Agenda Document Pack - Audit, Performance and Risk Committee - 26/02/2026
Moray Council · 26 February 2026
Back to Audit, Performance and Risk Committee — 26 February 2026 and its agenda
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Audit, Performance and Risk Committee Thursday, 26 February 2026 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, 26 February 2026 at 09:30 to consider the business noted below. AGENDA 1. Welcome and Apologies 2. Declaration of Member's Interests 3. Minute of meeting of 29 October 2025 5 - 10 4. Action Log of 29 October 2025 11 - 12 5. Quarter 2 (July-September 2025) Performance Report - Adult Services 13 - 20 6. Quarter 2 (July to September 2025) Performance Report for Children and Families and Justice Social Work 21 - 54 7. Internal Audit Section - Update Report 55 - 76 8. Internal Audit Section Completed Projects Report 77 - 150 9. Update on the Delivery of the Unpaid Carers Strategy 151 - 162 Page 1
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10. Moray Integration Joint Board Draft Strategic Risk Register 163 - 190 11. Internal Audit Plan Year Ending 31 March 2027 191 - 218 12. Payment Verification 219 - 222 13. Unscheduled Care - Home Assessment Pathway 223 - 228 14. Items for Escalation to MIJB Page 2
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MORAY INTEGRATION JOINT BOARD SEDERUNT Councillor Ben Williams (Chair) Councillor Scott Lawrence (Voting Member) Mr Derick Murray (Voting Member) Mr Sean Coady (Member) Ms Sonya Duncan (Member) Ms Aimee McIntosh (Member) Ms Deborah O'Shea (Member) Ms Judith Proctor (Member) Mr Sandy Riddell (Member) Mr Michael Ritchie (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 Wednesday, 29 October 2025 Council Chambers, Council Office, High Street, Elgin, IV30 1BX PRESENT Mr Sean Coady, Ms Sonya Duncan, Councillor Scott Lawrence, Mr Derick Murray, Ms Deborah O'Shea, Ms Judith Proctor, Mr Sandy Riddell, Councillor Ben Williams APOLOGIES Ms Aimee McIntosh, Mr Michael Ritchie IN ATTENDANCE Corporate Programme Manager; Service Manager, Education and Social Care; Chief Internal Auditor; Service Manager, Provider Services; Self-Directed Support and Unpaid Carers Team Manager; Angela Pieri, Engagement Lead, Grant Thornton and Caroline O'Connor, Committee Services Officer ALSO IN ATTENDANCE Councillor Bridget Mustard 1. Chair The meeting was chaired by Councillor Ben Williams. 2. Declaration of Member's Interests Mr Murray stated for transparency, in relation to Item 11 "2024-25 Audited Annual Accounts", that he was Chair of the NHS Grampian Audit and Risk Committee. The Board noted there were no other declarations of member's interests. 3. Minute of meeting of 19 June 2025 The minute of the meeting of 19 June 2025 was submitted and approved. Item 3. Page 5
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4. Action Log of 19 June 2025 The Action Log of the meeting of 27 March 2025 was discussed and updated accordingly. 5. Quarter 1 (April to June 2025) Performance Report - Adult Services The meeting had before it a report by the Corporate Programme Manager updating Committee on performance as at Quarter 1 2025 (April - June). Mr Riddell raised the importance of aligning insights between this report and the Children and Families and Social Work Services Performance Report also on the agenda, particularly in relation to mental health indicators. In response, the Chief Officer agreed the parallel reporting of performance does not make the connections, noting a joined-up approach was required to ensure a clear understanding of outcomes and impact and undertook to progress work to draw out the connections in order to provide assurance. Councillor Lawrence asked to what extent the current unmet need was related to insufficient recruitment and how much was due to broader pressures on the existing workforce. In response, the Chief Officer advised there were a combination of factors including complexity of care needs, workforce capacity and, although noting there had been improvements in recruitment in some areas, this resulted in increased delivery costs and resources strains. The Head of Service/Depute Chief Officer further advised there had been a significant reduction in waiting times however recognised the current reporting framework did not fully reflect the improvements. He confirmed work was ongoing with external providers to develop a collaborative model, the issues would be considered in more depth at a scheduled development session and offered to bring back a more detailed report on unmet need. Following consideration the Committee unanimously agreed to :- i) note the performance of local indicators for Quarter 1 (April to June 2025), against revised targets for 2025/26, as presented in the Performance Report at Appendix 1; ii) note the analysis of indicators that have been highlighted and actions being undertaken to address performance that is outside of acceptable target ranges as detailed in section 5; iii) note the commentary in section 6 and graphs for the National and Ministerial Steering Group indicators in Appendix 2; and iv) approve the revised list of local indicators for future quarterly reports included in paragraph 7.3 and the intention to provide deep dives into specific areas of interest through the year. 6. Quarter 1 (April to June 2025) Performance Report for Children and Families and Justice Social Work Page 6
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The meeting had before it a report by the Interim Chief Social Work Officer/Head of Service informing Committee on Children and Families and Justice Social Work Performance as at Quarter 1 (April to June 2025). Mr Riddell asked how the test of change to be taken forward by the Policy, Commissioning and Development Team referenced at paragraph 4.17 would be managed in terms of timescales and outputs. In response, the Service Manager Education and Social Care apologised the information was not detailed in the report but confirmed there was a clear schedule which would be provided to Committee. Following consideration the Committee unanimously agreed to note:- i) the performance of local indicators for Quarter 1 as presented in the Performance Report at Appendix 1; and ii) 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. Mr Murray, with reference to the Chief Internal Auditor's decision to delay the review of Support for Carers to a future audit plan referred to in paragraph 4.1, noted there had been delays in implementation of the Strategy and suggested the review be carried out in the near future. In response, the Chief Internal Auditor agreed however noted his review would include the Strategy along with the arrangements and he would therefore want the Strategy to be implemented before undertaking a review. In response to a follow-up question from Mr Riddell asking for a definitive timescale in terms of there being an added incentive to ensure implementation of the Strategy was progressed, the Chief Internal Auditor confirmed it would be added to the Audit Plan for 2027/28 to review what had been implemented, what the intentions were and what had happened in practice. Following consideration the Committee unanimously agreed to note the audit update. 8. Internal Audit Section Completed Projects Report The meeting had before it a report by the Chief Internal Auditor providing Committee with an update on audit work completed since the last meeting of the Committee. In response to a concern raised by Mr Murray regarding the storage of records in officers homes referred to in Recommendation 3 of Appendix 2, the Chief Financial Officer provided assurance there was now a system in place meaning there was no longer an issue with file locations as all new files are being scanned into the system and backlog files are being processed through the mailroom. In order to provide further assurance, Councillor Lawrence confirmed similar reassurance had been provided to the last meeting of the Council's Audit and Scrutiny Committee. Following consideration the Committee unanimously agreed to note the audit update. Page 7
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9. Update on the Delivery of the Unpaid Carers Strategy The meeting had before it a report by the Service Manager Provider Services providing an update to Committee on the progress made in implementing the Moray Carers Strategy, with particular emphasis on key activities and developments over the reporting period. The Service Manager Provider Services noted at the time the report was prepared, the service was still in the process of putting arrangements in place and suggested the wording in recommendation ii) be changed to remove "Lead Officer" and substitute with "Strategy Group" to remove the responsibility from one individual person. Following a short discussion on the competency of there not being a singular person being accountable, the Chair suggested the wording of recommendation ii) be amended to "Lead Officer, supported by the Strategy Group". Following consideration and there being no one otherwise minded, the Committee unanimously agreed to:- i) note the progress made to date in delivering the objectives set out in the Carers Strategy; and ii) instruct the Lead Officer, supported by the Strategy Group, to provide quarterly progress reports to this Committee to support ongoing monitoring and scrutiny of the Strategy implementation. 10. External Auditors' Report to those charged with Governance The meeting had before it a report by the Chief Financial Officer asking Committee to consider the reports to those charged with governance from the Board's External Auditor for the year ended 31 March 2025. The Committee joined the Chair in thanking those involved in providing the External Auditor's Report and thereafter unanimously agreed to note the reports from the External Auditor as set out in Appendices 1 and 2 of the report and recommended them for approval by the Moray Integration Joint Board. 11. 2024-25 Audited Annual Accounts The meeting had before it a report by the Chief Financial Officer presenting to Committee the Audited Annual Accounts for the year then ended 31 March 2025. Following consideration the Committee unanimously agreed to note the Audited Annual Accounts for the financial year 2024/25 and the letter of Representation and recommended them to the Moray Integration Joint Board for approval. 12. Public Sector Internal Audit Standards - External Quality Assessment of the Internal Audit Section - Follow Up Review The meeting had before it a report by the Chief Internal Auditor providing an update on the implementation of recommendations detailed within the external quality assessment undertaken on the Council's Internal Audit Section. Page 8
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Following consideration the Committee unanimously agreed to note the report. 13. Health and Social Care Moray Strategic Delivery Plan 2025-2028 - Progress Update to 30 September 2025 The meeting had before it a report by the Corporate Programme Manager providing Committee with an update on progress to September 2025 of the implementation of the Strategic Delivery Plan. Following consideration the Committee unanimously agreed to:- i) note the progress to September 2025 of the Strategy Delivery Plan (2025-2028) attached at Appendix 1; ii) note the areas that are progressing well and those where adjustments to timescales are required as outlined in paragraphs 4.3 to 4.10; and iii) approved the amendment to the outcome identified in paragraph 4.11. 14. Items for Escalation to MIJB The Committee noted that there were no items for escalation to the Moray Integration Joint Board. 15. Internal Audit Section Follow Up Review - NHS Grampian [Para 6.2.5] The meeting had before it a report by the Chief Internal Auditor providing an update to Committee on the internal audit work completed on NHS Grampian systems and practices. Following consideration the Committee unanimously agreed to note the report. 16. Internal Audit Follow Up Reviews - Information, Communication and Technology [Para 6.2.5] The meeting had before it a report by the Chief Internal Auditor providing an update to Committee on the follow up reviews undertaken by the Internal Audit Section to evidence implementation of audit recommendations. Following consideration the Committee unanimously agreed to note the report. Page 9
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MEETING OF MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE THURSDAY 29 OCTOBER 2025 ACTION LOG Item No. Title of Report Action Required Due Date Action By Update for 26 February 2026 1. Q1 Performance Report 31/08/23 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. Q2 Performance Report 30/01/25 Chief Officer to issue email update with information relating to the rise in targets detailed in Emergency Admissions graphs in Appendix 1. TBC Chief Officer Targets are being amended. Members will be emailed with background information detailing how targets are calculated. Item 4. Page 11
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Item No. Title of Report Action Required Due Date Action By Update for 26 February 2026 3. Q1 (April to June 2025) Performance Report – Adult Services 29/10/25 Depute Chief Officer to prepare a detailed report on unmet need for future meeting. TBC Sean Coady Under development as part of the ongoing performance reporting 4. Q1 (April to June 2025) Performance Report – Children, Families & Justice SW 29/10/25 Schedule to be provided to Committee including timescales and outputs relating to the test of change to be taken forward by the Policy, Commissioning and Development Team in para 4.17 TBC Carl Campbell Page 12
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 26 FEBRUARY 2026 SUBJECT: QUARTER 2 (JULY - SEPTEMBER 2025) PERFORMANCE REPORT – ADULT SERVICES BY: HEAD OF ADULT SERVICES 1. REASON FOR REPORT 1.1 To update the Committee on performance as at Quarter 2 2025 (July - September). 2. RECOMMENDATION 2.1 It is recommended that the Committee consider and note the performance of local indicators for Quarter 2 (July to September 2025), against revised targets for 2025/26, as presented below. 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 Data below identifies local indicators for the MIJB and the functions delegated by NHS Grampian (NHSG) and Moray Council, enabling broader scrutiny and assurance 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. Some of these local indicators sit with acute, although can and do impact our whole system. RAG scoring based on the following criteria: GREEN If Moray is performing better than target. AMBER If Moray is performing worse than target but within agreed tolerance. RED If Moray is performing worse than target by more than agreed tolerance. 4.2 The detailed performance report for quarter 2 is noted below. Summary of Previously Agreed Indicators 4.3 The historical trends in performance within Health and Social Care Moray (HSCM) as demonstrated by the agreed indicators up to the end of quarter 2 of the Item 5. Page 13
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financial year 2025/26. Where there is no nationally set target, the average of activity for previous calendar year has been utilised. 4.4 Accident and Emergency – On Target Target 21.4 Actual Q2 21 Accident and Emergency Code Short Name Current Target Q1 2024/25 Q2 2024/25 Q3 2024/25 Q4 2024/25 Q1 2025/26 Q2 2025/26 Value Value Value Value Value Value HSCM AE-01 A&E Attendance rate per 1000 population (All Ages) 21.4 21.5 22.6 19.7 22 22.1 21 The trend for Emergency Department attendances is improving, with improvement in the last three quarters. 4.5 Delayed Discharges – improving Target 26 Actual Q2 37 Delayed Discharges Code Short Name Current Target Q1 2024/25 Q2 2024/25 Q3 2024/25 Q4 2024/25 Q1 2025/26 Q2 2025/26 Value Value Value Value Value Value HSCM DD-01 Number of delayed discharges (including code 9) at census point. 26 33 40 33 40 32 37 HSCM DD-02 Number of bed days occupied by delayed discharges (including code 9) at census point 850 922 1,115 981 1,149 1,015 1,217 4.6 In Quarter 2, delays rose from Quarter one from 32 to 37. This shows a declining trend, but was indicative of the overall NHS Grampian trend - NHSG averaged 180 delays across this period. It should be noted that Moray achieved 2 below the national target of 24 during this period. Overall the trend is an improving picture. 4.7 Mitigation and Impact • Discharge Without Delay programme • Home Assessment Pathway progressing • External care at home provision sustainability. • Proportionate care and telecare options are being expanded. • Resource Allocation meetings have been redesigned for efficiency. • Flexible Commissioning: Scotland Excel’s framework opens the provider market and diversifies services. • New Service Types: In-home short breaks and day opportunities expand support and workforce roles. Page 14
