against budget. The appendices to the report also provide progress towards the achievement of efficiency savings and provide up-to-date forecasts on the level of efficiency savings that are expected to be achieved in the financial year. At 30 September 2024, the IJB’s core services are overspent by £9.530 million, partially offset by a forecast underspend of £3.950 million in Strategic Funds expenditure. This results in a total provision outturn to 31 March 2025 of a £5.580 million overspend. This is a result of an increase in costs due to inflationary and demand pressures, alongside the fact that £3.400 million of savings are at risk of not being achieved in 2024/25. We will seek to understand the effectiveness of the IJB’s budgetary control system in communicating accurate and timely financial performance, including the arrangements for identifying, monitoring and reporting of savings. We will consider the overall financial position reached by the IJB and we will seek to understand the future financial implications of this. We will also look to understand how the IJB communicates overspend positions to the partner authorities and the arrangements in place to fund in-year deficits. We have not identified a risk in relation to the IJB’s financial management arrangements at the planning stage. We will revisit the risk assessment as part of our final audit processes. Use of Resources to Improve Outcomes IJB’s need to make best use of their resources to meet stated outcomes and improvement objectives, through effective planning and working with strategic partners and communities. This includes demonstrating economy, efficiency and effectiveness through the use of financial and other resources, and reporting performance against outcomes. We will review the arrangements that the IJB has developed to address workforce challenges and improve performance. We will also review the processes the IJB has in place to meet outcomes and improvement objectives, for working with strategic partners and communities and reporting performance against outcomes, financial and other resources. We have not identified a risk in relation to the IJB’s use of resources to improve outcomes at the planning stage. We will revisit the risk assessment as part of our final audit processes. Page 144
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Wider scope and best value arrangements (5) 25Moray Integration Joint Board External Audit Plan 2024/25 Vision, leadership and governance The IJB holds a committee-based structure which has delegated functions to several committees who subsequently become responsible for the administration of services. The Audit, Performance and Risk Committee undertakes the role of Those Charged with Governance (TCWG) and has several responsibilities including; scrutinising risks included in the risk register, reviewing performance reports presented at committee meetings and reviewing both internal and external audit reports to ensure the effectiveness of internal control procedures. 2023/24 was the third year in succession that Internal Audit provided a limited assurance opinion, indicating that there were weaknesses in the framework of governance, risk management and control. Progress updates on implementation of internal audit recommendations is presented to the Audit, Performance and Risk Committee and we will review arrangements put in place by the IJB in response to the limited assurance opinion and internal audit findings to date. There has been a period of organisational change at the IJB, with a number of senior management personnel departing the IJB. The IJB have taken steps to address this and appointed Judith Proctor as the Interim Chief Officer in July 2024, with the position being made permanent in November 2024. We will review the effectiveness of the IJB’s scrutiny and governance arrangements, leadership and decision making, and transparent reporting of financial and performance information. Our work will also include reviewing the consistency of the Annual Governance Statement with the key findings from audit, scrutiny, and inspection. We will review the results of any external inspections undertaken during the audit and report the results of these in our Annual Report. We will continue to review your arrangements before we issue our Annual Report. We have not identified a risk in relation the IJB’s arrangements for vision, leadership and governance at the planning stage. We will revisit the risk assessment as part of our final audit processes. Page 145
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Wider scope and best value arrangements (6) 26Moray Integration Joint Board External Audit Plan 2024/25 Local government bodies have a duty under the Local Government in Scotland Act 2003 to make arrangements which secure Best Value. Best Value is continuous improvement in the performance of the body’s functions, having regard to: • efficiency • effectiveness • economy • the need to meet equal opportunity requirements. Local government bodies are required to follow statutory guidance in respect of their Best Value duties. Under the Code of Audit Practice, the audit of Best Value in Integration Joint Boards is fully integrated within the annual wider scope work performed by appointed auditors and their teams. Auditors are not expected to carry out detailed or separate work on the Best Value themes. It is acknowledged that as part of our review of arrangements embedded within our wider scope work, key aspects of the Best Value themes on Governance and Accountability and The Use of Resources will be covered. As part of our integrated wider-scope annual audit work, we as appointed auditors use a risk-based approach to assess and report whether the audited body has made proper arrangements for securing Best Value. We have not identified any significant risks in relation to Moray Integration Joint Board’s Best Value arrangements at the planning stage. Page 146
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Logistics07 Moray Integration Joint Board External Audit Plan 2024/25 27 Page 147
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|© 2025 Grant Thornton UK LLP Commercial in Confidence 28Moray Integration Joint Board External Audit Plan 2024/25 28 The Audit Timeline - Logistics (1) Planning February – March 2025 Key Dates Final September 2025 Completion October 2025 Key elements • Planning meeting with management to set audit scope • Planning requirements checklist to management • Agree timetable and deliverables with management • Issue the Audit Plan to management and Audit, Performance and Risk Committee • Review of key judgements and estimates Key elements • Audit teams to complete fieldwork and detailed testing • Weekly update meetings with management Key elements • Draft Audit Findings issued to management • Audit Findings meeting with management • Draft Audit Findings issued to Audit, Performance and Risk Committee • Audit Findings presentation to Audit, Performance and Risk Committee • Annual Audit Report • Finalise and sign financial statements & audit report Year end: 31 March 2025 Audit, Performance and Risk Committee and Board: Date: October 2025 Audit phases: Audit, Performance and Risk Committee: 27 March 2025 We are required to submit audit plans to Audit Scotland by 31 March 2025, and the target date to submit audited accounts and the Annual Audit Report is by 30 September 2025. We have set out below our planned timescales for the IJB audit and it is expected that target timelines will not be met due to audit resourcing constraints. Wider Scope & Best Value July 2025 Page 148
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|© 2025 Grant Thornton UK LLP Commercial in Confidence The Audit Timeline - Logistics (2) Audited body responsibilities Where audited bodies do not deliver to the timetable agreed, we need to ensure that this does not impact on audit quality or absorb a disproportionate amount of time, thereby disadvantaging our other audit engagements. Where additional resources are needed to complete the audit due to an audited body not meeting their obligations, we are not able to guarantee the delivery of the audit to the agreed timescales. In addition, delayed audits due to client issues may incur additional audit fees. Our requirements To aid the audit process, you need to ensure that you: • produce draft accounts, comprising financial statements and related reports, of good quality, by the deadline you have agreed with us; • prepare good quality working papers which support the figures included in the financial statements, in line with the working paper requirements schedule that we have shared with you, and make these available to us at the start of the year end audit visit; • provide all agreed data reports to us at the start of the audit, which are fully cleansed and reconciled to the figures in the financial statements; • ensure that all appropriate staff are available to us for queries over the planned period of the audit , or as otherwise agreed, and; • respond promptly and appropriately to all audit queries, within agreed timescales. Moray Integration Joint Board External Audit Plan 2024/25 29 Page 149
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|© 2025 Grant Thornton UK LLP Commercial in Confidence 30Moray Integration Joint Board External Audit Plan 2024/25 30 Our team and communications Service delivery Audit reporting Audit progress Technical support Formal communications • Annual audit closure meeting • The Audit Plan • The Annual Audit Report • Progress and Sector Update Reports • Audit planning meetings • Audit clearance meetings • Communication of issues log • Technical updates Informal communications • Open channel for discussion • Communication of audit issues as they arise • Notification of up-coming issues (where appropriate) Angela L Pieri Engagement Lead T: 0161 214 6337 E: Angela.L.Pieri@uk.gt.com Andrew Wallace Audit Manager T: 0141 223 0671 E: Andrew.D.Wallace@uk.gt.com Lucy X Bell Audit Senior / In-charge • Key contact for senior management and Audit, Performance and Risk Committee • Overall quality assurance • Audit team management • Resource management • Wider scope and best value reporting • Day-to-day point of contact • Audit planning/interim • Audit fieldwork Pool of technical specialists (e.g. IT audit) Jasvir Singh Audit In-Charge T: 0141 223 0771 E: Jasvir.Singh@uk.gt.com Page 150
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Fees and related matters08 Moray Integration Joint Board External Audit Plan 2024/25 31 Page 151
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Audit Fees Across all sectors and firms, the Financial Reporting Council (FRC) has set out its expectation of improved financial reporting from organisations and the need for auditors to demonstrate increased scepticism and challenge and to undertake additional and more robust testing. As a firm, we are absolutely committed to meeting the expectations of the FRC on audit quality and public sector financial reporting. This includes, for Audit Scotland contracts, meeting the expectations of the Audit Scotland Quality Team and the Scottish quality framework. Audit fees were shared by Audit Scotland with the IJB in January 2025. Audit fees are paid to Audit Scotland who in turn pay us. We reserve the right to review our fee during the audit should significant delays be encountered and/or new technical matters arise. Relevant Professional Standards Audit Scotland set the baseline audit fee. We can increase the fee, from the baseline, for the inclusion of additional risks, new technical matters or specific client matters identified. We are required to consider all relevant professional standards, including paragraphs 4.1 and 4.2 of the FRC’s Ethical Standard (revised 2024) which state that the Engagement Lead must set a fee sufficient to enable the resourcing of the audit with partners and staff with appropriate time and skill to deliver an audit to the required professional and Ethical standards. Moray Integration Joint Board External Audit Plan 2024/25 32 The baseline fee of £34,000 has been set by Audit Scotland. In accordance with Audit Scotland guidance, we are able to discuss a variation to the audit fee where additional work is required. Further detail on the audit fee is available at page 33. Due to the significant financial sustainability issues impacting the IJB, we expect to complete additional wider scope work around this key theme. Although the full extent of our procedures are not yet known it is expected the additional time, will be at least £2,500. This would mean the baseline fee would be £36,500. We reserve the right to review our fee during the audit should significant delays be encountered and/or new technical matters arise. Page 152
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Audit Fees (2) Audit fees for 2024/25 We seek the additional fee to external auditor remuneration due to: • Significant additional work that is required in the wider scope analysis than would usually be expected. This included a more detailed section on financial sustainability appreciating the significance of savings and budget pressures in 2024/25 and beyond. This would mean the external auditors remuneration would be £38,950 and the total fee would be £36,500. The audit fee is being discussed with the Chief Finance Officer. Additional Fees (Non-Audit Services) Fee Assumption In setting the fee for 2024/25 we have assumed that you will: • prepare a good quality set of accounts, supported by comprehensive and well-presented working papers which are ready at the start of the audit • provide appropriate analysis, support and evidence for all critical and significant judgements and estimates made in preparing the financial statements • provide early notice of proposed complex or unusual transactions which could have a material impact on the financial statements • Provide ongoing access to officers and management experts throughout the audit and timely responses to audit queries. Moray Integration Joint Board External Audit Plan 2024/25 33 Service Fees (£) External Auditor Remuneration £36,450 Additional audit fee £2,500 Pooled Costs £920 Contribution to Performance Audit and Best Value £7,000 Sectoral cap adjustment -£10,370 2024/25 Fee £36,500 Service Fees (£) At planning stage we confirm there are no planned non-audit services Nil Page 153
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Independence considerations09 Moray Integration Joint Board External Audit Plan 2024/25 34 Page 154