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4.8 Hospital Readmission - Improving Emergency Readmission within 7 days - Q2 4.1 Emergency Readmission within 28 days - Q2 9.2 Hospital Readmissions Code Short Name Current Target Q1 2024/25 Q2 2024/25 Q3 2024/25 Q4 2024/25 Q1 2025/26 Q2 2025/26 Value Value Value Value Value Value HSCM HR-01 % Emergency Readmissions within 7 days of discharge 3.7% 3.6% 4.6% 3.1% 3.9% 4.1% 4.1% HSCM HR-02 % Emergency Readmissions within 28 days of discharge 7.4% 6.9% 8.9% 6.9% 7.4% 9.4% 9.2% 4.9 The 7 day emergency readmission percentage remained static in this quarter. This continues to be above target, however, it should be noted that readmission is not always for the same clinical reason. 4.10 Mitigation With the Home Assessment Pathway now operational, it is expected that this will directly impact and reduce readmissions to hospital. 4.11 Mental Health - On Target Mental Health Code Short Name Current Target Q1 2024/25 Q2 2024/25 Q3 2024/25 Q4 2024/25 Q1 2025/26 Q2 2025/26 Value Value Value Value Value Value HSCM MH-01 Percentage of patients commencing Psychological Therapy Treatment within 18 weeks of referral 90% 69.8% 60% 44% 65% 60% 57% 4.12 The demand for mental health and primary care Psychological Therapies continues to increase. The figures collated cover both Primary and Secondary Care. Secondary care Health Improvement, Efficiency, Access and Treatment (HEAT) targets are 85% improved and are meeting the 18 week referral to treatment target, with 92% of people being referred within 18 weeks. However Primary Care Psychological Therapies continue to perform well below the current target figure. This is due to a variety of factors but the establishment of Group classes and robust triage is in place helping to improve the referral to treatment target. The majority of Moray Health and Social Care Partnership (HSCP) referrals in Moray are under 65, reflected across NHS Grampian. 4.13 Attention Deficit Hyperactivity Disorder (ADHD) Register has over 500 cases awaiting assessment. All cases are triaged and the most urgent and vulnerable people, those with a co-morbid mental illness, are being seen in Mental Health Outpatients. The Clinical Director, GP Clinical Lead and more recently colleagues within Autism Scotland are reviewing Moray referral criteria for ADHD. Page 15
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4.14 Drugs and Alcohol Treatment within 3 weeks NHS Grampian achieved 95.5% of people receiving treatment within 3 weeks in 2025, compared to 95.1% in 2024, showing a slight improvement. 4.15 Harm reduction (drug and alcohol) Outreach remains consistent and a second recovery community event was held in Lossiemouth in this quarter. This incorporated a national Overdose Awareness Day and a recovery walk. The integrated pathway in Moray has single point access and same day prescribing, with 96.8% of people starting treatment within 3 weeks of referral. The target is 90%. The prevent suicide North East app now has 171 users in quarter 2. This is monitored by Moray HSCP’s Scottish Action for Mental Health (SAMH). 26 Training courses were delivered by SAMH in quarter 2 to 301 people. 4.16 Mitigation • Group development and job planning aim to increase throughput and maximise capacity. • Ward model changes in Ward 4 (e.g, single consultant model) are improving patient flow. • Migration to TRAK (NHSG reporting system) will provide improved data reporting for Primary Care 4.17 Staff Management – NHS improving, Council static. Staff Management Code Short Name Current Target Q1 2024/25 Q2 2024/25 Q3 2024/25 Q4 2024/25 Q1 2025/26 Q2 2025/26 Value Value Value Value Value Value HSCM SM-01 NHS Sickness Absence - % of hours lost 5% 7% 6.4% 7% 4.9% 5.9% 5.2% HSCM SM-02 Council Sickness Absence - % of calendar days lost 5% 7.5% 7.3% 7.3% 8.2% 8.1% 8.1% 4.18 Both NHS staff and Council staff sickness absence is above the target of 5%, with the NHS staff showing an improvement. However Council staff are showing highs of over 8%. Quarter 2 saw an increase in respiratory illness being recorded for short term sickness. 4.19 Mitigation • Vaccination campaigns for flu and COVID-19 aim to reduce severity and duration of illness. Staff uptake of flu vaccine in NHS Grampian was recorded as third highest in Scotland. • Wellbeing Initiatives are promoted throughout the organisation and its partners. NHS Grampian actively encourage the We Care website for staff access to health and wellbeing resources. These are shared across HSCM staff groups. • Safe Staffing Tools are used daily to monitor and manage workload and reduce stress related absences in clinical areas. • Attendance meetings are in place with both Council and NHS staff groups. Page 16
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4.20 Self-Directed Support (SDS) Self-Directed Support Code Short Name Current Target Q1 2024/25 Q2 2024/25 Q3 2024/25 Q4 2024/25 Q1 2025/26 Q2 2025/26 Value Value Value Value Value Value HSCM SDS-01 SDS Services – No of Option 1 Services end of quarter Data only 283 293 HSCM SDS-02 SDS Services - No of Option 2 Services end of quarter Data only 302 323 HSCM SDS-03 SDS Services - No of Option 3 Services end of quarter Data only 1,410 1,435 4.21 Pathways are now in place, and updates to assessments have been implemented to capture each individual’s preferred SDS option more accurately. The expanded commissioning framework is expected to strengthen choice and control, ensuring decisions are driven not by commissioning models or service availability, but by the level of responsibility individuals wish to take for their own care and support. 4.22 For SDS Option 1, most of the budget use relates to the employment of Personal Assistants. Work is currently underway to enhance recruitment and retention of this vital workforce within Moray. 4.23 Unmet Need Overview and Analysis (improving Q2) Unmet Need Code Short Name Current Target Q1 2024/25 Q2 2024/25 Q3 2024/25 Q4 2024/25 Q1 2025/26 Q2 2025/26 Value Value Value Value Value Value HSCM UN-02 No of people assessed and waiting for a package of care Data only 203 205 198 185 167 149 HSCM UN-Hrs No of hours of care yet to be provided for individuals (in total) Data only 1,626 1,483 1,330 1,307 1,205 1,055 4.24 The number of people assessed and waiting for a package of care decreased in this quarter, as did the number of hours of care yet to be provided. Page 17
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4.25 This financial year has seen a steady decrease in people waiting for care from a high of 164 to a low of 120 in July. People waiting in hospital have decreased, showing a modest improvement. The number of unmet need hours not provided has seen a steady improvement to September. Care at Home packages from January 2025 to January 2026 have however, increased in intensity, with packages of 30 hours or more accounting for a third of all care delivered. High Cost packages to quarter two saw an additional recurring spend of £263,783, for 19 packages. This is a reflection of the acuity care required resulting in higher costs. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” 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 There are no new policy or legal implications arising directly from this report. The report is consistent with existing statutory duties and governance arrangements. (c) Financial implications There are no direct financial implications associated with this report. However, performance insights may inform future resource planning and prioritisation aligned with strategic objectives. Page 18
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(d) Risk Implications and Mitigation While there are no immediate risks arising from this report, the performance framework will continue to be reviewed and adapted to ensure responsiveness to emerging risks and system pressures. There is also a risk that the MIJB may not deliver on the outcomes set out in the Strategic Plan. Where such risks are identified, they will be escalated and presented to the Board for appropriate oversight and action. (e) Staffing Implications While there are no direct staffing implications arising from this report, it is important to acknowledge the ongoing challenges with recruitment, retention and staff absence across health and social care services. These workforce pressures continue to impact the MIJB’s ability to deliver services in line with strategic objectives. Recruitment difficulties, particularly in rural and specialist roles, combined with high levels of sickness absence in some areas, pose a significant operational risk. These issues are being monitored closely, are considered within workforce planning, and service redesign efforts. (f) Property There are no property implications directly associated with this report. (g) Equalities/Socio Economic Impact An Equality Impact Assessment (EIA) is not required for this report, as it does not introduce or amend any policy or service that would directly affect individuals with protected characteristics. However, performance data may be used to inform future service improvements that promote equity and inclusion. (h) Climate Change and Biodiversity Impacts There are no direct climate or biodiversity implications arising from this report. However, it is recognised that extreme weather events and rising energy costs may increasingly impact service delivery, particularly in rural areas. These factors will be considered in future strategic planning. (i) Directions No new directions are required as a result of this report. (j) Consultations Senior Management Team, Operational Management Team Health and Social Care, Service Managers, Caroline O’Connor, Committee Services Officer, Moray Council and their comments are incorporated in the report. 6. CONCLUSION 6.1 This report provides the Committee with an overview of the performance of specified Local indicators and outlines actions being undertaken to improve performance. It provides updates on National Indicators where trends can be assessed that offers further insight into delivery of our strategic objectives. Page 19
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This performance report supports the MIJB’s ongoing commitment to transparency, continuous improvement, and delivery of the strategic outcomes set out in the Strategic Plan. Author of Report: Sean Coady, Head of Adult Services Background Papers: Available on request Page 20
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 26 FEBRUARY 2026 SUBJECT: QUARTER 2 (JULY TO SEPTEMBER 2025) PERFORMANCE REPORT FOR CHILDREN AND FAMILIES AND JUSTICE SOCIAL WORK BY: INTERIM CHIEF SOCIAL WORK OFFICER/HEAD OF SERVICE 1. REASON FOR REPORT 1.1 To inform the Committee on Children and Families and Justice Social Work performance as at Quarter 2 (July to September 2025). 2. RECOMMENDATIONS 2.1 It is recommended Committee scrutinises and notes: i) the performance of local indicators for Quarter 2 as presented in the Performance Report at Appendix 1; and ii) the analysis of the local indicators as detailed in Appendix 1. 3. BACKGROUND 3.1 The purpose of this report is to inform Committee of the quarterly performance data which provides the analysis of the delivery of Children, Families and Justice Social Work services. 3.2 Appendix 1 identifies local indicators for the Moray Integration Joint Board (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 measures set against the national performance indicators. 4.2 Appendix 1 provides a summary and the historical trends: • Child Protection activity • Looked after Children Item 6. Page 21
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• Justice and Youth Justice 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’s Services Partnership and reported to the Child Protection Committee (CPC) through the Child Protection Minimum Data Set. Appendix 1 begins with Child Protection Q3 from page 1 to 10, Financial Q1 data is from page 10 to 30. Any trends or 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 reported over the financial year 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 4, 54 children were registered on the North East Child Protection Register (NECPR). There is no reliable way of comparing data with other areas before this information is officially published nationally. The National data for the reporting year 1 August 2023 to 31 July 2024 was published by Scottish Government on 25 March 2025. Looked After Children 4.6 At the end of Financial (Fin) Quarter 2, the number of looked after children is 173. This includes 5 New Scots (formally Unaccompanied Asylum-Seeking Children (UASC)) and 4 children who are cared for on a part time basis (Short Breaks). 4.7 86.5% (45/52) 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 increased capacity 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 average 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 28% of looked after children in Moray are in approved Kinship care with family members, which is in line with the average. Work continues 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 necessary in the future. 4.9 20.8% (36/173) 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 average of comparator authorities (17.5% for 2022/23). This figure includes four young people who are Page 22
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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 18.5% (32/173) which is 1% higher than the average of comparator authorities. In common with most of the comparator local authorities, Moray is higher than the Scotland national average percentage of 10%. 4.10 95.5% of brothers and sisters in Foster Care and Kinship Care remain together with at least one sibling. The Maintaining Relationships Project is developing an approach and policy to ensure brothers and sisters can 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 (3 or more children). 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 in Moray. Justice and Youth Justice 4.12 At the end of Financial (Fin) Quarter 2, there were 524 people supported by Justice and Youth Justice Services of whom 49 are “care experienced” young people (CEYP), Youth Justice, 16 and Justice, 33. 4.13 Overall, the number of CEYP in Justice and Youth Justice Social Work has consistently remained below 12% since 2023. 4.14 Most individuals supported by Youth Justice and Justice Social Work are male (76% Justice Social Work, 78% 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 of a child or family member. 4.15 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. Policy, Development, Trauma-Informed and Commissioning 4.16 A range of new Trauma-Informed courses have been made available to staff across the partnership. Since the inclusion of trauma informed practice modules onto CLIVE, 691 people have successfully completed the ‘Understanding the impact of trauma and responding in a trauma-informed way’ module. 4.17 The 6-monthly analysis of complaints that were received and responded to by the Children and Families and Justice Social Work Service is an established part of the Service’s self-evaluation approach. Between January and June 2025, 30 complaints were received and responded to: 18 at Stage 1 and 12 at Stage 2. This is in line with the upward trend in the number complaints indicated by longitudinal data (since Jan 2022), suggesting that responding to complaints is likely to place further pressure on the service, particularly in the light of the Page 23
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demands of Child Friendly Complaints. Other developments as well as commissioning in the Service are on pages 22 - 32 in Appendix 1. 5. KEY MATTERS RELEVANT TO RECOMMENDATION 5.1 Detailed charts and performance indicator data is attached in Appendix 1. 6. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” This report notes that a review of key performance indicators is currently being developed in respect of the wider service functions that will align with key priority areas across the Children’s Services partnership. (b) Policy and Legal None arising as a direct result of this report. (c) Financial implications None arising as a direct result of this report. (d) Risk Implications and Mitigation None arising as a direct result of this report. (e) Staffing Implications There are no proposed changes to the staffing or reporting relationships. (f) Property None arising as a direct result of this report. (g) Equalities/Socio Economic Impact None arising as a direct result of this report. (h) Climate Change and Biodiversity Impacts None arising as a direct result of this report. (i) Directions None arising as a direct result of this report. (j) Consultations Children, Families and Justice Social Work Senior Management Team. 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 24