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Independence considerations Ethical Standards and ISA (UK) 260 require us to give you timely disclosure of all significant matters that may bear upon the integrity, objectivity and independence of the firm or covered persons (including its partners, senior managers, managers). In this context, there are no matters that we are required to report. As part of our assessment of our independence at planning we note the following matters: We confirm that there are no significant facts or matters that impact on our independence at planning as auditors that we are required or wish to draw to your attention and consider that an objective reasonable and informed third party would take the same view. The firm and each covered person have complied with the Financial Reporting Council’s Ethical Standard and confirm that we are independent and are able to express an objective opinion on the financial statements. No non-audit services provided by Grant Thornton UK LLP have been identified. Any changes and full details of all fees charged for audit related and non-audit related services by Grant Thornton UK LLP and by Grant Thornton International Limited network member Firms will be included in our Annual Audit Report at the conclusion of the audit. Matter Conclusions Relationships with Grant Thornton We are not aware of any relationships between Grant Thornton and the IJB that may reasonably be thought to bear on our integrity, independence and objectivity. Relationships and Investments held by individuals We have not identified any potential issues in respect of personal relationships with the IJB or investments in the IJB held by individuals. Employment of Grant Thornton staff We are not aware of any former Grant Thornton partners or staff being employed, or holding discussions in respect of employment, by the IJB as a director or in a senior management role covering financial, accounting or control related areas. Business relationships We have not identified any business relationships between Grant Thornton and the IJB. Contingent fees in relation to non-audit services No contingent fee arrangements are in place for non-audit services provided. Gifts and hospitality We have not identified any gifts or hospitality provided to, or received from, a member of the IJB’s board, senior management or staff (that would exceed the threshold set in the Ethical Standard). Moray Integration Joint Board External Audit Plan 2024/25 35 Page 155
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Communication of audit matters with those charged with governance 10 Moray Integration Joint Board External Audit Plan 2024/25 36 Page 156
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Communication of audit matters with those charged with governance Our communication plan Audit Plan Annual Audit Report Respective responsibilities of auditor and management/those charged with governance Overview of the planned scope and timing of the audit, form, timing and expected general content of communications including significant risks and Key Audit Matters Planned use of internal audit Confirmation of independence and objectivity A statement that we have complied with relevant ethical requirements regarding independence. Relationships and other matters which might be thought to bear on independence. Details of non-audit work performed by Grant Thornton UK LLP and network firms, together with fees charged. Details of safeguards applied to threats to independence Significant matters in relation to going concern Significant findings from the audit Significant matters and issue arising during the audit and written representations that have been sought Significant difficulties encountered during the audit Significant deficiencies in internal control identified during the audit Significant matters arising in connection with related parties Identification or suspicion of fraud involving management and/or which results in material misstatement of the financial statements Non-compliance with laws and regulations Unadjusted misstatements and material disclosure omissions ISA (UK) 260, as well as other ISAs (UK), prescribe matters which we are required to communicate with those charged with governance, and which we set out in the table here. This document, the Audit Plan, outlines our audit strategy and plan to deliver the audit, while the Annual Audit Report will be issued prior to approval of the financial statements and will present key issues, findings and other matters arising from the audit, together with an explanation as to how these have been resolved. We will communicate any adverse or unexpected findings affecting the audit on a timely basis, either informally or via an audit progress memorandum. Respective responsibilities As auditor we are responsible for performing the audit in accordance with ISAs (UK), which is directed towards forming and expressing an opinion on the financial statements that have been prepared by management with the oversight of those charged with governance. The audit of the financial statements does not relieve management or those charged with governance of their responsibilities. Moray Integration Joint Board External Audit Plan 2024/25 37 Page 157
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Delivering audit quality11 Moray Integration Joint Board External Audit Plan 2024/25 38 Page 158
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Delivering audit quality (1) How our strategy differentiates our service Our investment in a specialist team, and leading tools and methodologies to deliver their work, has set us apart from our competitors in the quality of what we do. The FRC highlighted the following as areas of particularly good practice in its recent inspections of our work: • use of specialists, including at planning phases, to enhance our fraud risk assessment • effective deployment of data analytical tools, particularly in the audit of revenue • clear oversight at group level when working with component auditors, including detailed review of working papers to flush out the critical issues early. Our quality strategy We deliver the highest standards of audit quality by focusing our investment on: Creating the right environment Our audit practice is built around the markets it faces. Your audit team are focused on the Public Sector audit market and work with clients like you day in, day out. Their specialism brings experience, efficiency and quality. Building our talent, technology and infrastructure We’ve invested in digital tools and methodologies that bring insight and efficiency, and invested in senior talent that works directly with clients to deploy bespoke digital audit solutions. Working with premium clients We work with great public and private businesses that, like you, value audit, value the challenge a robust audit provides, and demonstrate the strongest levels of corporate governance. We’re aligned with our clients on what right looks like. Our objective is to be the best audit firm in the UK for the quality of our work and our client service, because we believe the two are intrinsically linked. Moray Integration Joint Board External Audit Plan 2024/25 39 The right people at the right time We are clear that a focus on quality, effectiveness and efficiency is the foundation of great client service. By doing the right audit work, at the right time, with the right people, we maximise the value of your time and ours, while maintaining our second- to-none quality record. Bringing you the right people means that we bring our specialists to the table early, resolving the key judgements before they impact the timeline of your financial reporting. The engagement leader always retains the final call on the critical decisions; we use our experts when forming our opinions, but we don’t hide behind them. Page 159
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Delivering audit quality (2) Wendy Russell Partner, UK Head of Audit Quality underpins everything at Grant Thornton, as our FRC inspection results in the chart below attest to. We’re growing our practice sustainably, and that means focusing where we know we can excel without compromising our strong track record or our ability to deliver great audits. It’s why we will only commit to auditing businesses where we’re certain we have the time and resource, but, most importantly, capabilities and specialist expertise to deliver. You’re in safe hands with the team; they bring the right blend of experience, energy and enthusiasm to work with you and are fully supported by myself and the rest of our firm. Good or limited improvements required Significant improvements required Improvements required FRC’s Audit Quality Inspection and Supervision Inspection (% of files awarded in each grading, in the most recent report for each firm) 0% 20% 40% 60% 80% 100% Moray Integration Joint Board External Audit Plan 2024/25 40 Digital differentiation We’re a digital-first audit practice, and our investment in data analytics solutions has given our clients better assurance by focusing our work on transactions that carry the most risk. With digital specialists working directly with your teams, we make the most of the data that powers your business when forming our audit strategy. Oversight and control Wherever your audit work is happening, we make sure that its quality meets your exacting requirements, and we emphasise communication to identify and resolve potential challenges early, wherever and however they arise. By getting matters on the table before they become “issues”, we give our clients the time to deal with them effectively. Page 160
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Delivering audit quality (3) Moray Integration Joint Board External Audit Plan 2024/25 41 Audit Quality Framework The Audit Quality Framework (AQF) published by Audit Scotland sets out it’s approach to achieving high quality public audit by all auditors and providers. The AQF is the framework used to provide the Auditor General and the Accounts Commission with robust, objective, and independent quality assurance, over the work conducted on their behalf by Audit Scotland and external firms. This work includes delivering the respective performance audit and Best Value work programmes and the annual audits of public bodies across Scotland’s public sector. Audit quality is at the core of public audit in Scotland and is the foundation for building consistency and confidence across all audit work. High-quality public audit provides the public, decision-makers, and politicians, with the assurance and information they need, and it helps Scotland’s Parliament hold public bodies to account. This is more important than ever when public services face rising demand and tightening budgets Annual Audit Quality Report Audit Scotland’s Audit Quality and Appointment (AQA) team prepares an annual Audit Quality Report to provide assurance on audit quality, including compliance with the Financial Reporting Council’s Ethical Standard, to the Auditor General for Scotland and the Accounts Commission. This annual report summarises the AQA’s assessment of audit quality conducted on audit work, delivered by Audit Scotland and the six appointed firms (including Grant Thornton UK LLP) on behalf of the Auditor General for Scotland and the Accounts Commission on the 2022/23 audits. The report provides evidence that auditors have designed and implemented audit quality arrangements to assure the quality of their audit work and highlights areas for further improvement. This report is available at Quality of public audit in Scotland: Annual report 2023/24 and is published on annual basis. Independent External Reviews Independent external assurance offers the highest level of assurance to stakeholders. ICAEW replaced ICAS for 2021/22 independent reviews following a successful tendering exercise undertaken by Audit Scotland in 2022. ICAEW review audit files to assess the quality of audit work and compliance with the International Standards on Auditing (UK), Financial Reporting Council’s Practice Note 10 and Audit Scotland’s Code of Audit Practice. External reviews cover the firms and Audit Directors in Audit Scotland over a three-year cycle, with the external review results shown within the chart below for the last five financial years. Page 161
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Appendices12 Moray Integration Joint Board External Audit Plan 2024/25 42 Page 162
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|© 2025 Grant Thornton UK LLP Commercial in Confidence 43Moray Integration Joint Board External Audit Plan 2024/25 43 Appendix 1 - Respective responsibilities Moray Integration Joint Board Your responsibilities include: • Maintaining adequate accounting records and working papers • Preparing accounts for audit, comprising financial statements, which give a true and fair view, and related reports • Establishing and maintaining a sound system of internal control • Establishing sound arrangements for proper conduct of affairs, including the regularity of transactions • Maintaining standards of conduct for the prevention and detection of fraud and other irregularities • Maintaining strong corporate governance arrangements and a financial position that is soundly based • Establishing and maintaining an effective internal audit function. External Audit Our responsibilities include: • Compliance with the FRC Ethical Standard • Compliance with the Code and UK Auditing Standards (ISA’s UK) in the conduct and reporting of our financial statements audit • Compliance with the Code and guidance issued by Audit Scotland in the conduct and reporting of our wider scope work • Providing assurance on specified returns and other outputs (where required), as specified in guidance issued by Audit Scotland • Liaison with and notifying Audit Scotland when circumstances indicate a statutory report may be required. • Contributing to relevant performance studies (as set out in Audit Scotland’s Planning Guidance for 2024/25). The Code sets out auditor responsibilities and responsibilities of the audited body. Key responsibilities are summarised below. Please refer to the Code for further detail. Page 163
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Appendix 2 - The Grant Thornton Digital Audit – Inflo A suite of tools utilised throughout the audit process 01 Collaborate Ingest Detect Information requests are uploaded by the engagement team and directed to the right member of your team, giving a clear place for files and comments to be uploaded and viewed by all parties. What you’ll see • Individual requests for all information required during the audit • Details regarding who is responsible, what the deadline is, and a description of what is required • Graphs and charts to give a clear overview of the status of requests on the engagement The general ledger and trial balance are uploaded into Inflo. This enables samples, analytical procedures, and advance data analytics techniques to be performed on the information directly from your accounting records. Journals interrogation software which puts every transaction in the general ledger through a series of automated tests.From this, transactions are selected which display several potential unusual or higher risk characteristics. What you’ll see • Journals samples selected based on the specific characteristics of your business • A focused approach to journals testing, seeking to only test and analyse transactions where there is the potential for risk or misstatement 02 03 Moray Integration Joint Board External Audit Plan 2024/25 44 Page 164