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APPENDIX 1 1 | P a g e CHILDREN & FAMILIES AND JUSTICE SOCIAL WORK - QUARTER 2 (JUL-SEPT 2025) 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 4 WHICH IS LATEST AVAILABLE DATA (MAY-JUL 2025). At the end of the Child Protection Quarter 4, (CP Q4) there were 528 contacts, enquiries and referrals (all under the heading referrals) to the Access Team for 473 children as per Graph 1 below: Graph 1: CP Quarter 4 - Referrals received by Access Team from May to July 2025 Graph 1 above illustrates the data for all contacts with the Access Team. Enquiries relate to a request for advice or guidance from a member of the public or a partner agency. The team receives information such as a Police Concern Report, not requiring action or follow up, while referrals are formal requests for assistance or where it is deemed necessary to take further action. Referral sources are Social Work, Scottish Children’s Reporters Administration (SCRA), Police, Courts, Education, Health, 3rd Sector, community, families and young people, where the following actions are considered: • Information to be passed to the Named Person • Visit to the child, young person and their family • Interagency Referral Discussion – where partners meet to share information and consider risk and create a safety plan • Immediate action to reduce a significant and immediate risk of harm to a child The number of referrals can be more than the number of children, as they can come from more than one source for the same child. Child Protection is prioritised with the allocation of a social worker to lead on the assessment of need and risk. The family's strengths and support networks are considered by the creation of genograms to identify networks of supportive family members, friends and community supports, who can contribute to the child’s safety and wellbeing. Family Group Decision Making, commissioned from Children First, is engaged to focus the family and friend network for a plan to reduce the flow-into care at the earliest possible opportunity. When applied at the early stages of support, effective plans can reduce the need for children 0 50 100 150 200 250 May-25 Jun-25 Jul-25 209 193 126 190 170 113 REFERRALS RECEIVED BY ACCESS TEAM Referrals: No. in last month Referrals: No of children Page 25
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APPENDIX 1 2 | P a g e to move from the care of their parents and the resultant trauma. Pie chart 1 below shows the sources of referrals in CP Q4: Pie chart 1: Sources of referral In CP Q4, 32% of referrals were from the Police (170), followed by Health and Social Work 20% (105), Education 19% (97), Family and Community 18% (97), and 11% coming from other agencies (59) (as per pie chart 1). Where the number of referrals is higher than the number of children, due to there being more than one referral source on the same child (e.g. Health, Education and Police) this potentially reflects consistent thresholds across the partnership. This quarter has seen a reduction in the number of referrals into social work. The previous quarter reported a significant increase, in part relating to referrals from education partners prior to the end of the academic year. Managers in the Access Team and the Quality Improvement Officer for Education have met fortnightly to ensure a manageable flow of referrals though the Child Planning Pathway to social work with appropriate thresholds being applied reflecting reduced referrals. Overall referral numbers will fluctuate to reflect the needs of children in our communities and how effective our early help and support to families is in meeting children's assessed needs. Graph 2 below shows the number of IRDs held for the number of children in CP Q4: Graph 2: IRDs and number of children subject to an IRD Police, 170, 32% Education, 97, 19% Health and Social Work, 105, 20% Family & Community, 97, 18% Other Agency, 59, 11% SOURCES OF REFERRAL 0 10 20 30 40 50 60 70 Q1 24-25 Q2 24-25 Q3 24-25 Q4 25-26 47 40 41 46 64 66 57 68 IRDs and No. of Children No. of IRDs held in Quarter No. of Children involved Page 26
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APPENDIX 1 3 | P a g e Graph 2 shows the quarterly trends in IRDs (between 1 Aug 2024 and 31 Jul 2025). An interagency referral discussion (IRD) is part of our wider Child Protection Procedures. Where a child is referred and there is information to suggest they are at a potential or actual significant risk of harm, and there is a need for further information to be shared, an IRD is convened. Police, Social Work, Health and other professionals who know the child come together to discuss concerns, analyse risk and consider next steps. A safety plan can be created, joint interviews with children and young people planned, health assessments, where appropriate, for children and consideration of need for an Initial Child Protection Planning Meeting (ICPPM) discussed. Multi-agency safety planning responds to immediate risk of harm or creates a plan to reduce risk for a child enabling them to remain with their family, whilst wider support is considered. In CP Q4, 68 children were involved in 46 IRDs. For each quarter, the number of children is greater than the number of IRDs as each IRD considers all children in a family. There has been little fluctuation in the number of IRDs in Moray over the four quarters with an average of 43. Pie chart 2 below provides the main reason for an IRD: Pie chart 2: Main reasons for IRD Throughout CP Q4, physical assault (21, 29%) remains a consistent reason for an IRD being held, followed by emotional abuse (11, 15%), sexual assault (9, 12%), mental health (9, 12%), neglect (7, 10%), domestic abuse (7, 10%), and child criminal exploitation (3, 4%). Following the IRDs, 11 Initial Child Protection Planning Meetings were convened, and 13 Joint Investigative Interviews were requested. Graph 3 below shows the trend across 2025 for joint investigative interviews and the national model of Scottish Child Investigative Interviews (SCIM): Graph 3: Joint Investigative Interviewing Page 27
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APPENDIX 1 4 | P a g e Graph 4 – JII & SCIM Graph 4 above shows the activity of Joint Investigative Interviewing across CP Q4 during which 16 children were recommended for Joint Investigative Interview (JII); 14 Scottish Child Interview Model (SCIM) JIIs were completed, 2 children declined to be interviewed. Graph 5 below shows the trend since Q4 2024/25 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 family groups: Graph 5: Initial Child Protection Planning Meetings (ICPPM) At the end of CP Q4, 11 Initial and Pre-birth CPPMs were held for 26 children, all of whom were placed on the register. 100% were held in timescale of 28 days from the notification of concern. 73% of Initial and Pre-birth CPPMs had parental attendance which is positive while maximum attendance remains the aim. Graph 6 below shows the trend from IRD to ICCPM over a five-year period from 2020/21 to 2024/25: 12 22 10 11 26 7 12 6 7 11 0 5 10 15 20 25 30 Q4 Q1 Q2 Q3 Q4 May-Jul Aug-Oct Nov-Jan Feb-Apr May-Jul 2024/25 NO OF CHILDREN & UNBORN - ICPPMS Number of children subject to Initial and Pre-Birth CPPMs Number of Initial and Pre-Birth CPPMs Page 28
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APPENDIX 1 5 | P a g e Graph 6: Conversions from IRD to ICCPM 2020/21 to 2024/25 This five-year trend in conversion rates of ICPPMs to CP registration in Graph 6 above has offered an opportunity for reflection on social work practice. The conversion rate of 100% over the 4 Quarters Aug/Oct to May/Jul may indicate good decision making in deciding which children should be progressed for multi-agency child protection plans but may also suggest self-fulfilling planning i.e. those being taken to ICPPMs all end up with child protection registration. To understand this in more detail a focussed review for unborn babies following the pan Grampian Support in Pregnancy Pathway is being undertake. This will helpfully provide an insight into the partnership application of the pathway and important outcomes for families where a potential or actual risk of significant harm is indicated at an IRD and progression to an ICPPM is agreed. A small percentage of children discussed in IRDs progress to ICPPMs, this as an IRD has multiple outcomes and progressing to an ICPPM is only required where the child remains at significant risk of harm where a safety plan has been agreed in the interim. Audit of IRDs takes place to ensure consistency in the function of the meeting and the quality of 528 referrals 46 IRDs 11 ICPPMs The conversion rate from referral to IRD is 8.7% The conversion rate from IRD to ICPPM is 23.9% Page 29
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APPENDIX 1 6 | P a g e information shared and analysis of risk to inform decision making and an agreed safety plan at the meeting. Information from audit is shared with agencies to consider improvements where required. It would be helpful to understand better the decision to proceed to IRD and what support is provided to a family prior to the meeting taking place. This aspect of collaborative partnership working represents the response from the team around a child to a rise in concerns for their wellbeing. Where a child has a multi-agency plan of support a Child’s Planning Meeting may be an appropriate option in some situations. In the main as IRD’s exclude parents and the child or young person from the discussions and Police do not attend a child planning meeting, this is appropriate on occasion where the risk is from a member of the child’s family, or close support, or a disclosure of Police information requires to be protected. During CP Q4, there were 19 Review Child Protection Planning Meetings (RCPPM) held for 28 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. 6 of the RCPPMs held in this quarter were first reviews, of which, 66% were held within the 6-month timescale. The reason that the meetings were note held in timescale was linked to engaging parents; one meeting was postponed to allow a parent to attend and participate. Another was delayed due to the prioritisation of a baby’s health appointment. Graph 7 below shows in CP Q4, 2025 that 17 children were de-registered and 26 new children were registered. This meant at the end of CP Q4, the number of children who were on the Child Protection Register (CPR) had increased by 9 (from 45 to 54). Large families (three or more children) were added to the CPR in this quarter, accounting for the increase: Graph 7: Child Protection Registration (CPR) Trends from 2023/24 to 2024/25 Graph 8 below shows CP Registration comparator authority trends to from 2018 to 31 July 2024: Graph 8: Child Protection Registration Comparator Authority Trends: 2018 to 31 July 2024 Page 30
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APPENDIX 1 7 | P a g e Graph 9: Number of Child Protection Registrations Comparator Authority Trends: 2018 to 31 July 2024 Chart 10: Number of Child Protection Deregistration Comparator Authority Trends: 1 August 2018 to 31 July 2024 Pie chart 3 below depicts the reasons that children were added to the CPR in CP Q4. The reasons for new registrations often differ from the reasons for having an IRD. This is because, throughout the information-sharing process and child in need assessment, a more comprehensive understanding of the family's needs and a clearer perspective on risk and safety emerges: Pie chart 3: Reasons for new child protection registrations in the reporting period In CP Q4, “other concerns” was the most prevalent reason for child protection registration. This is used by the Reviewing Officer where the categories are not reflective of the family Page 31
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APPENDIX 1 8 | P a g e situation. Sexual abuse was the second most prevalent concern followed by domestic abuse and emotional abuse. Pie chart 4 below depicts all of the reasons for children being placed on the CPR at the end of CP Q4. Neglect was the most prevalent concern and is represented more than the other categories: *Note there may be more than one concern documented for each child. Pie chart 4: Child Protection Concerns As shown in Graph 11, below at the end of CP Q4, there were 12 family groups consisting of one child, four family groups with two children and nine family groups of three or more children on the child protection register: Graph 11: Family Groups At the end of CP Q4, eight children on the Child Protection Register had one previous registration, and six children had two or more. This data highlights a pattern of recurring child protection concerns for some children and families as per Graph 12 below: Page 32
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APPENDIX 1 9 | P a g e Graph 12: Previous Registrations The core objective of Children and Families and Justice Social Work is to ensure the safety and wellbeing of children through timely, proportionate, and effective support. Repeat registrations indicate that, for a small number of children and families, risks have re- emerged or were not sufficiently reduced following previous support. To address this, the partnership needs to consider: ▪ The staged closure of families to social work and the move to child planning for families where children have required a protection plan. Child planning must continue at a multi-agency level following closure to social work and focussed quality assurance activity in this area for those children who move again to child protection planning, would be of benefit. ▪ Learning from repeat registrations to identify systemic gaps and improve practice, informed by the above Graph 13: Time on Moray Child Protection Register Regarding Graph 13, the aim is to support families to make the necessary changes to safely parent their children in a timeframe which meets the needs of their children, for example, up to 12 months. Should risks not have significantly reduced, then alternative measures should be considered for example referring to the Children's Reporter to consider if a compulsory supervision order is required. Where risk has been sufficiently reduced, and the Page 33
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APPENDIX 1 10 | P a g e child is experiencing safe and good enough care, then de-registration is considered, with the evidence understood and agreed by partners. Graph 14 below shows the trend for 2024/25 against CP Quarter 4 data. The consistently higher prevalence in the last year, of children aged 5-10 years highlights the need for earlier support and diversion services, ensuring this is provided at the earliest stages of a child’s development: Graph 14: Age of children on the Child Protection Register THE FOLLOWING SECTIONS REPORT AGAINST FINANCIAL QUARTER 2 (JUL - SEPT 2025) Graph 15 below identifies that at the end of Financial Quarter 2 (FQ2), there were 173 children who were looked after by Moray which is an overall increase from 165. Large families accommodated in this period contribute to the rise: Graph 15: Number of children looked after away from home and at home There was an increase in the number of newly accommodated children in 2024/25 which is being analysed through the ‘Critical Mass’ work to support a better understanding of this data and identify mitigating actions – a strategy for reducing the flow-into care. Pie chart 5 below provides information on the internal and external care settings for children and young people: Page 34
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APPENDIX 1 11 | P a g e Pie chart 5: Care setting categories At the end of FQ2, 45% of children were in family settings at home or in kinship care with 55% in other settings such as foster care or residential houses. This has remained a stable figure highlighting many looked after children have been able to remain within their network of family and friends. There has been an ongoing focus on kinship care as an option which has been supported by Family Group Decision Making. With this, Moray has been able to avoid children being cared for out with their familiar network of family and friends. At end of FQ2 there were 52 children living in foster care, with 45 children living with Moray Council foster carers and 7 living with independent foster carers. This identifies that, despite the challenges in recruiting carers both locally and nationally, Moray has ensured that most children are living with in-house foster carers. This is significant as it enables the vast majority of looked after children in Moray to maintain vital connections within their local community, including family, friends, education, and healthcare. A significant majority of young people are in family-based care (131, 76%) rather than residential care (including short breaks) (42, 24%). The Carer Recruitment Campaign has seen new foster carers and supported lodgings caregivers approved to support young people remaining in Moray in family-based care. There remains the commitment to support young people in family-based care including supporting families to identify and promote kinship care options via Family Group Decision Making. At the end of September 2025, 95.5% of brothers and sisters in Foster Care and Kinship Care remain together with at least one sibling. The National Average is 79%. Where brothers and sisters are not together, this is for a variety of reasons including lack of suitable resource, an assessed need to live separately or diverse needs. Maintaining relationships between brothers and sisters remains a priority. As such, Moray is 16.5% above the average indicator. There has been an impact of the increase in newly accommodated young people in in 2024/25 where there has been an associated increase in the use of residential care as foster care is at capacity in Moray. Page 35