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|© 2025 Grant Thornton UK LLP Commercial in Confidence Appendix 3 - New or revised IFRS Amendments to IAS 21 – Lack of exchangeability IAS 21 has been amended by the IASB to specify how an entity should assess whether a currency is exchangeable and how it should determine a spot exchange rate when exchangeability is lacking. The amendments are effective in the UK from 1 January 2025. IFRS 18 Presentation and Disclosure in the Financial Statements IFRS 18 will replace IAS 1 Presentation of Financial Statements. All entities reporting under IFRS Accounting Standards will be impacted. The new standard will impact the structure and presentation of the statement of profit or loss as well as introduce specific disclosure requirements. Some of the key changes are: • Introducing new defined categories for the presentation of income and expenses in the income statement • Introducing specified totals and subtotals, for example the mandatory inclusion of ‘Operating profit or loss’ subtotal. • Disclosure of management defined performance measures • Enhanced principles on aggregation and disaggregation which apply to the primary financial statements and notes. IFRS 18 will be effective in the UK from 1 January 2027.Amendments to IFRS 9 and IFRS 7 – Classification and measurement of financial instruments These amendments clarify the requirements for the timing of recognition and derecognition of some financial assets and liabilities, adds guidance on the SPPI criteria, and includes updated disclosures for certain instruments. The amendments are effective in the UK from 1 January 2026. IFRS 19 Subsidiaries without Public Accountability: Disclosures IFRS 19 provides reduced disclosure requirements for eligible subsidiaries. A subsidiary is eligible if it does not have public accountability and has an ultimate or intermediate parent that produces consolidated financial statements available for public use that comply with IFRS Accounting Standards. IFRS 19 is a voluntary standard for eligible subsidiaries and is effective in the UK from 1 January 2027. Moray Integration Joint Board External Audit Plan 2024/25 45© 2025 Grant Thornton UK LLP The following IFRS Standards and amendments have been recently issued but have not yet been adopted by the Code of Audit Practice. Many of the items below will have limited or nil applicability for the IJB but are included for completeness purposes. IFRS 17 Insurance contracts IFRS 17 replaces IFRS 4. IFRS 17 provides consistent principles for all aspects of accounting for insurance contracts. It removes existing inconsistencies and enables investors, analysts and others to meaningfully compare companies, contracts and industries. It has been effective in the UK since 1 January 2023. Page 165
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© 2025 Grant Thornton. All rights reserved. ‘Grant Thornton’ refers to the brand under which the Grant Thornton member firms provide assurance, tax and advisory services to their clients and/or refers to one or more member firms, as the context requires. Grant Thornton International Ltd (GTIL) and the member firms are not a worldwide partnership. GTIL and each member firm is a separate legal entity. Services are delivered by the member firms. GTIL does not provide services to clients. GTIL and its member firms are not agents of, and do not obligate, one another and are not liable for one another’s acts or omissions. Moray Integration Joint Board External Audit Plan 2024/25 46 Page 166
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Informing the audit risk assessment for Moray Integration Joint Board 2024/25 Angela Pieri Director T 0161 214 6337 E Angela.L.Pieri@uk.gt.com Andrew Wallace Manager T 0141 223 0671 E andrew.d.wallace@uk.gt.com APPENDIX 2 Item 9. Page 167
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence The contents of this report relate only to the matters which have come to our attention, which we believe need to be reported to you as part of our audit process. It is not a comprehensive record of all the relevant matters, which may be subject to change, and in particular we cannot be held responsible to you for reporting all of the risks which may affect your business or any weaknesses in your internal controls. This report has been prepared solely for your benefit and should not be quoted in whole or in part without our prior written consent. We do not accept any responsibility for any loss occasioned to any third party acting, or refraining from acting on the basis of the content of this report, as this report was not prepared for, nor intended for, any other purpose. 2 Page 168
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence Table of Contents Section Page Purpose 4 General Enquiries of Management 6 Fraud 9 Fraud Risk Assessment 10 Laws and Regulations 15 Impact of Laws and Regulations 16 Related Parties 18 Going Concern 20 Accounting Estimates 22 Accounting Estimates - General Enquiries of Management 23 Appendix A – Accounting Estimates 26 3 Page 169
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence Purpose The purpose of this report is to contribute towards the effective two-way communication between Moray Integration Joint Board’s external auditors and Moray Integration Joint Board’s Audit Committee, as 'those charged with governance'. The report covers some important areas of the auditor risk assessment where we are required to make inquiries of the Audit Committee under auditing standards. Background Under International Standards on Auditing (UK), (ISA(UK)) auditors have specific responsibilities to communicate with the Audit Committee. ISA(UK) emphasise the importance of two-way communication between the auditor and the Audit Committee and also specify matters that should be communicated. This two-way communication assists both the auditor and the Audit Committee in understanding matters relating to the audit and developing a constructive working relationship. It also enables the auditor to obtain information relevant to the audit from the Audit Committee and supports the Audit Committee in fulfilling its responsibilities in relation to the financial reporting process. Communication As part of our risk assessment procedures we are required to obtain an understanding of management processes and the Moray Integration Joint Board’s oversight of the following areas: • General Enquiries of Management • Fraud, • Laws and Regulations, • Related Parties, • Going Concern, and • Accounting Estimates. 4 Page 170
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence Purpose This report includes a series of questions on each of these areas and the response we have received from Moray Integration Joint Board’s management. The Audit Committee should consider whether these responses are consistent with its understanding and whether there are any further comments it wishes to make. 5 Page 171
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence General Enquiries of Management Question Management response 1. What do you regard as the key events or issues that will have a significant impact on the financial statements for 2024/25? Underlying deficit or 24/25 2. Have you considered the appropriateness of the accounting policies adopted by Moray Integration Joint Board’s? Have there been any events or transactions that may cause you to change or adopt new accounting policies? If so, what are they? Accounting Policies are reviewed each year as the Accounts are prepared and changes incorporated where deemed necessary. No changes to accounting policies are anticipated for the 2024/25 accounts 3. Is there any use of financial instruments, including derivatives? If so, please explain No 4. Are you aware of any significant transaction outside the normal course of business? If so, what are they? Not aware 6 Page 172
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence General Enquiries of Management Question Management response 5. Are you aware of any changes in circumstances that would lead to impairment of non-current assets? If so, what are they? N/A 6. Are you aware of any guarantee contracts? If so, please provide further details N/A 7. Are you aware of the existence of loss contingencies and/or un-asserted claims that may affect the financial statements? If so, please provide further details N/A 8. Other than in house solicitors, can you provide details of those solicitors utilised by Moray Integration Joint Board’s during the year. Please indicate where they are working on open litigation or contingencies from prior years? No 7 Page 173
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence General Enquiries of Management Question Management response 9. Have any of the Moray Integration Joint Board’s service providers reported any items of fraud, non- compliance with laws and regulations or uncorrected misstatements which would affect the financial statements? If so, please provide further details Not aware of any 10. Can you provide details of other advisors consulted during the year and the issue on which they were consulted? None 11. Have you considered and identified assets for which expected credit loss provisions may be required under IFRS 9, such as debtors (including loans) and investments? If so, please provide further details N/A 8 Page 174
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence Fraud Matters in relation to fraud ISA (UK) 240 covers auditors responsibilities relating to fraud in an audit of financial statements. The primary responsibility to prevent and detect fraud rests with both the Audit Committee and management. Management, with the oversight of the Audit Committee, needs to ensure a strong emphasis on fraud prevention and deterrence and encourage a culture of honest and ethical behaviour. As part of its oversight, the Audit Committee should consider the potential for override of controls and inappropriate influence over the financial reporting process. As Moray Integration Joint Board’s external auditor, we are responsible for obtaining reasonable assurance that the financial statements are free from material misstatement due to fraud or error. We are required to maintain professional scepticism throughout the audit, considering the potential for management override of controls. As part of our audit risk assessment procedures we are required to consider risks of fraud. This includes considering the arrangements management has put in place with regard to fraud risks including: • assessment that the financial statements could be materially misstated due to fraud, • process for identifying and responding to risks of fraud, including any identified specific risks, • communication with the Audit Committee regarding its processes for identifying and responding to risks of fraud, and • communication to employees regarding business practices and ethical behaviour. We need to understand how the Audit Committee oversees the above processes. We are also required to make inquiries of both management and the Audit Committee as to their knowledge of any actual, suspected or alleged fraud. These areas have been set out in the fraud risk assessment questions below together with responses from Moray Integration Joint Board’s management. 9 Page 175
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence Fraud risk assessment Question Management response 1. Has Moray Integration Joint Board’s assessed the risk of material misstatement in the financial statements due to fraud? How has the process of identifying and responding to the risk of fraud been undertaken and what are the results of this process? How do the Moray Integration Joint Board’s risk management processes link to financial reporting? The MIJB has established risk management, governance and operating procedures to mitigate the risk of material misstatement in the financial statements. Agreed arrangements within the NHS for the investigation of fraud. In regard to the Council, Financial Regulations detail that all staff irregularities should be reported to the Audit and Risk Manager.(MIJB Chief Internal Auditor). This is supported by the Policy to Combat Fraud, Theft, Bribery and Corruption and the Whistleblowing Policy. In addition, the Council participates in the National Fraud Initiative data matching exercise and also publicises a point of contact to report fraud or irregularities involving the misuse of council resources. All irregularities and system reviews will be reported to the Audit, Performance and Risk Committee. The strategic risk register detailing the MIJB’s principal risks are regularly reviewed by SMT, with an annual report provided to MIJB Board. Services are also required to maintain risk registers detailing identifiable risks and mitigating actions/controls. In addition, the Chief Internal Auditor (MIJB) also prepares a risk-based audit plan that considers the IJB’s strategic objectives, associated risks and senior management's view. 2. What have you determined to be the classes of accounts, transactions and disclosures most at risk to fraud? Risk registers are also maintained by the parent organisations. Internal Audit will also review and test transactions to ensure compliance with Council Regulations and Procedures. The use of IDEA, a computer assisted software system is used to analyse and select a sample for testing. 3. Are you aware of any instances of actual, suspected or alleged fraud, errors or other irregularities either within Moray Integration Joint Board as a whole, or within specific departments since 1 April 2024? If so, please provide details No irregularity known below the £5000 reporting threshold 10 Page 176
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence Fraud risk assessment Question Management response 4. As a management team, how do you communicate risk issues (including fraud) to those charged with governance? Both the NHS and the Council have their own regulations regarding fraud. The NHS Counter Fraud Authority (NHSCFA) is a health authority charged with identifying, investigating and preventing fraud and other economic crimes within the NHS and the wider health group. The Council’s Financial Regulations require that all irregularities be reported to the Audit and Risk Manager. The Audit and Risk Manager is also responsible for supporting the Council’s risk management arrangements which includes regularly reviewing the principal risks facing the Council. Principal risks facing the MIJB are reviewed regularly by SMT and the strategic risk register is the accordingly updated. The Chief Internal Auditor has recently obtained an agreement to report NHS Grampian internal audit reviews to the MIJB Audit, Performance and Risk Committee. This will include an audit review of NHS Grampian’s approach to fraud prevention, detection, and investigation 5. Have you identified any specific fraud risks? If so, please provide details Do you have any concerns there are areas that are at risk of fraud? Are there particular locations within Moray Integration Joint Board where fraud is more likely to occur? As part of the risk-based approach to preparing the Annual Audit Plan the Chief Internal Auditor of the MIJB will consider fraud risks in determining the reviews to be undertaken. However, this only relates to Council funded services 6. What processes do Moray Integration Joint Board have in place to identify and respond to risks of fraud? The NHS Counter Fraud Authority (NHSCFA) is responsible for identifying, investigating and preventing fraud within the NHS. The Council Financial Regulations detail that irregularities should be reported to the Audit and Risk Manager. This is supported by the Policy to Combat Fraud, Theft, Bribery and Corruption and the Whistleblowing Policy. In addition, the Council participates in the National Fraud Initiative data matching exercise and also publicises a point of contact to report fraud or irregularities involving the misuse of council 11 Page 177
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence Fraud risk assessment Question Management response 7. How do you assess the overall control environment for Moray Integration Joint Board, including: • the existence of internal controls, including segregation of duties; and • the process for reviewing the effectiveness the system of internal control? If internal controls are not in place or not effective where are the risk areas and what mitigating actions have been taken? What other controls are in place to help prevent, deter or detect fraud? Are there any areas where there is a potential for override of controls or inappropriate influence over the financial reporting process (for example because of undue pressure to achieve financial targets)? If so, please provide details The responsibility for developing and maintaining sound control environment rests with management. However, internal audit prepares a risk based audit plan which considers the MIJB’s strategic objectives and associated risks. While the prevention of fraud and error rests with management through the design and operation of suitable systems of control, reviews undertaken by Internal Audit will make recommendations to improve the control environment 8. Are there any areas where there is potential for misreporting? If so, please provide details None noted 12 Page 178