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APPENDIX 1 12 | P a g e Aside this we will be implementing the revised Continuing Care Procedure. This is aligned with our clear plan to support young people in their transition to adulthood and after care, allowing them to remain in their family, fostering and residential home as non-looked after children until the age of 21 - 'Staying Put'. Moray hosts five young people who are New Scots (formerly Unaccompanied Asylum- Seeking Children) via the National Transfer Scheme. These children and young people are assigned to Moray by the mandated Home Office scheme and are then supported by the Throughcare and Aftercare Team. They are supported as looked after children to ensure they receive full support. Initially, these young people are in Supported Lodgings or Supported Accommodation. The team continues to successfully support them to move into their own independent housing once they have been granted asylum. Moray also hosts several other New Scots, but they are not all looked after children due to their age or asylum status. The number of new arrivals of New Scots in FQ2 was one. The resource allocation system in Moray means there are the resources to support New Scots including any future manageable increases in numbers. Graph 16: Moray foster care households Of our 44 fostering households, 90% are actively caring for a child. Not all fostering households have children living in their care. At the end of FQ2 this comprises of four (10%) 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 has been broadening the approval range and capacity of Moray foster carers, with additional support and advice, to enable care for a wider group of children and maximise capacity. Graph 17 below shows the children being cared for by Moray Council Foster Carers (internal) and those being cared for by Foster Carers commissioned by Moray Council (external): Graph 17: Children who live in foster care Page 36
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APPENDIX 1 13 | P a g e Graph 17 identifies that at the end of FQ2, there were 45 children cared for by Moray foster carers, which is a decrease from FQ1, which was 48. Young Carers work is reported to other Integration Joint Board Committees and is being reviewed with a view to inclusion in this report. Graph 18 below shows the number of kinship households in Moray and the children and young people in kinship care: Graph 18: Kinship care settings 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. We are continuing to review our Kinship Policy in line with revised guidance from the Scottish Government. Residential care is divided into those in residential care in Moray (internal) and those out with Moray (external). The children’s houses in Moray (11) Cala, Rowan Lea and Land Street, continue to operate at full capacity (14) with some young people who are over 18, subject to Continuing Care, and not recorded as looked after children as per below: Graph 19: Residential care settings Page 37
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APPENDIX 1 14 | P a g e Out of Area care tends to be specialist residential houses or residential schools. There has been a consistent focus on providing this care in Moray where possible, so children remain close to their families and support network. The figure for the Out of Area category is 21. 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. We are working with Action for Children and the new transition project. The project will provide targeted support for young people moving on from residential care in Moray or those returning to Moray. This is in early stages of implementation, with a transition worker joining the team around the child or young person. Residential care settings can be the correct care setting for some children and young people, often due to previous unsuccessful multiple family care. 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. As illustrated in Graph 20 below, as at 30 September 2025, there were 59 young people receiving care from the Through Care After Care (TCAC) Team including 12 receiving Continuing Care support: Graph 20: Through Care, After Care and Continuing Care It is anticipated that the numbers of young people subject to Continuing Care will increase as this approach becomes more embedded in Moray. There will be a likely increase in the use Page 38
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APPENDIX 1 15 | P a g e of Continuing Care for 16- and 17-year-olds and for those in residential care which is supported by a refreshed policy but has significant resource implications. The team is divided into three areas: • Through Care: Young people receiving support to plan and prepare for independence. • After Care: Young people who have left care and receive support whilst living independently or in a continuing care. • Continuing Care: Young people who choose to remain in their current care beyond their 16th or 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 receive the same support and care as when they were, providing a more natural and seamless transition to adulthood. 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 – “Staying Put”. This is a key legal 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, which is dependent, in part, on the numbers of young people arriving in Kent, making future forecasting a significant challenge. The team offers 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. Positive Destinations for Looked After Children A new area of reporting is in relation to positive destinations. This relates to school leaving looked after children (S4-S6) moving on to education, employment and training. Within the Corporate Parenting Strategic Group there is a focus on positive destinations to consider why the outcomes for looked after children in this area are not improving. It is important to note the numbers of young people are small where they can be easily identified, tracked and supported. The Throughcare and Aftercare Team has been working with colleagues in Education to support these young people. Maintaining Relationships Project The Maintaining Relationships Project will be launched in October 2025 at UHI Moray. A new maintaining relationships working group will be established to support implementing, embedding, and evaluating the guidance. Focus groups with children, young people and professionals have been planned for January 2026. Justice Services and Youth Justice Graph 21 below provides details on care experienced young people being supported by Justice Services: Graph 21: Care experienced young people supported by Justice Services Page 39
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APPENDIX 1 16 | P a g e Nationally, care experienced young people (CEYP) are overrepresented in the Scottish Justice Systems. At the end of FQ2, 9.3% (49 of 524) were CEYP (up to age 26) in the Justice System (Youth Justice 16, Justice Social Work 33) as depicted in graph 21. This figure has consistently remained below 12% since 2023 with the percentage fluctuating over the last year. The aim is to address identified needs and risks to reduce the chance of offending or re-offending and maximise support building on existing relationships across our partnership agencies. Research informs that early entry or prolonged exposure to the criminal justice system can draw children into the system rather than rehabilitate and divert from the system, therefore the use of short-term support is prioritised where possible. Children who are remanded or sentenced to custodial sentences in secure care are included in the numbers above and has resulted in inaccurate data due to individuals being open to both the Youth Justice and Justice Social Work team for transitional purposes. This will be addressed in the next reporting period. Graph 22 below provides the age range of children and young people being supported by Youth Justice Services: Graph 22: Age of children in Youth Justice 402 442 473 48 51 517.9 8.3 9.3 0 100 200 300 400 500 Jul-25 Aug-25 Sep-25 Care Experienced Young People Supported by Justice Services Open to Justice Team Open to Youth Justice % CEYP open to both MYJ and JS Expon. (Open to Justice Team) 0 20 40 60 Jul-25 Aug-25 Sep-25 0 0 0 26 26 33 21 21 171 4 1 Ages of Young People in Youth Justice YJ: Age Band: 5-10 YJ: Age Band: 11-15 YJ: Age Band: 16-17 YJ: Age Band: 18+ Page 40
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APPENDIX 1 17 | P a g e The average age of a child receiving Youth Justice services through this quarter is 15 years old which is the same as the previous quarter. At the end of FQ2 there are no under 11’s supported by the service. This is positive in that the needs of our younger children are being appropriately met by other services. Most of the work continues to be with children aged 11 to 15 years and is undertaken in a multi-agency way, working closely with key partners such as Police Scotland, education services and our local children's houses. Whilst the team works with all schools throughout Moray, it has strong links with Moray Social, Emotional and Behavioural Needs Service (SEBN). There has been a very small number of young people aged over 18 years in the Youth Justice Service over FQ2, where support has been delivered jointly with the Justice Social Work team. Planned transitions and joint working between these teams minimises the impact on the young person. Pie chart 6 below provides information on the gender of individuals supported by Youth Justice Services: Pie chart 6: Gender of individuals in Youth Justice At the end of FQ2, most individuals supported by Youth Justice were males accounting for 78% of children and young people supported by the service. There has been a small increase of females in the service over this quarter. Pie chart 7 below provides information on the gender of individuals in Justice Services: Pie chart 7: Gender of individuals in Justice Services YJ Gender: Male, 40 YJ Gender: Female, 11 GENDER OF YOUNG PEOPLE IN YOUTH JUSTICE YJ Gender: Male YJ Gender: Female Page 41
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APPENDIX 1 18 | P a g e In Justice Social Work 16% of individuals supported by the service were females, which has increased slightly 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. Recent feedback includes: Justice Social Work reports (JSWR) remain a priority to reduce delays in sentencing and for FQ2 the target of 100% on time has been met. There has been a slight decrease in report requests over FQ2. Whilst reports are prepared at the request of any Court for an individual living in Moray, most reports are submitted to Elgin Sheriff Court as per graph 23 below: Graph 23: Justice social work reports (JSWR) 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. Pie chart 8 below provides Justice Service report types for court: 111 94 100 0 20 40 60 80 100 120 Q2 JUSTICE SOCIAL WORK REPORTS (JSWR) - SUBMITTED ON TIME No. Social Enquiry Reports submitted on Time No. of People % of Reports on time Page 42
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APPENDIX 1 19 | 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. At the end of FQ2 there were three DTTO assessments in progress and two Orders imposed which involves at least two appointments per week for testing and supporting identified needs. Graph 24 below provides details of structured deferred sentences from 2022/23 to 2025/26: Graph 24: Structured deferred sentences (SDS) from 2022/23 to 2025/26 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 by the service. The number of in SDS disposals in FQ2 has decreased, however remain slightly higher than in the previous year in FQ2. Graph 25 below provides bail supervision details from 2022/23 to 2025/26: Page 43
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APPENDIX 1 20 | P a g e Graph 25: Bail supervision from 2022/23 to 2025/26 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 small reduction in the number of assessments requested in FQ2 and an increase in bail supervision orders imposed, with a slight increase compared to last year in FQ2. There continues to be a significant number of assessments not resulting 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 which is hoped will assist in reducing these numbers whilst offering more positive outcomes for individuals within their local communities. There is a plan to use the Outcomes Star as a model for identifying the impact of this work and additional support through a third sector organisation is being explored to improve outcomes for individuals subject to bail supervision. FQ2 has seen a decrease in the imposition of Community Payback Orders (CPO) since the previous quarter and in comparison, to the previous year. There is no clear indication for this decrease but may be due to the use of more effective early interventions as per graph 26 below: Graph 26: Community Payback Orders with supervision requirement Page 44
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APPENDIX 1 21 | P a g e Most individuals made subject to a CPO are seen on the day of sentencing, for those where this has not been possible, an appointment with their allocated social worker is made within seven days of an Order being imposed. There has been an improvement in the number of individuals seen within these timescales and additional support offered to staff when completing data to improve accuracy. Where an individual is subject to an Unpaid Work Requirement there is a focus on providing opportunities to develop skills as well as contribute to our local communities. Feedback from this service includes: 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. It is noted that there was no diversion from prosecution assessments for females during September 2025 and further monitoring of this data will continue. Outcomes Star data indicates most individuals feel an improvement in their wellbeing at the end of a DfP. Information contained within exit questionnaires include: Work is being undertaken to improve the recording and examination of this data and feedback. Page 45
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APPENDIX 1 22 | P a g e Finalised updated guidance for DfP is awaited from the Scottish Government, however there are plans from Community Justice Scotland to provide training to all staff which it is anticipated will improve local and national practice. Graphs 27 and 28 below provides details on diversion from prosecution for females and males: Graph 27: Diversion from prosecution: Female Graph 28: Diversion from prosecution: Male Policy, development, trauma-informed and commissioning Trauma-Informed Practice During FQ2, a range of courses, some of them consisting of multiple modules, have been made available to staff across the partnership. Since the inclusion of the trauma informed practice modules onto CLIVE, 691 people across the local authority have successfully completed the ‘Understanding the impact of trauma and responding in a trauma-informed way’ module. Reflective training sessions have been developed and delivered to allow staff to explore how they can take their online learning and apply it within their roles. Page 46
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APPENDIX 1 23 | P a g e Queries about trauma-informed practice, the applicability of courses and modules as well as expressions of interest to participate in the STILT programme are to be directed to the Trauma Lead Officer on TraumaInformedPractice@moray.gov.uk. New Procedures This quarter saw two new procedures ratified in relation to mini learning reviews and smoking, alcohol and substance consumption in care. The Mini Learning Reviews Procedure outlines the approach to undertaking rapid, single agency examination and exploration of decision-making, professional processes, outcomes of actions, chronologies of significant events, case recording, complaints investigations and correspondence. It forms part of the Service’s self-evaluation approach and applies when the criteria for multiagency full learning reviews have not been met. The Smoking, Alcohol and Substance Consumption in Care Settings policy has been developed to support the work of social workers within Moray Children and Families and Justice Social Work Service. Based on research, national and local drivers as well as benchmarking with other local authorities, it outlines tasks and expectations for staff, carers and adopters and aims to facilitate consistent experience for children, young people and their carers as well as to work towards positive health outcomes for children and young people in care settings. Training and Development The Social Work training calendar currently offers training in Action Plans, Chronologies, Continuing Care Procedures, Assessment, Personality Disorder, Contextual Safeguarding, Mental Health, Substance Use and Child Protection Processes. The training offer is under regular review with more areas to be developed in line with identified needs across the service. Monthly forums continue to run offering support to all newly qualified social workers and social workers in training across Children, Justice and Adult Services. These sessions are well attended with positive feedback being received. Throughout the second quarter, approximately a third of Children’s Social Work staff accessed training provided by the partnership. This training included: ➢ Gangs and County Lines ➢ Risk, Harm and Vulnerability ➢ Child Sexual Exploitation ➢ Graded Care Profile 2 Staff will have opportunities to benefit from training on professional communication skills and corporate parenting soon. Self-evaluation: complaints received and responded to between January and June 2025 The 6-monthly analysis of complaints that were received and responded to by the Children, Families and Justice Social Work Service is an established part of the service’s self-evaluation approach. Page 47
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APPENDIX 1 24 | P a g e Between January and June 2025, 30 complaints were received and responded to: 18 at Stage 1 and 12 at Stage 2. This is in line with the upward trend in the number of complaints indicated by longitudinal data (since Jan 2022), suggesting that responding to complaints is likely to place further pressure on the service, particularly in the light of the demands of Child Friendly Complaints. Whilst the number of complaints is steadily increasing, the number of upheld complaints has been on the decline, with this reporting period closing with zero fully upheld complaints and 5 upheld complaint points. The majority of these related to a lack of communication between the Service and people receiving it; this is in line with previous findings of thematic analysis. The importance of good and timely communication will be reiterated during relevant meetings and there is training in development in respect of professional communication skills. Children and Families and Justice Social Work Commissioning The Commissioning team in Children, Families and Justice Social Work leads and oversees eight key areas of service contracts. Pie chart 9 below illustrates FQ2 spend distribution: Pie chart 9: Percentage of Spend during FQ2 The individual contracted service areas will be discussed next in turns. Family Support Services The family support services area, accounting for 9% of the spend, consists of: 1. Independent advocacy service 2. Three support services for prevention and early intervention: 2.1 Families Together 2.2 Functional Family Therapy 2.3 Aberlour Youth Point Moray. Page 48
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APPENDIX 1 25 | P a g e 1. Independent advocacy Moray’s Children’s Rights Service, delivered by Quarriers, provides advocacy and support to all young people in Moray, as well as their parents, carers, brothers and sisters. During this quarter, the service received 54 new referrals: 37 for children and young people and 17 for parents, carers, brothers and sisters. This represents an increase compared to the previous quarter, as illustrated in graph 29 below: Graph 29: Independent Advocacy per number of people from 2023 to 2025 Notably, this quarter recorded higher proportion of referrals for children and young people compared to parents, carers and brothers and sisters, changing the pattern observed over the past three quarters increase in referral for children in need of protection and their families. While overall referral numbers have remained consistent, the volume of young people, parents and carers receiving ongoing support has steadily increased. Further, only a low number of individuals exits the service, indicating that once relationships are established, support is sustained across multiple meetings and circumstances. In FQ2, 196 young people and 169 parents, carers and brothers and sisters were receiving support. This means that the overall workload of the service is growing, as illustrated in graph 30 below: Page 49
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APPENDIX 1 26 | P a g e Graph 30: Advocacy Caseloads from 2023/24 to 2025/26 Graph 31 below provides details of the types of meetings supported advocacy services: Graph 31: Types of Meetings Supported Quarriers provides advocacy and support to ensure that children, young people, and their parents or carers have their voices heard in a wide range of situations. The accompanying graph illustrates the number of professional meetings attended by Quarriers this quarter, further broken down into Social Work, Education and Health-led meetings, where they advocated on behalf of children, young people and their families. 2. Prevention and early intervention services The three prevention and early intervention services—Aberlour Youth Point, Families Together, and Functional Family Therapy—provided support to a total of 115 children, young people, and their families during this quarter. 2.1. Aberlour Youth Point Moray Aberlour Youth Point Moray provides targeted support for children and young people who face challenges in maintaining positive engagement at home, school or within their community. The service also extends support to parents and carers of the children and young people involved. Throughout their engagement with the service, young people assess their progress against SHANARRI indicators at the initial meeting and at regular intervals thereafter. The scores are provided on a 5-point scale, where 1 identifies an area for improvement and 5 shows an area where things are going very well. Page 50
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APPENDIX 1 27 | P a g e Graph 32 below outlines the service impact outcomes for every young person who received support in this quarter. Overall, most of them indicated maintained or improved scores, demonstrating the sustained benefits of the support provided: Graph 32: Service Impact Outcomes Four young people completed their engagement with the service during this time. The scores they provided at the beginning and at the end of their journey indicates improvements in most areas, indicating the positive impact of the service, as illustrated in the graphs below. Positive qualitative feedback corresponds with the impact identified above; as indicated by the quote on the right. 2.2. Families Together This restorative family service, delivered by Children First, provides a range of supports, including one to one and group sessions, family focussed money advice service, practical assistance (e.g., food parcels and school bank referrals) and the Family Group Decision Making approach. Through the financial worker, two families achieved significant financial improvements, including gains of £1,364 and the management of £830.60 debt. Four families completed their time under the family support work with Children First during this quarter. Page 51
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APPENDIX 1 28 | P a g e 2.3 Functional Family Therapy Functional Family Therapy (FFT) is a short term, strengths-based programme designed to help families improve communication and relationships, with the goal of keeping them together. Currently, 17 families are receiving support through this service. During this quarter, two families completed their work with the Action for Children service. The graph below presents outcome measures assessed at the conclusion of their engagement. These scores, rated by young people, parents, and therapists, cover six key areas and are measured on a five-point scale, where a score of 3 or above represents a significant clinical outcome: Graph 33: Clinical Outcome Measures Graph 34 below illustrates the impact of FFT showing progress from averaged initial scores provided by the young people and their families at the start of the intervention to the final scores at its conclusion. These results indicate an overall reduction in the young people’s emotional difficulties because of the intervention: Graph 34: Outcomes by Support Area Pre & Post Service The two families who finished the FFT programme this quarter, had initially been assessed as “likely” and “highly likely” at risk of family breakdown. On completion this risk reduced to Page 52
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APPENDIX 1 29 | P a g e “very unlikely”. The quotation on the left highlights the positive changes experienced by one parent. Support for Unpaid Carers Delivered by Quarriers, this service accounts for 3% of the total Q2 expenditure and fulfils statutory obligations under The Carers (Scotland) Act 2016. Out of area care via Scotland Excel and Moray frameworks Out of area care via Scotland Excel and Moray frameworks accounted for 60 percent of the total spend in FQ2. The number of children in the various types of care arrangements are outlined in table 1 below: Table 1: Care by Type, Commission Type and No of Children Type of care arrangement Number of children Q1 Q2 Residential care commissioned through the Scotland Excel Residential framework 12 16 Residential care with 2 providers commissioned via Moray frameworks 7 7 Foster care commissioned through the Scotland Excel Fostering and Continuing Care Framework 7 9 Local Residential Care Accounting for 14% of the spend, residential care is provided to eight young people by Action for Children across two homes in Moray. This is a static number, as eight beds are commissioned through this contract. Children with a Disability – Residential Services Page 53
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APPENDIX 1 30 | P a g e The Scotia residential service, accounting for 9% of the spend, is delivered by Aberlour Childcare Trust in Alba Place, Elgin. Currently, three young people benefit from this service. Monitoring arrangements confirm these children are fully supported, maintaining relationships with family and friends, and enjoy a wide range of inclusive community activities. The quote from a parent on the right exemplifies the positive impact of the service and their commitment to maintaining relationships with the wider family and friends. Children with a disability- support services Commissioned services supporting children and young people with disabilities account for 4% of the total expenditure and consist of two services, a short breaks provision and group activities service. Short Breaks Services This contract provides day care and overnight short breaks for 12 young people. They deliver 15-day care sessions and (on average) 21 overnight sessions per month. This allows a break for the family, the benefits of which is deemed positive, as demonstrated by the quote on the right. Group Activities A total of 40 sessions were delivered during this period, comprising 15 summer, 13 weekend and 12 after school sessions. In total, 80 hours of service delivery provided across two locations in Moray, with plans to expand as referrals from other localities increase. The accompanying quotation from a parent of a young person who accessed the service this quarter highlights the positive reception and impact of these sessions. Page 54
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 26 FEBRUARY 2026 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 and note this audit update. 3. BACKGROUND 3.1 Global Internal Audit Standards (GIAS) require the Chief Internal Auditor to prepare and present reports to committee on internal audit’s activity relative to the audit plan and on any other relevant matters. 4. KEY MATTERS RELEVANT TO RECOMMENDATION Audit Plan 2025/26 4.1 I am pleased to report that the Audit Plan for 2025/26 is nearing completion. The reviews of Complex and Challenging Needs Services and non-payroll expenditure to test compliance with Financial Regulations and Procurement Regulations have been completed. The remaining review of Social Care Financial Assessments/Contributing to Your Care is progressing and is expected to be completed by 31 March 2026. Follow Up Reviews 4.2 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 reviews: Item 7. Page 55
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Moray Integrated Community Equipment Store 4.3 An audit was previously undertaken of the Moray Integrated Community Equipment Store. This Store manages aids and equipment to assist individuals with daily activities such as cooking, dressing, and bathing. Items range in value from a few pounds to over £1,000 for specialised equipment like hoists and seating. A key feature is the return and reuse of equipment, which is decontaminated when possible. The follow-up review noted progress on previous recommendations, but some remain outstanding and require revised implementation dates. The Follow-Up Report, which evaluates the implementation of the agreed recommendations, is provided in Appendix 1. 4.4 Banking and Reconciliation A follow-up review assessed the implementation of recommendations from the audit of the Council’s banking and reconciliation arrangements. The Council operates three main bank accounts to manage significant incoming funds, and the audit examined processes to ensure timely and accurate reconciliation. The original report highlighted the need for some administrative improvements. The follow-up review confirms that all recommendations have now been implemented. The Follow-Up Report is provided 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 the Global 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. Page 56
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(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 57
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Appendix 1 Moray Council Internal Audit Section 1 DEPARTMENT: Health & Social Care Moray SUBJECT: Moray Integrated Community Equipment Stores REPORT REF: 24'013 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: Effective systems and procedures operating to ensure accurate records are maintained to account for all Occupational Therapy equipment held within Stores and issued to Service Users 5.1 A full stock check should be undertaken to ensure records correspond to the actual number of items held within Stores. High Yes 31/03/2024 Implemented – The review confirmed that Stores officers completed a full stock check after implementing new stock management arrangements. The stock take was verified by an officer from the Internal Audit Section with only minor variances noted between system recorded figures and the actual stock held. Page 58
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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 Items of equipment should be kept wherever possible in Asset Number order within the Stores Building. Asset Numbers should be clearly recorded where possible on shelving. Medium Yes 31/03/2024 Variances were investigated and explanations obtained. Implemented - Asset numbers are now clearly recorded on shelving used for storing equipment. Shelf locations across the store have also been added to the Stores Software Application (ELMS). 5.2 The software application used for purchasing equipment should be regularly updated with the stock issued to ensure an accurate unit price is maintained. Further exploration should be undertaken of ELMS with the purpose of enabling the direct purchase of Medium Medium Yes Yes 31/03/2024 (Revised Implementation Date 30/06/2025) 31/10/2024 (Revised Implementation Implemented – The follow-up review found that the separate stores management software application used for purchasing occupational therapy equipment is now being updated when items are issued, to ensure accurate stock valuation. Part Implemented – The follow-up review found that while the purchasing of occupational therapy equipment is still Page 59
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Appendix 1 Moray Council Internal Audit Section 3 Risk Ratings for Recommendations High Key controls absent, not being operated as designed or could be improved. Urgent attention required. Medium Less critically important controls absent, not being operated as designed or could be improved. Low Lower level controls absent, not being operated as designed or could be improved. No. Audit Recommendation Priority Accepted (Yes/ No) Date of Completion Status / Explanation equipment. Date 30/11/2025) undertaken through a separate stores management software application, the Service is working with the ELMS software provider to develop an accurate stock valuation function. This is nearing completion. A revised implementation date of 30/11/2025 has been agreed with the Service. 5.3 A review should be undertaken of the current policy of revaluing re-used items of equipment at 50% of the original unit price. Medium Yes 31/01/2024 (Revised Implementation Date 30/06/2025) Implemented – It has been agreed by senior management within the service to revalue re- used equipment at 50% of the original purchase price has been reviewed and it has been decided to continue with the policy of 50% revaluation. 5.4 Users of the Service should be advised that any equipment received should be included within their personal property content insurance. Medium No 31/01/2024 (Revised Implementation Date 30/06/2025) Not Implemented – The Service has decided that individuals will not be required to include occupational therapy equipment under their personal property contents insurance. However, individuals will be advised to inform Page 60