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence Fraud risk assessment Question Management response 9. How does Moray Integration Joint Board communicate and encourage ethical behaviours and business processes of it’s staff and contractors? How do you encourage staff to report their concerns about fraud? What concerns are staff expected to report about fraud? Have any significant issues been reported? If so, please provide details Established arrangements exist to communicate and encourage ethical behaviours and business processes of its staff and contractors. Managers have an ongoing responsibility for implementing effective systems of control which secure the legitimacy of expenditure, the safeguarding of assets and income, the reliability of management information, the accuracy of record keeping and compliance with statutory guidance. They are also responsible for communicating this policy to their staff and ensuring established systems are followed. As detailed, the NHS Counter Fraud Authority (NHSCFA) is responsible for identifying, investigating and preventing fraud and other economic crimes within the NHS and the wider health group. The Council has a Policy to Combat Fraud, Theft, Bribery and Corruption. This policy is built around a counter fraud culture supported by practices to deter and detect fraudulent and corrupt activities. It takes account of the Council’s statutory obligations, including, and in particular, the provisions of the Bribery Act 2010. Council Financial Regulations detail that all irregularities should be reported to the Audit and Risk Manager. In addition, a Confidential ‘whistle blowing’ policy and procedure is in place, enabling employees to raise any concerns about any aspect of the Council’s work without fear of victimisation, subsequent discrimination or disadvantage, and in the knowledge that such concerns will be properly investigated 10. From a fraud and corruption perspective, what are considered to be high-risk posts? How are the risks relating to these posts identified, assessed and managed? There is an expectation that all staff and elected board members will act within the law and with honesty and integrity at all times. In particular, all staff and elected board members are expected to refrain from engaging in fraudulent or corrupt activity of any kind and shall refrain from offering, making or accepting bribes, whether financial or otherwise. Governance standards promote values and behaviours for the MIJB that demonstrate how it will uphold good practice and high standards of conduct. These include codes of conduct for both elected board members and employees and reflect the principles of public life identified by the Nolan Committee, including selflessness, honesty and integrity. This also takes in the Duty (Public Service) and Respect principles added by the Scottish Government 13 Page 179
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence Fraud risk assessment Question Management response 12. What arrangements are in place to report fraud issues and risks to the Audit Committee? How does the Audit Committee exercise oversight over management's processes for identifying and responding to risks of fraud and breaches of internal control? What has been the outcome of these arrangements so far this year? The Public Sector Internal Audit Standards (PSIAS) applicable to Local Government in Scotland requires Internal Audit to report functionally to the Audit, Performance and Risk Committee on various issues relative to the work of the Internal Audit Service, including special investigations. The Audit, Performance and Risk Committee has a remit which includes ensuring that the highest standards of probity and public accountability are demonstrated. This involves oversight of internal control processes as a contribution to good governance and generally supporting an anti-fraud, theft, corruption, and bribery culture. This Committee considers reports produced by Internal and External Audit on the IJB’s systems; reports which include recommendations to strengthen internal controls and in turn reduce the risk of fraud and related behaviours going undetected 13. Are you aware of any whistle blowing potential or complaints by potential whistle blowers? If so, what has been your response? None noted 14. Have any reports been made under the Bribery Act? If so, please provide details None noted 14 Page 180
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence Law and regulations Matters in relation to laws and regulations ISA (UK) 250 requires us to consider the impact of laws and regulations in an audit of the financial statements. Management, with the oversight of the Audit Committee, is responsible for ensuring that Moray Integration Joint Board’s operations are conducted in accordance with laws and regulations, including those that determine amounts in the financial statements. As auditor, we are responsible for obtaining reasonable assurance that the financial statements are free from material misstatement due to fraud or error, taking into account the appropriate legal and regulatory framework. As part of our risk assessment procedures we are required to make inquiries of management and the Audit Committee as to whether the body is in compliance with laws and regulations. Where we become aware of non-compliance or suspected non-compliance we need to gain an understanding of the non-compliance and the possible effect on the financial statements. Risk assessment questions have been set out below together with responses from management. 15 Page 181
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence Impact of laws and regulations Question Management response 1. How does management gain assurance that all relevant laws and regulations have been complied with? What arrangements does Moray Integration Joint Board have in place to prevent and detect non-compliance with laws and regulations? Are you aware of any changes to the Moray Integration Joint Board’s regulatory environment that may have a significant impact on the Moray Integration Joint Board’s financial statements? Generally speaking each service area are familiar with the statutory regime in which they operate and will keep up to speed with developments through their professional associations such as CIPFA or SOLAR. Changes to legislation, consultations and guidance are notified to the IJB by the Scottish Government and are distributed to the relevant departmental area. The legal section has teams which specialise in different areas of Council activity and will be involved (at the request of client departments) in the implementation of more complex changes (such as formation of the IJB) and in any areas where legislation is unclear. Legal compliance will often be subject to external regulation (for example data protection). The IJB’s Integration Scheme (detailing the powers given to officers to implement services under specified legislation) is reviewed annually in line with revised legislative powers, in consultation with client departments 2. How is the Audit Committee provided with assurance that all relevant laws and regulations have been complied with? Overview of committee reports undertaken by Legal Services 3. Have there been any instances of non-compliance or suspected non-compliance with laws and regulation since 1 April 2024 with an on-going impact on the 2024/25 financial statements? If so, please provide details Not aware of any 4. Are there any actual or potential litigation or claims that would affect the financial statements? If so, please provide details None known 16 Page 182
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence Impact of laws and regulations Question Management response 5. What arrangements does Moray Integration Joint Board have in place to identify, evaluate and account for litigation or claims? The legal section has teams which specialise in different areas of activity and will be involved (at the request of client departments) in the implementation of more complex changes (such as formation of the MIJB) and in any areas where legislation is unclear. Where necessary external advice will be sought 6. Have there been any reports from other regulatory bodies, such as HM Revenues and Customs, which indicate non-compliance? If so, please provide details None known 17 Page 183
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence Related Parties Matters in relation to Related Parties Moray Integration Joint Board are required to disclose transactions with bodies/individuals that would be classed as related parties. These may include: ■ bodies that directly, or indirectly through one or more intermediaries, control, or are controlled by Moray Integration Joint Board ■ associates; ■ joint ventures; ■ a body that has an interest in the authority that gives it significant influence over the Moray Integration Joint Board; ■ key management personnel, and close members of the family of key management personnel, and ■ post-employment benefit plans (pension fund) for the benefit of employees of the Moray Integration Joint Board, or of any body that is a related party of the Moray Integration Joint Board. A disclosure is required if a transaction (or series of transactions) is material on either side, i.e. if a transaction is immaterial from the [type of body]’s perspective but material from a related party viewpoint then the Moray Integration Joint Board must disclose it. ISA (UK) 550 requires us to review your procedures for identifying related party transactions and obtain an understanding of the controls that you have established to identify such transactions. We will also carry out testing to ensure the related party transaction disclosures you make in the financial statements are complete and accurate. 18 Page 184
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence Related Parties Question Management response 1. Have there been any changes in the related parties including those disclosed in Moray Integration Joint Board’s 2024/25 financial statements? If so please summarise: • the nature of the relationship between these related parties and Moray Integration Joint Board whether Moray Integration Joint Board has entered into or plans to enter into any transactions with these related parties • the type and purpose of these transactions No changes 2. What controls does Moray Integration Joint Board have in place to identify, account for and disclose related party transactions and relationships? Senior Officers and Elected Board Members make annual returns and members interests are regularly updated on the website, any significant factors that arise as part of this process would be factored into the Related Parties Note in the Annual Accounts. 3. What controls are in place to authorise and approve significant transactions and arrangements with related parties? Normal procedures following the parties authorisation policies would apply – transactions over agreed limits are checked by Chief Financial Officer or Director of finance 4. What controls are in place to authorise and approve significant transactions outside of the normal course of business? For significant transactions that are new and outside the normal course of business IJB Board approval is required. 19 Page 185
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence Going Concern Matters in relation to Going Concern The audit approach for going concern is based on the requirements of ISA (UK) 570, as interpreted by Practice Note 10: Audit of financial statements and regularity of public sector bodies in the United Kingdom (Revised 2020). It also takes into account the National Audit Office's Supplementary Guidance Note (SGN) 01: Going Concern – Auditors’ responsibilities for local public bodies. Practice Note 10 confirms that in many (but not all) public sector bodies, the use of the going concern basis of accounting is not a matter of significant focus of the auditor’s time and resources because the applicable financial reporting frameworks envisage that the going concern basis for accounting will apply where the body’s services will continue to be delivered by the public sector. In such cases, a material uncertainty related to going concern is unlikely to exist. For this reason, a straightforward and standardised approach to compliance with ISA (UK) 570 will often be appropriate for public sector bodies. This will be a proportionate approach to going concern based on the body’s circumstances and the applicable financial reporting framework. In line with Practice Note 10, the auditor’s assessment of going concern should take account of the statutory nature of the body and the fact that the financial reporting framework for local government bodies presume going concern in the event of anticipated continuation of provision of the services provided by the body. Therefore, the public sector auditor applies a ‘continued provision of service approach’, unless there is clear evidence to the contrary. This would also apply even where those services are planned to transfer to another body, as in such circumstances, the underlying services will continue. For many public sector bodies, the financial sustainability of the body and the services it provides are more likely to be of significant public interest than the application of the going concern basis of accounting. Financial sustainability is a key component of value for money work and it is through such work that it will be considered. Page 186
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence Going Concern Question Management response 1. What processes and controls does management have in place to identify events and / or conditions which may indicate that the statutory services being provided by Moray Integration Joint Board will no longer continue? Regular reporting on the IJB’s Finances would highlight any conditions which may mean the MIJB is no longer to deliver statutory duties. Regular performance reports would also highlight this 2. Are management aware of any factors which may mean for Moray Integration Joint Board that either statutory services will no longer be provided or that funding for statutory services will be discontinued? If so, what are they? Not aware of any 3. With regard to the statutory services currently provided by Moray Integration Joint Board does Moray Integration Joint Board expect to continue to deliver them for the foreseeable future, or will they be delivered by related public authorities if there are any plans for Moray Integration Joint Board to cease to exist? The MIJB would expect to continue to deliver statutory services 4. Are management satisfied that the financial reporting framework permits Moray Integration Joint Board to prepare its financial statements on a going concern basis? Are management satisfied that preparing financial statements on a going concern basis will provide a faithful representation of the items in the financial statements? The annual accounts are prepared on a going concern basis and this will provide a faithful representation of the items included in the financial statements Page 187
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence Accounting estimates Matters in relation to accounting estimates ISA (UK) 540 (Revised December 2018) requires auditors to understand and assess a body’s internal controls over accounting estimates, including: • The nature and extent of oversight and governance over management’s financial reporting process relevant to accounting estimates; • How management identifies the need for and applies specialised skills or knowledge related to accounting estimates; • How the body’s risk management process identifies and addresses risks relating to accounting estimates; • The body’s information system as it relates to accounting estimates; • The body’s control activities in relation to accounting estimates; and • How management reviews the outcomes of previous accounting estimates. As part of this process auditors also need to obtain an understanding of the role of those charged with governance, which is particularly important where the estimates have high estimation uncertainty, or require significant judgement. Specifically do Audit Committee members: • Understand the characteristics of the methods and models used to make the accounting estimates and the risks related to them; • Oversee management’s process for making accounting estimates, including the use of models, and the monitoring activities undertaken by management; and • Evaluate how management made the accounting estimates? We would ask the Audit Committee to satisfy itself that the arrangements for accounting estimates are adequate. 22 Page 188
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence Accounting Estimates - General Enquiries of Management Question Management response 1. What are the classes of transactions, events and conditions, that are significant to the financial statements that give rise to the need for, or changes in, accounting estimate and related disclosures? None directly but the value of the pension liability from partner organisations would have implications 2. How does the Moray Integration Joint Board’s risk management process identify and address risks relating to accounting estimates? Managed by the partner organisations 3. How does management identify the methods, assumptions or source data, and the need for changes in them, in relation to key accounting estimates? The results of prior year audits are looked at to see whether there was any material concerns raised or amendments made 4. How do management review the outcomes of previous accounting estimates? As above 5. Were any changes made to the estimation processes in 2024/25 and, if so, what was the reason for these? No changes Page 189
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence Accounting Estimates - General Enquiries of Management Question Management response 6. How does management identify the need for and apply specialised skills or knowledge related to accounting estimates? Each area is looked at in isolation and the relevant skills/knowledge/capacity considered 7. How does the Moray Integration Joint Board determine what control activities are needed for significant accounting estimates, including the controls at any service providers or management experts? Ensuring that relevant information is provided on time and accurately to ensure that the information received can be relied upon 8. How does management monitor the operation of control activities related to accounting estimates, including the key controls at any service providers or management experts? Regular updates provided by preparers of the Accounts on any issues that arise 9. What is the nature and extent of oversight and governance over management’s financial reporting process relevant to accounting estimates, including: - Management’s process for making significant accounting estimates - The methods and models used - The resultant accounting estimates included in the financial statements. The unaudited accounts are reported to Committee and then again upon completion of the audit. External Audit reporting also helps to inform on estimates. Page 190
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence Accounting Estimates - General Enquiries of Management Question Management response 10. Are management aware of any transactions, events, conditions (or changes in these) that may give rise to recognition or disclosure of significant accounting estimates that require significant judgement (other than those in Appendix A)? If so, what are they? Not aware of any 11. Why are management satisfied that their arrangements for the accounting estimates, as detailed in Appendix A, are reasonable? No major changes required to annual accounts in previous years 12. How is the Audit Committee provided with assurance that the arrangements for accounting estimates are adequate ? Annual accounts are reported 25 Page 191
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© 2024 Grant Thornton UK LLP Moray Integration Joint Board 2024/25 Commercial in confidence Appendix A Accounting Estimates Estimate [Examples] Method / model used to make the estimate Controls used to identify estimates Whether management have used an expert Underlying assumptions: - Assessment of degree of uncertainty - Consideration of alternative estimates Has there been a change in accounting method in year? Valuation of defined benefit net pension fund liabilities Based on information from actuaries Information provided to actuaries based on year end position reducing the need for use of estimates. Yes Disclosure in accounts regarding the changes that could happen and the impact it would have on the figues included in the accounts No Accruals Based on actual entries in the ledger, or on information received from departments No In most cases based on actual ledger entries so no estimation . Where estimates are provided we know it will be based on professional judgement and we would query it it was materially different from estimates provided No Accrued income Based on actual entries in the ledger, or on information received from departments No In most cases based on actual ledger entries so no estimation . Where estimates are provided we know it will be based on professional judgement and we would query it it was materially different from estimates provided No 26 Page 192
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© 2024 Grant Thornton UK LLP ‘Grant Thornton’ refers to the brand under which the Grant Thornton member firms provide assurance, tax and advisory services to their clients and/or refers to one or more member firms, as the context requires. Grant Thornton UK LLP is a member firm of Grant Thornton International Ltd (GTIL). GTIL and the member firms are not a worldwide partnership. GTIL and each member firm is a separate legal entity. Services are delivered by the member firms. GTIL does not provide services to clients. GTIL and its member firms are not agents of, and do not obligate, one another and are not liable for one another’s acts or omissions. grantthornton.co.uk Page 193
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APPENDIX 3 Best Value Consolidated List of Improvement Actions 1 2023/24 Recommendations • Recommendations identified on the wider scope risks and planned audit work. Background Recommendations Action Owner Progress Update March 2025 Completion Date (black – due date Green completed date) 1. Revenue Budget Setting The IJB is required to set its budget before the end of March. Whilst the IJB set a working budget on 28 March 2024 it did not formally approve the 2024/25 revenue budget until 30 May 2024 The IJB should ensure it presents its final budget, with all agreed savings, before the start of the financial year CFO Work has been on going to produce a balanced budget and will be presented to the MIJB Committee 27 March 2025 31 March 2025 27 March 2025 2. Financial Sustainability – Reserves The IJB intend to utilise £1.346 million of earmarked reserves to bridge the budget deficit in 2024/25. There is a risk that continued reliance on reserves to bridge funding gaps will create financial sustainability issues for the IJB The IJB will need to continue to monitor the percentage level of adequate reserves as funding gaps continue to grow and the IJB looks to transformation in future years to ensure reserves do not dip to an unsustainable level CFO Consideration has been given to the level of reserves in the IJB and the savings achieved are not able to provide a level of general reserves for 2025/26 For 2025/26 budget the IJB again intends to utilise £1 million of ear marked reserves to bridge the budget deficit. The latest Audit Scotland publication makes reference to the fact a significant number of IJBs are using reserves and not just unique to Moray. 31 March 2025 27 March 2025 3. Medium Term Financial Strategy The Medium Term Financial Strategy was last updated in March 2023 and is considered out of date. If the plan is not updated on a regular basis, there is a risk that the IJB are unaware of the potential funding implications over the medium term. The IJB should re-evaluate the financial outlook over the medium term and update the Medium Term Financial Strategy to identify the total funding gap over the medium term CFO The medium term financial strategy was delayed but has been updated and will be presented at the MIB on 27 March 2025 30 Nov 2024 27 March 2025 4.Reporting of NHS Grampian Internal Audit Activity Internal audit reporting is heavily based on activities within Moray Council. Moray IJB should look to strengthen the reporting of NHS Grampian’s internal audit results within the IJB to provide oversight to members and to provide a complete picture of both organisations To ensure oversight of NHS Grampian internal audit reports, reporting to the Audit, Performance and Risk Committee needs to be strengthened. Chief Internal Auditor Implemented – An agreement has now been reached with the management of NHS Grampian and their Internal Audit Provider to allow the Chief Internal Auditor to confidentially report NHS Grampian's internal audit reviews of systems and practices of interest to the MIJB to the Audit, Performance, and Risk Committee 30 Sept 2024 implemented 5. Internal Audit Recommendations Following the retirement of the previous Chief Officer, the current Chief Officer has been appointed on an interim basis. Furthermore, the Chief Social Worker at the Council is also appointed on an interim basis The IJB and Council need to secure permanent positions for the both posts to provide certainty over the future direction of the IJB Chief Executives – Moray Council and NHS Grampian Following an open recruitment process a permanent Chief Officer was appointed in November 2024, the role being offered and accepted by the person undertaking the role as an interim. Given this, they were able to start in the permanent role immediately. A process will now be undertaken to recruit to the permanent CSWO role. CO 31 Dec 2024 CSWO 31March 2025 Item 9. Page 195
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APPENDIX 3 Best Value Consolidated List of Improvement Actions 2 Background Recommendations Action Owner Progress Update March 2025 Completion Date (black – due date Green completed date) 6. Internal Audit Limited Assurance Opinion This is the third year in succession that Internal Audit have provided a limited assurance opinion. Fundamentally, this indicates there are weaknesses in the framework of governance, risk management and control. The IJB should have definitive plans in place to avoid further limited assurance opinions Senior Management Team Progress has been made, however there are still concerns with the recommendations being implemented following audits, progress on CareFirst and realisation of the savings, that the Internal Audit Manager is still considering giving a limited assurance. 31 March 2025 7. Internal Audit Recommendations As part of their reviews, internal audit make recommendations for management to take action. Whilst the IJB have introduced a recommendations tracker, this is not presented to each Audit Committee meeting The IJB should ensure that the tracker of internal audit recommendations is reviewed periodically and reported to each Audit, Risk and Performance meeting Corporate Manager Tracker has been completed and ownership agreed at OMT meetings, with monthly escalations to SMT on an exception basis. Then if SMT deem it should be escalated to APR a report will be compiled. 31 March 2025 Page 196
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APPENDIX 3 Best Value Consolidated List of Improvement Actions 3 Prior Year Recommendations • Recommendations made as part of the wider scope work for the 2022/23 audit. Background Recommendations Progress update 2023/24 Progress Update at March 2025 Completion Date (black – due date Green completed date) 1. Performance Report Management should review the format of the Performance Report and content to ensure it is succinct, focuses on the IJB;s performance and outcomes, and supports the user of the financial statements to understand the IJB’s purpose and achievements in year There have been limited changes made to the format of the report due to staffing changes during the year. Intention is to review for next financial year Due to continuation of limited staffing resources this has not been able to achieved in this financial year. The performance will be reviewed for 2025/26 following the approval of the Strategic delivery plan which will be presented to the IJB Committee on 27 March 2025 Will be in place for 2025/26 3. Financial Sustainability - Reserves The IJB will need to continue to monitor the percentage level of adequate reserves as funding gaps continue to grow and the IJB looks to transformation in future years to ensure reserves do not dip to an unsustainable level Transformation/savings plan in place for 2024/25. Minimal use of reserves used to balance the budget. No change in level of general reserves There have been no general reserves maintained in the IJB and the level of ear marked reserves has decreased as they have been used during the year. 4. Financial Sustainability - Transformation A depth of pace will need to be undertaken on the transformation programme to ensure the IJB can bridge the significant funding gap in a short space of time, to ensure that not only efficiencies can be delivered but that financial sustainability can be achieved. To ensure financial sustainability for the medium to longer term, the IJB will need to ensure that it is able to deliver increased productivity and efficiency initiatives to reduce costs and deliver financial benefits. The IJB will need to upscale the pace and delivery of transformation to achieve and mitigate the risk of becoming financially unsustainable A significant transformation/ savings plan is in place for 2024/25 onwards Savings plan in place for 2024/25 covered 2 financial years and the savings plan in place for 2025/26 will again be over more than 1 financial year. Transformation plans are also part of the savings plan for future years. 6. Vision, Leadership and Governance – Internal Audit Moray IJB should ensure audit recommendation dates are realistic when set and are monitored for implementation. Where dates are moved or not met, a thorough understanding and follow up of these should be sought and explanations provided. A mechanism should be implemented to follow up on officers should missing recommendation deadlines become regular Internal audit consult senior managers as part of the audit process. All dates set by internal audit are in agreement with the service with realistic achievable dates See details at point 7 above, same requirement Page 197