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Appendix 1 Moray Council Internal Audit Section 4 Risk Ratings for Recommendations High Key controls absent, not being operated as designed or could be improved. Urgent attention required. Medium Less critically important controls absent, not being operated as designed or could be improved. Low Lower level controls absent, not being operated as designed or could be improved. No. Audit Recommendation Priority Accepted (Yes/ No) Date of Completion Status / Explanation their insurer if the equipment has a structural impact on their property. 5.5 Maximum and minimum stock levels should be implemented in ELMS to assist officers in ensuring the effective management of stock levels. Medium Yes 31/03/2024 Implemented - The review has confirmed that maximum and minimum stock level functions are now used within ELMS. The Service also intends to review these stock level parameters regularly. 5.6 A record should be maintained of the stock checks undertaken, and any adjustments to stock figures for equipment recorded within ELMS should require the authorisation of the supervisor. Medium Yes 31/01/2024 Implemented – Records of weekly stock checks are now maintained. It was also confirmed that adjustments to stock levels within ELMS can now only be authorised by Supervisory Officers. 5.7 In regard to the stock of returned specialised chairs noted during the audit review, a decision should be undertaken regarding their future use. Medium Yes 31/03/2024 Implemented - The Service has decided to retain the chairs. A meeting between officers from the Equipment Stores of Aberdeen City, Aberdeenshire and Moray agreed to explore options regarding the use of these chairs and Page 61
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Appendix 1 Moray Council Internal Audit Section 5 Risk Ratings for Recommendations High Key controls absent, not being operated as designed or could be improved. Urgent attention required. Medium Less critically important controls absent, not being operated as designed or could be improved. Low Lower level controls absent, not being operated as designed or could be improved. No. Audit Recommendation Priority Accepted (Yes/ No) Date of Completion Status / Explanation other equipment within the Grampian area. In addition, the Service has advised that the chairs could be adapted to meet the specific needs of individuals, potentially providing an alternative to procuring new items. 5.8 Further development should be undertaken of ELMS to enable greater use of the software application in the management of stock items. Medium Yes 31/03/2024 Implemented – It was found that the Service is making greater use of the reporting functions within ELMS. In addition, data from ELMS is exported to another software application to allow for greater analysis of information. 5.9 Officers should be instructed to utilise the facility within ELMS to mark stock as out for delivery. Low Yes 30/06/2024 Implemented - Procedures are now in place requiring drivers delivering equipment from Stores to mark equipment as out for delivery within ELMS. 5.10 A review of off contract expenditure should be carried out and where necessary contracts developed. Low Yes 31/03/2024 Part Implemented – A review by the Service of expenditure to identify off-contract purchases has been completed. This review Page 62
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Appendix 1 Moray Council Internal Audit Section 6 Risk Ratings for Recommendations High Key controls absent, not being operated as designed or could be improved. Urgent attention required. Medium Less critically important controls absent, not being operated as designed or could be improved. Low Lower level controls absent, not being operated as designed or could be improved. No. Audit Recommendation Priority Accepted (Yes/ No) Date of Completion Status / Explanation (Revised Implementation Date 30/06/2025 Revised Implementation Date 31/10/2025) highlighted the procurement of specialised chairs, for which a formal contract arrangement is required. A revised implementation date of 31/10/2025 has been agreed with the Service. 5.11 Current operating practices should be recorded within a Service Operating Manual. Medium Yes 31/03/2024 Implemented - Operating Procedures are now in place to provide officers with a point of reference guidance in the administration of the Moray Integrated Community Equipment Store. 5.12 A review of service procedures should be undertaken to ensure the store is informed of a change in circumstance in a service user’s condition where an item of equipment may no longer be required. Medium Yes 29/02/2024 Implemented - The Moray Integrated Community Equipment Service is informed of equipment issued to an individual but is no longer required. Testing has confirmed that when informed, arrangements are made for the collection of this equipment. Page 63
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Appendix 1 Moray Council Internal Audit Section 7 Risk Ratings for Recommendations High Key controls absent, not being operated as designed or could be improved. Urgent attention required. Medium Less critically important controls absent, not being operated as designed or could be improved. Low Lower level controls absent, not being operated as designed or could be improved. No. Audit Recommendation Priority Accepted (Yes/ No) Date of Completion Status / Explanation Arrangements should then be undertaken for collection at the earliest opportunity. If no agreement can be made for an item of equipment to be returned to the store, consideration should be given to invoicing the service user. Medium Yes 31/01/2024 (Revised Implementation Date 30/11/2025) Part Implemented – The Service agreed that where no agreement can be reached for the return of equipment, consideration will be given to invoicing the cost of the item. However, this follow-up review found that the Service has not finalised the arrangements for undertaking this process. A revised implementation date of 30/11/2025 has been agreed with the Service. 5.13 Improvements identified to the Service during the audit review regarding the physical security of the Moray Integrated Community High Yes 31/03/2024 Implemented - A new alarm system has been fitted at the Moray Integrated Community Equipment Store and is now in operation. Page 64
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Appendix 1 Moray Council Internal Audit Section 8 Risk Ratings for Recommendations High Key controls absent, not being operated as designed or could be improved. Urgent attention required. Medium Less critically important controls absent, not being operated as designed or could be improved. Low Lower level controls absent, not being operated as designed or could be improved. No. Audit Recommendation Priority Accepted (Yes/ No) Date of Completion Status / Explanation Equipment Stores building should be implemented as a matter of urgency. Page 65
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Appendix 2 1 Final Internal Audit Report (Follow Up) Banking and Reconciliation September 2025 Distribution: Chief Financial Officer Assistant Manager – FMS & Banking 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 Full Priority 1 0 Priority 2 0 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. Page 66
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Appendix 2 2 Contents Page Banking and Reconciliation 1. Introduction & Scope 3 2. Key Issues 3-4 Detailed Report 3. Findings/Recommendations 5-8 4. Management Response 6-9 5. Follow Up Review 7-9 Appendices 1. Audit Terms of Reference and Definitions 2. Statement of Responsibility Page 67
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Appendix 2 3 1. Introduction and Audit Scope The 2025/2026 annual audit plan provides for a review to be undertaken of the Council's banking and reconciliation arrangements. Bank reconciliation is the process of matching the balances in an organisation's accounting records to the corresponding information on a bank statement. The aim of a bank reconciliation process is to ascertain the differences between the two and make appropriate adjustments to the accounting records to ensure accurate reflection of transactions and balances. The audit scope was to obtain assurance that an effective and systematic methodology is in place to ensure accurate and timely reconciliations are undertaken of the Council's main bank accounts for the receipt of income. This involved a review of the operating procedures, verification and testing of the reconciliations undertaken and the administration of suspense transactions where income has not been immediately identifiable on receipt. The audit has also involved undertaking a review of the Council's banking arrangements. The Council operates three main bank accounts for administering income received and these have been reviewed during the course of the audit. Focus has also been given to the processes for Funds In Transit collections to ensure that all monies received are identified and remain accounted for at all stages between collection and lodgement into the Council's bank accounts. The Council collects a significant and diverse range of income categories, such as Council Tax and Non-Domestic Rates, Housing Rents, Planning Fees, charges for Waste Services, and also encompasses funding of the Council through grant receipts and revenue support. The audit has involved interrogation of the Council's Financial Management System used for accounting and bank reconciliation purposes and the Capita Income Management System used to provide logs and breakdowns of income received by services. The audit was carried out in accordance with the Global Internal Audit Standards (GIAS). 2. Key Issues • The audit confirmed that monthly bank reconciliation exercises are undertaken for all Council bank accounts. However, it was noted that the certification by management of these monthly reconciliations is not retained beyond 28 days within the SharePoint Workflow System. The certification by management of the monthly bank reconciliation exercises should be retained to ensure evidence of an audit trail is Page 68
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Appendix 2 4 maintained of the scrutiny for a core financial control. • Overall, the audit found that within the scope of the review, effective banking and reconciliation arrangements were in place for all income received. It should be noted that significant funds are collected annually through the Council's bank accounts, e.g., in 2024/25, approximately £225 million in Government funding, £196 million in services fees and charges and £51 million in Council Tax. However, at the time of the audit, 18 entries, totalling £40,900 of income, were found to have remained unallocated to accounting codes within the Financial Management System for over one month, the oldest transaction being 2 months old. To ensure accounting records are accurate and reflect current transactions, income received should be allocated to the appropriate financial code at the earliest opportunity. Page 69
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5 Findings/Recommendations - Banking and Reconciliation 2025/26 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 1 Low When income is received, a unique reference is required to identify the source and post it to the correct customer account, and/or accounting code within the Financial Management System's general ledger. However, instances occur where income received into the Council's bank accounts either does not have any source reference, the reference quoted is invalid, or the income represents a miscellaneous receipt, such as a payment received that is not associated with a particular invoice. In these circumstances, an unreconciled item is created within the bank reconciliation process, as the amount will be reflected in the Council's bank account as received but cannot be correspondingly recorded within the Council's financial accounts until a manual identification is made, which allows posting to the correct customer account and / or accounting code. Additionally, identifying breakdowns should be provided by services for Funds In Transit which are accounted for at point of collection, before lodgement into the Council's bank account. The Unallocated income must be identified in a timely manner to allow accurate financial recording within the Council's general ledger. Services should be reminded of the need to provide income detail on a prompt basis. Any receipts not able to be identified within a reasonable timescale should be returned to the bank to progress to a conclusion. Page 70
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6 non-provision of this information also creates an unreconciled item which cannot be recorded within the Council's financial accounts. Overall, from the audit testing undertaken of the bank account reconciliation processes, effective management arrangements were found, where significant funds are identified and reviewed promptly to ensure that monies received are accounted for and allocated correctly to the appropriate accounting code within FMS. However, at the time of the audit, 18 entries, totalling £40,900 of income, were found to have remained unallocated within the FMS for over one month, the oldest transaction being 2 months old. For accurate and timely recording of income in the Council's accounting records, it is important that the source of the monies received is identified at the earliest opportunity. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Assistant Manager – FMS & Banking Yes 31/08/2025 All income will be allocated within 1 month of receipt which will allow ample time for identification. Any income remaining Page 71
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7 unidentified after 1 month will be returned to the originating source by the Council's Bank. Follow Up Review Implementation Status Revised Implementation Date Internal Audit Review Outcome Implemented N/A All unreconciled income noted at the time of the audit has now been allocated appropriately. Streamlined processes are in place to escalate coding queries with services and obtain identification and reallocation within the timescale of one month from receipt of income. Page 72
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8 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 2 Low The Council operates three main bank accounts for the administration of income received and these have been reviewed as part of this audit. On a daily basis, reconciling tasks are being undertaken by the Banking Team within the bank reconciliation module of FMS to ensure funds received are appropriately allocated and accounted for. Every month, a full formal reconciliation of each bank account is undertaken and is checked and approved by the Assistant Manager - FMS & Banking, within the SharePoint Workflow system. Audit testing noted that the evidence of authorisation within the SharePoint Workflow system is deleted after 28 days. An improvement to the process is required to ensure that evidence of all bank reconciliation checking and approval by service management is retained for reference purposes. Monthly bank account reconciliations should be signed and dated to retain evidence of the checks and approval undertaken by management of a core financial control. Page 73
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9 Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Assistant Manager – FMS & Banking Yes 31/08/2025 All bank reconciliations will continue to go through the SharePoint Workflow system. In addition, the approving manager will add their signature and date to the file to preserve the evidence of authorisation when the file moves to the SharePoint records site. Follow Up Review Implementation Status Revised Implementation Date Internal Audit Review Outcome Implemented N/A From July 2025 onwards, a process has been implemented of the approving manager signing and dating all monthly bank reconciliations on validation, therefore retaining evidence of authorisation. Page 74
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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 75
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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 Service Manager Internal Audit and Risk. Page 76
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 26 FEBRUARY 2026 SUBJECT: INTERNAL AUDIT SECTION COMPLETED PROJECTS REPORT BY: CHIEF INTERNAL AUDITOR 1. REASON FOR REPORT 1.1 To provide an update on audit work completed since the last meeting of the Committee. 2. RECOMMENDATION 2.1 Committee is asked to consider and note this audit update. 3. BACKGROUND 3.1 Global Internal Audit Standards (GIAS) require the Chief Internal Auditor to prepare and present reports to the committee on internal audit’s activity relative to the audit plan and any other relevant matters. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 In line with the approved Internal Audit Plan, the following reviews were completed: Absence Management 4.2 An audit was undertaken to review the Council’s sickness absence management arrangements, including those relating to officers working under the direction of the Moray Integration Joint Board (MIJB). The scope of the audit examined whether the Council has adequate and appropriate policies, procedures, and controls in place for managing sickness absence. The review involved testing a random sample of employees on sick leave to assess compliance with the requirements set out in Council policies and guidance. 4.3 The audit found that the Council promotes employee well-being and has established comprehensive guidance, including the Health and Work Policy, Guidance on Managing Sickness Absence and the Sickness Absence Item 8. Page 77