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APPENDIX 3 Best Value Consolidated List of Improvement Actions 4 Background Recommendations Progress update 2023/24 Progress Update at March 2025 Completion Date (black – due date Green completed date) 8. Best Value – External Audit Action Log Moray IJB should create a mechanism to monitor progress against external audit recommendations and the report should be brought to the relevant Committee on a regular basis to ensure scrutiny and challenge by members Will be on the agenda for 2024/25 Included in the papers for IJB on 27 March 2025 and will be scrutinised on a regular basis thereafter 31 March 2025 Page 198
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 27 MARCH 2025 SUBJECT: INTERNAL AUDIT PLAN YEAR ENDING 31 MARCH 2026 BY: CHIEF INTERNAL AUDITOR 1. REASON FOR REPORT 1.1 To provide the Committee with information on the proposed internal audit coverage for the 2025/26 financial year. 2. RECOMMENDATION 2.1 It is recommended that the Committee considers this report and agrees the proposed audit coverage. 3. BACKGROUND 3.1 Internal auditing is an independent, objective assurance and consulting activity designed to add value and improve an organisation’s operations. It helps an organisation accomplish its objectives by bringing a systematic, disciplined approach to evaluate and improve the effectiveness of risk management, control and governance processes. 3.3 The Internal Audit Plan is a means of determining the priorities of the internal audit activity and how these fit with the wider goals of the Moray Integration Joint Board (MIJB). Internal Audit’s approach to annual audit planning is risk- based, with all areas which 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 that contribute to the achievement of the MIJB’s priorities and objectives. 3.4 The Annual Audit Plan details what Internal Audit anticipates being able to review in the year, assuming stability in resources available to the Section. The time allocation for all audits assumes that systems to be reviewed are adequately documented, detailing the controls put in place by management and that testing identifies that these controls are being complied with; however, if this is not the case, there will be an impact on the time taken to review planned areas and on the plan’s achievability. Item 10. Page 199
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3.5 The proposed Internal Annual Audit Plan for 2025/26 is attached at Appendix 1. I have updated the format to provide greater clarity regarding the allocation of time against review topics, verification and development needs of the Internal Audit Section and other contingency requirements 4. 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. (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. 5. CONCLUSION 5.1 The Committee is asked to consider and agree the planned audit coverage for the MIJB for 2025/26. Author of Report: Dafydd Lewis, Chief Internal Auditor Background Papers: Internal Audit Files Ref: mijb/ap&rc/ Page 200
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Appendix 1 MORAY INTEGRATION JOINT BOARD INTERNAL AUDIT PLAN 2025/26 Item 10. Page 201
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1.1 In June 2015, the Scottish Government Integrated Resources Advisory Group (IRAG) issued “Guidance for Integrated Financial Assurance” in support of the Public Bodies (Joint Working) (Scotland) Act 2014. The guidance required the Integration Joint Board (IJB) to seek assurance that its resources are sufficient to allow it to carry out its functions and assess the risks associated with this, and further to establish adequate and proportionate internal audit arrangements for the review of risk management, governance and control of the delegated resources. 1.2 The guidance recommends that a risk-based audit plan should be developed by the Chief Internal Auditor of the IJB and be approved by the IJB or another Committee (in Moray, the Audit, Performance and Risk Committee). Importantly, it also notes that the operational delivery of services within the Health Board and Local Authority on behalf of the IJB will be covered by their respective internal audit arrangements. 1.3 Internal auditing is an independent, objective assurance and consulting activity designed to add value and improve an organisation’s operations. It also helps an organisation accomplish its objectives by bringing a systematic, disciplined approach to evaluate and improve the effectiveness of risk management, control and governance processes. The Internal Audit Plan represents a summary of the coverage that the internal audit team aims to deliver throughout the 2025-26 financial year. Delivery of an internal audit programme of work that provides sufficient and appropriate coverage will enable a well- informed and comprehensive year-end annual internal audit opinion. The delivery of the internal audit service for the Moray Integration Joint Board is undertaken by the Moray Council’s Internal Audit Section. The Internal Audit Charter is a formal document that defines the internal audit’s purpose, authority, responsibility and position within the Council. The Internal Audit Charter is attached on Appendix 1 and is provided for information purposes to members of the Audit, Performance and Risk Committee. 1. Internal Audit Plan Page 202
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2.1 The following diagram sets out the various sources of information used to inform the audit universe of potential projects to review. . 2.2 Internal Audits' approach to annual audit planning is risk-based, with the areas detailed above 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. 2.3 The audit universe is risk assessed each year to help determine the annual Internal Audit Plan and ensure that suitable audit time and resources are devoted to reviewing the more significant areas of risk. An audit universe is the collective grouping of auditable ’components’ – sometimes also called auditable areas, units or entities – that support the development of the internal audit plan and help to identify appropriate internal audit coverage that the Audit and Risk Manager can then prioritise. 2. Internal Audit Plan: Approach The Audit Universe Consultation External Research Strategic Risk Register Professional Guidance & Publications Internal Audit Knowledge A documented risk-based audit universe has been developed to ensure that sufficient and appropriate areas are identified for consideration. 2. Internal Audit Plan: Approach Page 203
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2.4 The audit universe risk assessment is based upon a number of factors including: • materiality (based on expenditure or income) • sensitivity (based on whether a service is a statutory or non-statutory duty) • time elapsed since an area was last subject to review • Strategic Risk Register- assessment of any movement in the principal risks facing the Moray Integration Joint Board • overall audit assessment of the control environment 2.5 Consideration is also given to the demands within services to ensure proportionate audit coverage is taken across the Moray Integration Joint Board (MIJB). Note that the audit universe, whilst a key factor, is not the only consideration when determining the audit plan. Senior management has been consulted on priority areas for review. In addition to senior management, consultation has also been undertaken this year with the Chair of the Audit, Performance and Risk Committee in the preparation of the Annual Audit Plan for 2025/26. 2.6 These various sources are designed to enable the Chief Internal Auditor to meet a requirement to provide an annual internal audit opinion on the adequacy and effectiveness of the systems of internal control for inclusion in the annual governance statement published with the MIJB’s annual accounts. A review of the internal audit plans for other IJBs is also undertaken as per their committee reporting, which is available online. This provides an opportunity to gain an understanding of issues being faced by other IJB’s and identify any auditable areas. The audit of the core financial systems will appear in the audit plan every year in some form. This work aims to provide significant assurance to the Chief Financial Officer and wider senior management team of the integrity and robustness of the control framework of the systems that handle large numbers of transactions and account for all the authority’s income and expenditure. The core financial systems typically includer: • accounts payable / purchase to pay • accounts receivable / income • payroll (employee admin / organisational management) • housing rents • council tax • Non-Domestic Rates • Treasury management • Insurance The auditing of accounts payable and payroll expenditure may be undertaken annually to support the Audit and Risk Manager’s annual assessment of the robustness of the Council’s internal control system. The review of the above core financial systems will be undertaken over a 5 year audit planning. period Internal Audit Plan: Approach Internal audit will annually assess the adequacy of the arrangements to prevent and detect irregularities, fraud and corruption. This will be done by considering projects for the Audit Plan of subject areas that are regarded as high risk. In addition, an allocation of time will be included annually within the Audit Plan to review systems and practices where fraud or irregularities have been noted within other authorities. However, the primary responsibility for preventing and detecting corruption, fraud and irregularities rests with management who should institute adequate systems of internal control, including clear objectives, segregation of duties and proper authorisation procedures. 2. Internal Audit Plan: Approach 2. Internal Audit Plan: Approach . 2. Internal Audit Plan: Approach Page 204
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Conformance with Public Sector Internal Audit Standards 2.7 The Local Authority Accounts (Scotland) Regulations 2014 paragraph 7 requires that ‘a local authority must operate a professional and objective internal auditing service in accordance with recognised standards and practices in relation to internal auditing’. 2.8 The recognised standards adopted by all Scottish Councils are the Public Sector Internal Audit Standards (PSIAS) developed by standard setters, including the Chartered Institute of Public Finance and Accountancy and the Chartered Institute of Internal Auditors. The standards include a requirement for an External Quality Assessment (EQA) of internal audit once every five years. 2.9 Through the Scottish Local Authorities Chief Internal Auditors’ Group, which the Council participates in, it was agreed that the EQA requirement could be met through a peer review process. This required each council’s chief internal auditor to lead a review of another council’s internal audit service and receive a review in return. Perth and Kinross Council was selected to undertake the assessment of Moray Council. The overall conclusion of the external assessment is that Moray Council’s Internal Audit Service fully conforms with the PSIAS. As part of the PSIAS requirements, an annual internal quality assessment is required. This will be undertaken, and the findings and any improvement recommendations will be reported to the Audit, Performance and Risk Committee to ensure continuing compliance with PSIAS. The delivery of the Internal Audit Service is in accordance with the requirements of the Public Sector Internal Audit Standards. 2. Internal Audit Plan: Approach Page 205
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3.1 The Annual Audit Plan details what Internal Audit anticipates being able to review in the year, assuming stability in resources available to the Section. The time allocation for all audits assumes that systems to be reviewed are adequately documented, detailing the controls put in place by management and that testing identifies that these controls are being complied with. If this is not the case, there will be an impact on the time taken to review planned areas and on the plan’s achievability. 3.2 The Plan also includes time to assist services in developing their controls and approach to improving compliance. This reflects the continuing development of a more proactive value-added approach by Internal Audit to supplement the more traditional core compliance-oriented audit work. However, this needs to be balanced with the requirement for Internal Audit to complete sufficient work to provide an evidence based annual opinion on the adequacy and effectiveness of the MIJB’s internal control system. Internal Audit will continue to review the MIJB’s risk registers and update its own risk assessments based on audit findings throughout the Plan’s term. 3.3 Whilst undertaking planned work, it is possible that Internal Audit may identify governance issues that are not within the stated scope of the review being undertaken. PSIAS require that Internal Audit report such instances to those charged with governance. In this respect, Internal Audit reports may contain issues that appear to be “outwith scope”. 3.4 The objectives of each audit are to identify potential risks and provide assurance on the adequacy and effectiveness of the associated controls in the following areas: • Management – To ensure the consistency of operations or programs with established objectives and goals and effective performance. • Value – To ensure the effectiveness and efficiency of operations and employment of resources. • Regulatory – To ensure compliance with significant policies, plans, procedures, laws, regulations. • Information – To ensure the reliability and integrity of management and financial information processes, including the means to identify, measure, classify and report such information. • Security – To ensure safeguarding of assets 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. The proposed 2025/26 plan is presented in Appendix 2. In addition the Audit Plan also details allocation of days to support the Service and development requirements within the Internal Audit Section. Moray Council’s Audit and Scrutiny Committee, at its meeting on 12 February 2025, approved an audit plan that provided 80 days of input for audit work relating to the MIJB. In addition to the reviews detailed in Appendix 2, a review will also be undertaken to provide evidence of the implementation of recommendations from the Adult Care Commissioning audit undertaken by KPMG. 3. Internal Audit Plan 2025/26 Page 206
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4.1 The established working protocol is for audit reviews to be reported firstly to the Council’s Audit and Scrutiny Committee before the Audit, Performance and Risk Committee. However, depending on the proposed dates of future committees, some flexibility will be considered in this reporting arrangement to ensure that the requirement of meeting the objectives of both Committees can be achieved. 4.2 Completed reviews of projects detailed within the Annual Audit Plan will be reported to members of the Audit , Performance and Risk Committee on a regular basis. The reporting format was developed using audit management software used by the Internal Audit Service. It will include details of the scope and findings from the review undertaken and recommendations for improvements in the governance, risk, and control arrangements. Senior management’s responses to the recommendations will also be recorded within the internal audit report. 4.3 The Internal Audit Service also reports on follow up reviews to evidence implementation of the recommendations agreed by management. The follow up review will be undertaken after the last agreed date of a recommendation with the audit report has passed. However, due to the available resources of the Internal Audit Section and operational demands within services, some flexibility is required in the timescales of when reviews are undertaken and the reporting of follow up reports. 4.4 Requests for unplanned work will be considered against the capacity to ensure the internal audit’s independence and that the resource required to provide the annual audit opinion is not compromised. Any significant additional consulting activities that impact the delivery of the Plan will be communicated to the Audit, Performance and Risk Committee. 4.5 The output of audits completed during the year will inform the annual audit opinion. The annual internal audit opinion will conclude on the overall adequacy and effectiveness of the organisation’s framework of governance, risk management and control. This will be reported through the Internal Audit Annual Report, a key assurance source for the Annual Governance Statement (AGS). The role of internal audit is to provide independent assurance that an organisation's risk management, governance and internal control processes are operating effectively. Internal auditors must have an impartial, unbiased attitude and avoid any conflict of interest. If independence or objectivity is impaired, the Chief Internal Auditor will report these concerns to senior management and members of the Audit, Performance and Risk Committee. 4. Internal Audit Reporting Completed audit reviews will be regularly reported to the Audit, Performance and Risk Committee in accordance with the MIJB’s Scheme of Administration. Each audit report of a project will provide an audit assurance opinion of the effectiveness of the controls in place, the level of compliance with these controls and the action being taken to remedy significant findings or weaknesses. In addition to the reporting of audit reviews undertaken by the Internal Audit Service to the Audit, Performance and Risk Committee, members will also receive reports undertaken by the Internal Audit Provider of NHS Grampian of interest to the MIJB. 4. Internal Audit Reporting Page 207
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Appendix 1 Internal Audit Charter Author: Audit and Risk Manager Date for review: May 2029 Page 208
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1. INTRODUCTION 1.1 The Local Authority Accounts (Scotland) Regulations 2014 introduced a requirement for all Scottish Local Authorities to operate a professional and objective internal auditing service, which must be delivered in accordance with recognised standards. The standards and practices applied in the UK for all public sector internal audit providers, in-house, shared or outsourced, are the Public Sector Internal Audit Standards (PSIAS), which came into effect in April 2013, and were updated in March 2017. These standards are largely based on the International Professional Practices Framework (IPPF). A requirement of the PSIAS is that all local authorities should have an Internal Audit Charter. 2. Definition and Purpose of Internal Auditing 2.1 The overarching “mission” of an Internal Audit Service is to enhance and protect organisational value by providing risk-based and objective assurance, advice and insight. Internal Auditing is defined in the PSIAS as ‘an independent, objective, assurance and consultancy activity designed to add value and improve an organisation’s operations. Internal Audit adds value to the organisation (and its stakeholders) by enhancing governance, risk management and internal control and objectively providing assurance. 2.2 As part of the meeting Moray Council’s system of corporate governance, Internal Audit’s purpose is to support the Council in its activities designed to achieve its declared objectives and to do so: • In support of the Council’s vision, values and priority. • As a contribution to the Council’s management of risks, including assisting management to improve the risk identification and management process in particular where there is exposure to significant regulatory, financial, strategic, reputational and operational risk to the achievement of the Council’s objectives. • As an aid to ensuring that the Council and its elected members, employees and contracted third parties are operating within the law and relevant regulations and that public money is safeguarded and properly accounted for, and used economically, efficiently and effectively. Page 209
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• As a contribution towards establishing and maintaining a culture of honesty, integrity, openness, accountability and transparency throughout the Council in all its activities and transaction. • As a contribution towards ensuring that financial statements and other published performance information are accurate and reliable. 2.3 Moray Council also provides an internal audit service to Moray Integration Joint Board (MIJB) and the Grampian Valuation Joint Board (GVJB). It will apply the same standards as defined in this Charter to any work undertaken for the MIJB and the GVJB, with separate Internal Audit plans and reports presented to their respective ‘senior management’ and ‘board’. 3. POSITION OF INTERNAL AUDIT WITHIN THE ORGANISATION 3.1 The Internal Audit Service is managed by the Audit and Risk Manager. The Audit and Risk Manager will report functionally to the Audit and Scrutiny Committee and administratively (i.e., day-to-day operations) to the Head of Governance, Strategy and Performance (the Council’s Monitoring Officer). The Audit and Risk Manager will have access to the Chief Executive, to all Council officers and to the elected members in connection with any relevant matter 3.2 The Audit and Risk Manager will also have unrestricted access to, and communicate and interact directly with any Council Committee, including in private meetings without management present. 3.3 The Audit and Scrutiny Committee is charged with responsibility for ensuring good stewardship of the Council’s resources, enhancing the profile, status and authority of Internal Audit and affirming its independence. Specifically, in relation to audit matters, the committee: • Contributes to making the Council, its committees and services more responsive to the audit function and its purpose; • Enhances good governance arrangements by promoting internal control and risk management by supporting an anti- fraud culture, and by the review of revisions to financial procedures; • Has responsibility for focusing audit resources through agreeing to an annual programme of work; • Monitors delivery of the audit service through receipt of quarterly reports on work carried out by Internal Audit; Page 210
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• Considers the annual opinion provided by the Audit and Risk Manager on the adequacy and effectiveness of the control environment. 4. ORGANISATIONAL STATUS AND INDEPENDENCE 4.1 In terms of the PSIAS, the status of Internal Audit should enable it to function effectively, with recognition of the independence of Internal Audit that is fundamental to its effectiveness. Moray Council’s Financial Regulations detail that the Depute Chief Executive (Education, Communities and Organisational Development) is responsible for securing a continuous Internal Audit service to provide an independent and objective opinion on the control environment comprising risk management, internal control and governance. This remit is delegated to the Audit and Risk Manager. 4.2 Internal Audit will systematically review, appraise, make appropriate recommendations for improvement, and report upon: • The efficacy of governance arrangements put in place to achieve the organisation’s objectives and priorities. • The effectiveness of all internal controls and other arrangements put in place to manage risk, in particular where there is exposure to significant financial, strategic, reputational and operational risk to the achievement of the organisation’s objectives. • The completeness, reliability and integrity of information, both financial and operational performance, including working alongside services in a ‘critical friend’ role to authenticate any self-assessment evidence of service performance and improvement. • The systems formed to ensure compliance with policies, plans, procedures, laws and regulations whether established by the organisation or externally. • The effectiveness of arrangements for safeguarding the organisation’s assets and interests, including fraud prevention controls and detection processes. • The economy, efficiency and effectiveness with which resources are deployed. Page 211
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• The extent to which services’ operational practices are being carried out as planned and objectives and goals are met. 4.3 Internal Audit’s work covers: • All activities, systems, processes, policies and protocols that currently exist or under development. • All records, personnel and properties. • All services and other activities for which the organisation is responsible or accountable, whether delivered directly or by third parties through contracts, partnerships or other arrangements. Where the Audit and Risk Manager has or is expected to have roles and/or responsibilities that fall outside of Internal Auditing, safeguards will be established to limit impairments to independence or objectivity. 5. RIGHTS OF ACCESS 5.1 The Audit and Risk Manager and any member of the Internal Audit service are authorised in the performance of an audit engagement and have the authority to: • Have access at any reasonable time to all systems and records (both paper and electronic). • Require and receive explanations concerning any matter under examination from personnel relevant to their roles, including elected members or board members • Enter at all reasonable times and without notice any properties provided that the terms of the lease are observed where such properties are leased to a third party. • Require personnel to produce cash, stores, or other assets under their control. Page 212
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5.2 Internal Audit safeguards all information obtained in the carrying out its duties, only uses it for defined purposes, and makes no disclosure of any information held, unless this is authorised or there is a legal/professional requirement to do so. 6. AUDIT RESOURCES AND WORK PRIORITISATION 6.1 The Moray Council’s Internal Audit Annual Plan, as approved by the Audit and Scrutiny Committee, is the primary determinant of the relative priority to be placed on each part of the work of Internal Audit, with Internal Audit Annual Plans specific to the MIJB and the GVJB being approved and monitored by their respective ‘senior management’ and ‘board’. The audit planning process, to determine the priorities of the Internal Audit activity consistent with the organisation’s goals, includes consideration of the organisation’s priorities, plans, strategies, objectives, risks and mitigating controls, and the internal and external assurances provided. The Audit and Risk Manager determines the actual deployment of available resources covering the range and breadth of audit activity, which is integral to the assurance process across the activities of the Council, MIJB and GVJB in order to provide the statutory annual Internal Audit opinion to each organisation’s ‘senior management’ and ‘board’. This plan also requires to be sufficiently flexible to reflect the changing risks and priorities of each organisation. 6.2 The Audit and Risk Manager ensures that Internal Audit resources are appropriate, sufficient and effectively deployed to achieve the approved plan. Appropriate refers to the mix of qualifications, knowledge, skills and other competencies needed to perform the plan, such as compliance with the Code of Ethics set out in the PSIAS and with the Nolan principles established in the Seven Principles of Public Life. This is of particular importance and relevance for the profession of Internal Audit, founded as it is on the trust placed in its objective assurance about risk management, internal control and governance. 6.3 In the event that there is a need for additional audit work than there are resources available, the Audit and Risk Manager will identify the shortfall in the Plan and initially advise the Head of Governance, Strategy and Performance, the Depute Chief Executive (Education, Communities and Organisational Development) followed by the Audit and Scrutiny Committee as required. It will be for the Audit and Scrutiny Committee to decide whether to accept the risks associated with the non-delivery of such audit work or to recommend to the Council that it requires Management to identify additional resources. 6.4 Internal Audit responsibilities are not relieved in areas of the Council’s work that are subject to review by others, but reliance is placed on the work of other review agencies, principally the Council’s External Auditor, to avoid duplication, make the best use of resources and inform the overall assessment of governance arrangements. Page 213
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7. MANAGEMENT RESPONSIBILITIES 7.1 Responsibility for internal control rests with Management, who must ensure that proper internal control arrangements are in place. Internal Audit’s role is to evaluate the effectiveness of such internal control arrangements. Management is responsible for accepting and implementing audit recommendations and bears any risk from not taking agreed action. Internal Audit is not a substitute for an effective system of internal control implemented by management. 8. COUNTER FRAUD WORK 8.1 The prevention and detection of fraud is a management function and management is responsible for implementing and maintaining suitable systems of control to mitigate the risk of fraudulent activity. In support of the Council's counter fraud arrangement, the Audit and Risk Manager will consider including a project within the Annual Audit Plan to review systems or practices where irregularities or fraud have been reported within other Local Authorities. Internal audit also supports the Council’s commitment to fraud prevention and detection by overseeing data matching exercises carried out under the National Fraud Initiative. The Council takes the threat of fraud or related malpractice seriously and has adopted a Policy to Combat Fraud, Theft, Bribery and Corruption. In addition, a Whistle-blowing Policy has been developed in consultation with the Human Resources service to facilitate the reporting of any concerns. 8.2 The Financial Regulations provide that whenever any matter arises which involves, or is thought to involve, irregularities concerning cash, stores or other property of the Council or any suspected irregularity in the exercise of the functions of the Council, any Officer having knowledge thereof, shall, as soon as possible, notify Internal Audit. 9. OBJECTIVITY AND CONFLICTS OF INTEREST 9.1 The Council’s Code of Conduct for Employees sets out the required standards for the conduct of all employees and includes provisions for the declarations of interests, gifts and hospitality. 9.2 The Internal Audit service preserves its independence and objectivity by ensuring that: staff are free from any conflicts of interest when undertaking assurance audits by following the requirements of relevant professional bodies and HR policies; Page 214