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Notification and Certification Guide. These documents provide clear instructions for managing absence and minimising service disruption. However, a review of the average number of days lost through sickness absence per employee showed an increase in recent years. Audit testing of a sample of employees on sick leave found that management interventions, and/or the timing of those interventions, were not always in accordance with the Health and Work Policy. These variances were found to be less significant for officers working under the direction of the MIJB. The findings and recommendations are detailed in the audit report in Appendix 1. Complex and Challenging Needs Service 4.4 An audit was undertaken to review the Complex and Challenging Needs Service. The scope of the audit was to review the systems and procedures for delivering and managing the Service, specifically at the care facilities in Elgin and Lhanbryde. This was an audit of the administrative arrangements and not an assessment of the quality of care provided. Findings from the review noted a significant and ongoing reliance on overtime payments to officers supporting the care needs of individuals. As with other care providers, difficulties in recruiting staff have been experienced, which management has acknowledged. Additional measures have now been introduced, including the establishment of a short-life working group to seek solutions and support the Service's ongoing staffing challenges. Recommendations have also been made regarding financial administration, including the consideration of more formalised banking arrangements to manage the personal funds of supported individuals. The findings and recommendations are detailed in the audit report in Appendix 2. Procurement and Creditor Payments 4.5 Included in the Audit Plan for 2025/26 is a project to review payments made to suppliers of goods and services processed through the Council’s Financial Management System (FMS). The purpose of the audit was to review a key function of the FMS: ensuring the accurate payment and recording of expenditure. In addition, analysis and sample testing of invoices were undertaken to verify compliance with Financial, Authorisation, Procurement and Creditor Payment Processing Regulations and Guidelines. 4.6 Findings from the audit review confirmed that payments were accurately recorded and processed in FMS. However, testing identified instances of non- compliance with Financial Regulations and Value Added Tax Regulations, as well as one significant duplicate payment. The findings and recommendations are detailed in the audit report in Appendix 3. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Moray Partners in Care 2022-2032” Internal audit work supports good governance and assists in securing appropriate systems of internal control. Page 78
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(b) Policy and Legal The internal audit service is provided in terms of paragraph 7:1 of the Local Authority Accounts (Scotland) Regulations 2014, and there is a requirement to provide a service in accordance with the Global Internal Audit Standards. (c) Financial Implications No implications directly arising from this report. (d) Risk Implications and Mitigation Audit reports highlight risk implications and contain recommendations for management to address as a means of mitigating. (e) Staffing Implications No implications directly arising from this report (f) Property No implications. (g) Equalities/ Socio Economic Impacts No implications. (h) Climate Change and Biodiversity Impacts None directly arising from this report. (i) Directions None arising directly from this report. (j) Consultations There have been no direct consultations during the preparation of this report. 6. CONCLUSION 6.1 This report provides Committee with a summary of findings arising from audit project completed during the review period. Author of Report: Dafydd Lewis, Chief Internal Auditor Background Papers: Internal Audit Files Ref: Page 79
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Appendix 1 1 Final Internal Audit Report Absence Management October 2025 Distribution: Executive Director Education, Housing & Communities Head of Human Resources, ICT and Organisational Development 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 Limited Priority 1 2 Priority 2 8 Priority 3 1 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. Page 80
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Appendix 1 2 Contents Page Absence Management 1. Introduction & Scope 3-4 2. Key Issues 4-5 Detailed Report 3. Findings/Recommendations 6-30 4. Management Response 7-31 Appendices 1. Audit Terms of Reference and Definitions 2. Statement of Responsibility Page 81
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Appendix 1 3 1. Introduction and Audit Scope The Annual Internal Audit Plan for 2025/26 provides for a review of the sickness absence management arrangements of the Council, including those working under the direction of the Moray Integration Joint Board (MIJB). The most significant expenditure category within the Council is staffing, with annual spending of approximately £200 million in 2024/25. Effective staff absence management is crucial for maintaining service delivery, controlling costs and ensuring employee well-being. It impacts productivity, financial resources and the overall health of the organisation. There are legislative requirements for how the Council manages staff absence and in particular, sickness absence. In accordance with the Employment Rights Act 1996, the employer is liable to pay sick pay benefit or statutory sick pay to an employee who is incapable of work due to sickness or injury. The Health and Safety Executive expects employers to have policies and procedures in place for managing sick leave and return to work..The Moray Council has a Health and Work Policy. This Policy is intended to provide robust sickness absence procedures ensuring that, as far as possible, employees are supported and attendance at work is maximised. The Human Resources Service is responsible for authoring and updating the Health and Work Policy, where compliance by managers and officers is an important control to mitigate against several organisational risks, including: • Employment law breaches (unfair dismissal claims, disability discrimination claims). • Financial and operational risk (increased costs, inefficiencies, loss of public trust). • Reduced employee wellbeing and morale (negative workplace culture, exacerbation of health issues). • Inconsistent application of policies (employees lose confidence in fairness and reliability of management). • Missed opportunities for reasonable workplace adjustments A payroll and human resources software application called iTrent is used for recording and providing information on employee sickness absence. Approximately 3,725 full time equivalent (fte) are employed by the Council, which includes 804 fte working under the direction of the MIJB. At the time of this audit, there were 280 employees absent due to sickness (of which 67 were teaching staff). The Council, like other local authorities in Scotland, records the days lost through sickness absence per employee, which is then provided to the Local Government Benchmarking Framework (LGBF). The Improvement Service in Scotland administers the LGBF and is a tool for public performance reporting and can be used to drive improvement and accountability Page 82
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Appendix 1 4 within local government. Detailed below are the sickness days lost through sickness absence per employee within the Moray Council, against the Scottish average for all local authorities: Year Moray Council (Non- teaching) days lost through sickness absence per employee, per annum Scotland- wide average (Non teaching) days lost through sickness absence per employee, per annum Moray Council (teaching) days lost through sickness absence per employee, per annum Scotland- wide average (teaching) days lost through sickness absence per employee, per annum 2023/24 14.0 13.9 9.6 7.6 2022/23 12.8 13.3 7.9 6.8 2021/22 11.1 12.2 6.0 5.8 The scope of this audit assessed the adequacy of design and operating effectiveness of the key controls established to ensure cross-directorate adherence to the Health & Work Policy. The review involved the testing of procedures followed for a random sample of employees on sick leave to assess levels of compliance with this Policy. A similar absence management review of NHS contracted officers is subject to a separate review in 2025/ 26 to be undertaken by the NHS Grampian Internal Audit Provider. This review will be reported separately to the Audit, Performance and Risk Committee of the MIJB. The audit was carried out in accordance with Global Internal Audit Standards (GIAS). 2. Key Issues • The audit found that the Council has a range of employee wellbeing initiatives that can support effective strategies to manage staff absence, such as: ➢ Health and Work Policy and Guidances ➢ Structured return-to-work programmes including phased return, reasonable adjustments, etc ➢ Occupational Health provision promoting health and wellbeing ➢ Employee Assistance Programme promoting health and wellbeing. ➢ Employee wellbeing guidance including Mental Health and Wellbeing, Menopause Policy and Working Together for a Positive Workplace ➢ Staff Feedback e.g. employee surveys Page 83
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Appendix 1 5 ➢ Training on health and wellbeing including mental health ➢ Recognition programme (STAR awards) All of these represent good practice, yet the days recorded as lost through sickness absence per employee within the Council and reported to the LGBF detailed a ranking of 17th out of 32 Scottish local authorities for non-teaching staff and 29th out of 32 for teaching staff. In addition, audit testing of a random sample of employees on sick leave found that management interventions and/or the timings of these management interventions were not, in the majority of cases tested, in accordance with the Health and Work Policy or Guidances. • The Health and Work Policy, supported by Guidance to managing Sickness Absence and the Sickness Absence Notification and Certification Guide, provides detailed instructions for managing employee absence effectively and minimising disruption to services. In addition, the Policy and Guidances promote a healthy workplace and ensure consistent and fair treatment of all employees. However, the Health and Work Policy was last reviewed for update in 2018. It is appreciated that the Policy may still be appropriate; comparisons with similar policies in other organisations should be considered, to see if Councils with better performance have alternative or additional strategies in place for managing staff absence. • In addition to the documented Health and Work Policy and Guidances, the Human Resources Service provides regular training for managers to support their knowledge of managing sickness absence for employees within their service. Audit testing found that around 40% of managers had undertaken this training. Efforts to improve take-up of this course are required to provide managers with a greater understanding of how to proactively manage employee sickness absence and comply with legal obligations. Page 84
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6 Findings/Recommendations - Absence Management 2025/26 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 1 Medium In March 2018, the Council's Policy & Resources Committee approved the Health and Work Policy as part of the Policy Framework Review. The Policy records a review date of 2021; however at the time of the audit, no review had taken place. The Health and Work Policy provides detailed instructions for managing sickness effectively. However, from an overview of similar policies within other local authorities, consideration could be given to including further clarification or additional information, such as: . • Guidance in the event of a line manager vacancy, including delegation. • Data protection considerations • Clarifying the importance of applying for management discretion where appropriate. • Useful contacts and flow-charting illustrations. The Council's Health & Work Policy should be reviewed and updated, where required, to reflect current best practice and to ensure effective management and support for improvements in sickness absence. Thereafter, regular reviews should be scheduled. Page 85
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7 Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Head of People, Change & Community Strategy / Executive Director Education, Housing & Communities (interim arrangement until the appointment of the responsible officer) Yes 31/03/2027 The Health and Work Policy is part of the Council’s employment policy review framework. While a full review in 2021 was not undertaken, an initial assessment was completed that indicated there were other more urgent policy reviews required with no substantial change to legislation or best practice related to the Health and Work Policy at that time. In early 2020 the impact of Covid-19 was a significant factor in the management of attendance at work and absence was subject to interim arrangements and ongoing review. The policy has nonetheless been reviewed more recently as part of a review of operational management practice (2024) and research for other potential interventions (2025). The document version history will be updated to show the review work undertaken since 2018 and work will progress on the scheduled formal review during 2026/27, which is the soonest available opportunity. Page 86
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8 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 2 High The most significant area of expenditure within the Council and the Moray Integration Joint Board (MIJB) is staffing. In 2024/25, the Council’s annual staffing expenditure was approximately £160 million, while for the MIJB it was £40 million relating to Council employed officers. Although outside the scope of this review, it was noted that annual staffing costs within the MIJB relating to NHS Grampian employed officers were approximately 56 million for the same period. Effective management of staff absence is therefore crucial to maintaining service delivery, controlling costs, and supporting employee well-being. The Council has 3,725 full time equivalent (fte) contracted employees, including 804 fte who are working under the direction of the MIJB. Sickness absence arrangements for Moray Council are managed through the Health and Work Policy, which is supported by specific guidance covering areas such as sickness notification, handling short and long-term absences and conducting return-to-work discussions. Additionally, the Council has a contract with an external service provider for the delivery of an Employee Assistance Programme. This programme is designed to support staff well-being through services such as counselling, access to information and resources and general support/ guidance. The audit also found that the Human Resources Service offers effective support and advice to management regarding procedures to follow when an employee is absent due to sickness. Detailed on the next page are the sickness days recorded as lost through sickness absence per employee within the Moray Council, compared against the Scottish average for all local authorities, as provided to the Local Government Benchmarking Framework (LGBF). Page 87
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9 Year Moray Council (Non- teaching) days lost through sickness absence per employee, per annum Scotland- wide average (Non teaching) days lost through sickness absence per employee, per annum Moray Council (teaching) days lost through sickness absence per employee, per annum Scotland-wide average (teaching) days lost through sickness absence per employee, per annum 2023/24 14.0 13.9 9.6 7.6 2022/23 12.8 13.3 7.9 6.8 2021/22 11.1 12.2 6.0 5.8 The Local Government Benchmarking Framework (LGBF), developed and coordinated by the Improvement Service in Scotland, enables councils to compare their performance across various topics to facilitate service improvements and greater transparency. Employee sickness absence is one of the key performance indicators. The audit review notes that employee sickness absence within the Council has increased over the past few years, with currently a ranking of 17th out of 32 local authorities for sickness absence days among non- teaching staff, and 29th out of 32 for teaching staff. Enquiries noted that, in 2024/25, the Council recorded sickness absence rates of 15.7 days lost (per employee) for non-teaching staff and 10.8 days lost (per employee) for teaching staff. This reflects a further annual increase in employee sickness absence across both groups. An iTrent System report obtained at the time of the audit identified Page 88