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and by providing clarity on duties undertaken during audit consultancy engagements to ensure these do not impact on assurance audits and do not impair its independence and objectivity. 9.3 The Audit and Risk Manager has managerial responsibility for the corporate functions and resources, which develop, support and advise on the frameworks in place within the Council on Risk Management, Business Continuity and on Counter Fraud to support Management. In order to prevent a perceived impairment of objectivity and to ensure that Internal Audit independence and impartiality are maintained and demonstrated, no Internal Audit resources will be used in the performance of these functions. 10. OTHER PARTIES OUTWITH THE COUNCIL 10.1 The Council’s Audit and Risk Manager is also the Chief Internal Auditor for the Moray Integration Joint Board and the Internal Auditor for the Grampian Valuation Joint Board. While separate and distinct governance arrangements apply to these bodies, the principles outlined in this Charter apply and are adopted in respect of all work completed by Internal Audit. 11. REVIEW 11.1 The PSIAS requires that the chief audit executive periodically reviews the Internal Audit Charter and presents it to senior management and also to the Board for approval. In this context, the chief audit executive is the Audit and Risk Manager, senior management is the Corporate Management Team, and the Board is the Audit and Scrutiny Committee. Dafydd Lewis Audit and Risk Manager September 2024 Page 215
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Appendix 2 Internal Audit Annual Work Programme- 2025/26 At the start of each audit, a discussion will be held with the service to agree on the specific terms of reference for the audit, which includes the objective and scope of the review. The scheduling of reviews is dependent on officer availability, resourcing, and priorities. MORAY INTEGRATION JOINT BOARD Auditable Area Audit Strategic Risk Register (Control Assurance) Allocated Days Complex and Challenging Behaviour Services Review of systems and procedures within Complex and Challenging Behaviour Services in the management of Woodview and Barlink Social Work Establishments. Financial & Staffing 25 Support for carers – including respite support Review of established processes to provide information, advice and support for unpaid carers including short breaks and respite support. Consideration will be given to including the review of both adult and young carers within the scope of this audit. National Health and Wellbeing Outcomes 25 Social Care Financial Assessments/ Contributing to your Care An audit to check the processes and accounting arrangements in the charging of care to service users. Financial 30 Page 216
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INTERNAL AUDIT SECTION ONGOING SERVICE REQUIREMENTS Auditable Area Audit Allocated Days Public Sector Internal Audit Standards/ Global Internal Audit Standards Annual self-assessment of the Internal Audit function against the Public Sector Internal Audit Standards. Additional allocation of days to undertake GAP analysis review to identify any additional requirements between current practices and the new Global Internal Audit Standards. 25 Audit Planning for 2026/27 (Includes Council/ MIJB & GVJB) Develop and consult on proposed coverage for the Internal Audit Annual Plan 2026/27. 10 Critical Friend Consultancy In its ‘critical friend’ role, provide internal challenge and quality assurance on a sample of programmes and projects involving major change and systems implementation; provide independent challenge of the evidence to support improvement; and perform an independent and objective assessment of the evidence to support self-evaluation and improvement in support of Best Value. 5 Follow-Up Monitor progress with implementation of Internal Audit recommendations. 15 Page 217
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 27 MARCH 2025 SUBJECT: MORAY INTEGRATED COMMUNITY EQUIPMENT STORE AUDIT BY: SERVICE MANAGER, PROVIDER SERVICES 1. REASON FOR REPORT 1.1 To update Committee on the last audit completed by Internal Audit Section for the Moray Integrated Community Equipment Store. 2. RECOMMENDATION 2.1 It is recommended that Committee: i) scrutinise and note the outcome of the Internal Audit for the Moray Integrated Community Equipment Store; and ii) note the work being undertaken to take forward the Audit Recommendations. 3. BACKGROUND 3.1 Internal Audit carried out a full inspection of the Moray Integrated Community Equipment Store at the end of the period 2023/24. The audit recommendations were reported to this Committee on 29 February 2024 (para 9 of minute refers). 3.2 The Moray Integrated Community Equipment Store is based at Pinefield in Elgin but has satellite stores in Chanonry (Elgin), Dr Gray’s Hospital (Elgin), Seafield Hospital (Buckie), Stephen Hospital (Dufftown), Moray Coast Health Centre (Lossiemouth) and Woodend Hospital (Aberdeen). 3.3 The Moray Integrated Community Equipment Store sits within Provider Services, although the budget for equipment sits with Occupational Therapy. 3.4 The Moray Integrated Community Equipment Store is responsible for the following actions: i. Ordering and storing all identified equipment required. ii. Delivering all equipment. iii. Recovering used equipment. Item 11. Page 219
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iv. Sterilising and re allocating used equipment. v. Installing and Programming telecare. vi. Checking equipment 6 monthly/annually to ensure compliance with legislation: and vii. Updating Systems. 3.5 The Moray Integrated Community Equipment Store differs from most stores in that it has a recycling component. Most equipment that is allocated has the potential to be reused after a process of sterilisation. 3.6 The main building utilised at Pinefield is complex and challenging and is limited in relation to any adaptations and makes it difficult for the staff to manage an increasing flow of equipment as a result of increased demand. 3.7 The Moray Integrated Community Equipment Store operates the TRANMAN system used by Moray Council to order all equipment. However, another system, ELMS, is used for the management of equipment (prescribing, ordering, delivering) and the systems are unable to speak to each other. Both Aberdeen City and Aberdeenshire currently work under the same conditions with two separate systems. 3.8 There was a further full year end stock check carried out in March 2024. This went well with compliance rates at 100%. 3.9 A further 6-month audit was carried out at the end of September with 100% compliance, along with Internal Audit. This has now been incorporated into the services’ training plan and will be completed annually as part of the services learning and development programme. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 The audit found that there was a higher-than-expected number of variances between the stock recorded in ELMS and the physical stock held in the store. It is acknowledged that there was an issue with products in transit and that has been reviewed and a solution found. This has now progressed with the drivers/technicians using the ELMS App to pick and load equipment. The Store Person is now able to identify the number of items in transit as well as when it has been delivered. 4.2 System problems were identified due to the service having to operate TRANMAN and ELMS systems and the fact that neither directly link. Part of the original contract specification was for the ELMS System to further develop to enable the ability to purchase equipment and payment of invoices, however this has never come to fruition. This is something the service will continue to work on with the developers. 4.3 There are policy decisions which require to be made in relation to the management of stock items and the process by which the Health and Social Care Partnership wish to take, specifically in relation to charging service users and having the ability to recover funds from lost equipment. These will be taken forward and have already been identified for further progression as part of the Operational Management Team work flowing into the IJB and are also included Page 220
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in programmes being taken forward in relation to more effective and efficient working through the Budget Saving Operational Group (BSOG). 5. FINDINGS AND ACTIONS 5.1 It was found that there was a discrepancy rate in the 10 items tested at the time of audit. Given that the store is spread across 7 areas and the fact that items in transit were blind at the time of audit, it is more understandable as to how this could apply. Two further checks of 10 items provided an accuracy rate of 100%. However, a plan is now in place with identified audits throughout the year for the store, linking to the satellite stores. Further work has been carried out with the programme provider and a solution to manage stock which is recorded as leaving the store and before it has been signed off at its end location (those in transition) has now progressed with the drivers/technicians using the ELMS App to pick and load equipment. The Store Person is now able to identify the number of items that are on the shelf and items that are loaded in the van. 5.2 Given the challenges with the environment, the majority of items on ELMS have a location recorded so is easier to find. Also, due to the size and weight of some pieces of equipment, they need to be stored where appropriate. 5.3 The challenges of operating both TRANMAN and ELMS is complicated and onerous for staff regarding duplication of work. However, a process has been implemented to ensure that the purchasing system is updated on a regular basis. The store person has been given further support and time to ensure that the task has sufficient management in order to comply. 5.4 After further development with Commissioning and the System provider, work will start shortly in order that our staff can log the purchase orders through ELMS, although they will still require to be ordered and paid through TRANMAN. However, the service will be able to report on the items purchased. 5.5 Currently all reusable products, once returned to the service, reduce in value by 50%. This is in accordance with Internal Audit advice and guidance on the deflation cost of equipment. The depreciation value of stock held is taken into account during the year end stock check audit process. (Once a product has moved into a non-sterile area, it must be classed as having been used). 5.6 Currently the council’s insurance policy does not cover equipment issued. Those accessing the equipment are advised by the prescribing agent that this would be necessary. 5.7 It was found that there are no set limits to ensure maximum and minimum stock levels. The Service Co-ordinator, in conjunction with the System Administration Officer, negotiated with the prescribers to ensure that minimum and maximum levels have been set, although this is difficult as predicting what items will be coming back from the community can be challenging. There is ongoing work through the BSOG to look at the value of stock held within the store partially at the end of the financial year as this value remains high and could be reduced to meet budget savings identified through the equipment purchasing budget. The service continues to review this on an ongoing basis. Page 221
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5.8 Although work is progressing well in auditing stock within the service, areas of improvement were identified regarding recording results. The Service Co- ordinator has now fully implemented a process with recording system moving forward and has implemented a learning and development programme alongside internal audit. 5.9 It was found that the Moray Integrated Community Equipment Store holds 31 specialist chairs at the time of reporting, which were bespoke for those they were ordered for. These products are high cost and very specific to individuals who have been assessed for them. It remains a challenge to re-issue these items and match them to another individual with similar needs. Therefore, a pilot has been developed across the three partnerships, Moray, Aberdeenshire and Aberdeen City to share high cost/slow moving items of equipment. This maximises the chances of the equipment being suitable for other people in this wider geographical area and reduces the need for additional spend. This pilot will continue to be monitored through the service. 5.10 The audit recommended a formal procedure be established for maintaining a list of officers requiring access to the ELMS System and to ensure removal of those no longer requiring access. The Systems Administration Officer has now put in place guidance and a process to manage this moving forward and this has been implemented and circulated to all users. 5.11 It was highlighted that there were no operating manuals in place for the ELMS System within the Moray Integrated Community Equipment Store. The Service Co-ordinator has now put in place an internal operating manual which will continue to develop. 5.12 Security was noted as a concern as part of the audit, the Moray Integrated Community Equipment Store now has a newly fitted replacement alarm and number pad entry system. Continued discussion will be held with Estates Team to ensure this remains compliant. 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” 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 Recommendations made as a result of the Moray Integrated Community Equipment Store audit will require further and ongoing discussion regarding policy. This will be taken forward through the Operational Management Team within the Health and Social Care Partnership. (c) Financial implications Page 222
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The ability to manage efficiently the equipment levels in Moray will afford greater overview of resources available. (d) Risk Implications and Mitigation All risks associated with the Internal Audit of the Moray Integrated Community Equipment Store are being managed and overseen within Health and Social care Moray. (e) Staffing Implications None directly associated with this report. (f) Property Previous work and projects have identified the building at the Moray Integrated Community Equipment Store as being challenging and difficult to work within. Managing an additional 6 satellite sites contributes to the challenge. (g) Equalities/Socio Economic Impact An Equality Impact Assessment is not required for the Internal Audit report 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. (i) Directions There are no directions arising from this report. (j) Consultations The following have been consulted in the development of this report: Senior Management Team, Operational Management Team HSCM, Finance and Human Resources. 7. CONCLUSION 7.1 This report provides the Committee with an update of the audit of the Moray Integrated Community Equipment Store by Internal Audit. The audit was carried out in accordance with Public Sector Internal Audit Standards (PSIAS). Author of Report: John Campbell, Service Manager Background Papers: Available on request Ref: Page 223
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