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10 depression/stress/anxiety as the leading causes of sickness absence, accounting for approximately 30% of non-teaching staff and 45% of teaching staff. Risk Ratings for Recommendations Audit Finding Audit Recommendation 2 High The audit identified several areas where the Council promotes employee well-being and has established policies and guidance for effectively managing sickness absence, including: • Health and Work Policy, Guidance to managing Sickness Absence and Sickness Absence Notification and Certification Guide • Structured return-to-work programmes including phased return, reasonable work adjustments, etc. • Occupational Health provision promoting health and wellbeing • Employee Assistance Programme promoting health and wellbeing. • Employee wellbeing guidance including Mental Health and Wellbeing, Menopause Policy and Working Together for a Positive Workplace • Staff Feedback e.g. employee surveys The Council's Health and Work Policy, in conjunction with other employee wellbeing initiatives, provides direction that supports effective strategies for managing both short-term and long-term absences. However, from the audit testing undertaken, managers should be reminded of the need to comply with the requirements of the Health and Work Policy with specific reference to actions and timescales detailed within the Formal Absence Review Meetings framework. The audit review noted that the days lost through sickness absence per employee within the Council have been increasing over recent years. It is appreciated that there will be a cost implication, but consideration should be given to the further development of the iTrent system, which could streamline HR processes, improve workforce management and Page 89
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11 • Training on health and wellbeing including mental health • Recognition programme (STAR awards) and the wider employee engagement programme The Health and Work Policy outline actions and timescales within a framework of “Formal Absence Review Meetings” for managing both short-term and long-term employee absence. It also specifies the communication requirements and the potential outcomes that managers may implement when supporting and managing employees on sick leave. The audit reviewed a sample of employees on sick leave to assess compliance with the Health and Work Policy. The sample was randomly selected across Council and MIJB services, and the following points were noted: • From the sample of employees reviewed who were on sick leave, it was found that more than three quarters of all cases reviewed had communication timelines and actions that were not in accordance with those set out in the Health and Work Policy. This relates to when and how provide enhanced management reporting to monitor policy compliance and the effectiveness of initiatives to reduce sickness absence. Page 90
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12 managers should contact staff to discuss proposed actions regarding their ongoing or previous sickness absence. Audit testing was undertaken on a random sample of staff across all services, and instances of non-compliance with the timescales and actions detailed within the Formal Absence Review Meetings framework of the Health and Work Policy were identified, particularly in relation to the form of communication and adherence to timescales, which ranged from a few weeks to several years, The findings are based on a random sample of employees on sick leave. The scope of the audit focused on compliance with the Health and Work Policy. However, the review found a lack of the reasons for delays in communication and the actions taken in managing staff sickness. It is acknowledged that the operational demands on managers’ time may affect their ability to meet the requirements of the Health and Work Policy. Page 91
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13 • Included within the sample were officers working under the direction of the MIJB. Testing identified similar issues regarding adherence to the timescale and communication requirements detailed within the Health and Work Policy; however, the variances were not considered as significant when compared with officers under the direction of the Council. A balanced audit view was applied to any variances identified during testing of actions taken by managers in the sample of employees reviewed on sick leave, against the timescales detailed in the Health and Work Policy. While it is recognised that the demands on Trade Unions are significant, audit testing also noted delays in the availability of a Trade Union representative to accompany employees on sick leave to Formal Absence Review Meetings. The assistance of officers within the Human Resources Service in responding to queries and confirming the findings was greatly appreciated. Staff absence is recorded through a software application called iTrent. However, from an overview undertaken of absence management Page 92
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14 policies within other Councils, it appears that greater use is made of software applications in the recording, reporting and management of staff absence. It is understood that consideration is being given to an additional module within iTrent to allow improved digitisation of current processes; it is anticipated this would have a positive impact but would require time and resources to implement the necessary changes. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Head of People, Change & Community Strategy / Executive Director Education, Housing & Communities (interim arrangement until the appointment of the responsible officer) Yes 31/12/2025 Reminders are sent to managers through trigger reports to support management action in accordance with the policy requirements and timescales. Training courses are routinely advertised and a Leadership Forum on 9 September 2024 focussed on the responsibilities and requirements of the policy. Further reminders will be added into the HR Bulletin on a quarterly basis. Page 93
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15 Head of People, Change & Community Strategy / Executive Director Education, Housing & Communities (interim arrangement until the appointment of the responsible officer) Yes 31/12/2027 The need for improvement in absence management is acknowledged and has been under consideration by senior officers. As a result, it had been identified that action is required to fully understand the complexities and issues of absence management and to secure improvement. Therefore, work is underway to establish a transformation project aimed initially at improving absence within Education, where there is a large workforce and scope for improvement based on LGBF benchmarking. This will test out solutions that can be expanded to other services if successful. It is planned to report the proposal for approval to Council in December. Action is also underway to secure greater efficiency from the use of current technology. iTrent development is in the early stages of a transformation project, however, this is within the scope of the functionality currently within the Council contract which does include the system module recommended for development. Page 94
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16 To extend the use of the iTrent system to include greater absence analysis and case management would require the resourcing of an additional module for the system. This functionality would be a welcome development, however, a business case would be necessary to explore the extent to which it would provide a spend to save opportunity. Current resources are targeted to the council priorities in this area through the transformation programme: • improvement and enhancement of the current iTrent system functionality • improvements in the management of absence in accordance with the policy Following on from progress to deliver the benefits from the above two projects, consideration will be given to the benefits of a spend to save project to invest in an additional module for absence management. Page 95
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17 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 3 Medium As detailed previously, the audit reviewed a sample of employees on sick leave from across all services to ensure that the management of the absence was administered in accordance with the Health & Work Policy. While this policy is intended to be applicable to all staff, there are specific requirements for dealing with the absence of teaching staff set out in the Scottish Negotiating Committee for Teachers (SNCT) Handbook, which covers pay and conditions of service applicable across all Scottish councils. The SNCT is a tripartite body comprising representatives from teaching organisations, local authorities and the Scottish Government. The negotiated national framework for teachers’ pay and conditions of service includes provisions on sickness allowance. A review comparing the Council’s Health & Work Policy with the Scottish Negotiating Committee for Teachers (SNCT) Handbook identified differences in the actions required by the Council to support individuals on sick leave and in the authority of a Head of Education Clarification should be obtained, including from Legal Services, on whether the Council’s Health & Work Policy should be amended to reflect the differing conditions for absence management set out in the Scottish Negotiating Committee for Teachers (SNCT) Handbook. Page 96
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18 (Chief Education Officer) to extend the payment of sickness allowance. Discussions with Human Resources officers confirmed that these issues have been identified and that contact has been made with Legal Services to seek further clarification. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Head of People, Change & Community Strategy / Executive Director Education, Housing & Communities (interim arrangement until the appointment of the responsible officer) Yes Implemented Further discussions have now taken place with Legal Services regarding this issue. Following careful consideration, it has been agreed that no amendments should be made to the Health and Work Policy at this time. The Council’s approach to managing absence must allow for the individual circumstances of each case to be considered. Applying a blanket approach to a specific element, particularly one involving the interpretation of a national condition that would require a definitive ruling by a court or tribunal, does not allow for such consideration. No case has arisen to trigger this requirement to date, although it would be possible for there to be such a case in the future this Page 97
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19 is considered a low risk and could be dealt with if required. Page 98
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20 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 4 Low There is a Sickness Absence Notification and Certification Guide in place to support the Council's Health & Work Policy. The Guidance outlines the procedures and responsibilities for employees to notify their designated manager of a sickness absence. Within the Education Service, an additional section requires earlier notification to ensure sufficient notice for cover arrangements. However, no comparable requirement has been identified to ensure staff coverage in the delivery of other essential services, e.g., Health and Social Care. It is acknowledged that individual services have developed their own procedures for the notification of absence by officers. Consideration should be given to updating the Sickness Absence Notification and Certification Guide to include reference to service specific absence notification requirements, developed to address situations where staff are unavailable for work due to sickness. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Head of People, Change & Community Strategy / Executive Director Education, Housing & Communities (interim Yes 31/03/2027 Consideration of amending the Health and Work Policy as recommended will be taken forward as part of the scheduled policy review due to commence from April 2026. Page 99
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21 arrangement until the appointment of the responsible officer) Page 100
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22 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 5 Medium The Council has a contract with a company to provide an Occupational Health and Wellbeing Service (OH). The Health and Work Policy details when a referral regarding an employee’s sickness absence should be made to OH. On receipt of this referral, OH may be required to seek a “Specialist Report” concerning the employee’s condition from a General Practitioner or other specialist. A review of the contract between the Council and the OH company states that they “will endeavour to send Specialist Reports within 6 weeks of the date of request. It is acknowledged that Specialist Reports can take between 6 weeks and 3 months from the date of request.” Discussions with officers and audit testing found significant delays of up to 10½ months in the provision of these Specialist Reports. These delays may impact the ability to resolve issues concerning the employee's ongoing absence and may hinder an earlier return to work. In accordance with the contract between the Council and the OH company, there is a requirement for quarterly progress meetings. The delays in providing “Specialist Reports” within agreed timescales should be raised at these meetings and actions agreed with the OH provider to enable a timelier provision of these Reports in accordance with the conditions of the contract. Page 101
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23 Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Head of People, Change & Community Strategy / Executive Director Education, Housing & Communities (interim arrangement until the appointment of the responsible officer) Yes 31/12/2025 Following up on outstanding 3rd party reports will be added as a standing item on the regular contract management meetings. Where there are delays in securing 3rd party reports, in addition to pursuing through the OH provider, the employee concerned is asked to follow up through their medical team. If this is not successful, where necessary and possible, absence cases are progressed with the information that is available and this will continue to be emphasised to managers and HR advisers to avoid time delays wherever possible. Page 102
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24 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 6 Medium The Human Resources Service has developed a monthly reporting system called “Trigger Reports,” which are emailed to managers and detail officers within their service who are absent from work due to sickness. This is considered good practice, and testing confirmed consistent reporting by the Human Resources Service to managers of employees on sick leave within their service. However, a review of individual trigger reports noted that these reports only record an employee's details for the initial month of absence. If the employee remains absent in the following month, the manager will not be notified unless another employee within their service is absent, which then generates a further trigger report. While the demanding workloads of managers are appreciated, ongoing notification of an employee’s absence may assist in promoting a proactive approach to attendance management in accordance with the Health and Work Policy. Consideration should be given to ensuring that managers receive monthly Trigger Reports for all employees on sickness leave within their service for the duration of their absence. Page 103
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25 Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Head of People, Change & Community Strategy / Executive Director Education, Housing & Communities (interim arrangement until the appointment of the responsible officer) Yes 31/01/2027 Consideration of the viability and impact of this recommendation will be assessed following a period of 6 months initially (review scale of demand from administrative perspective) and 12 months for review of impact. Page 104
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26 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 7 Medium The Human Resources (HR) Service provides training courses (around 4 times a year) aimed at supervisors/managers who are responsible for managing employee absence. This is a half day course offering guidance on the principles and application of the Health and Work Policy. Testing was undertaken on a random sample of supervisors/managers responsible for the management of staff to ascertain whether training had been completed. The results of the testing undertaken revealed that around 40% of the supervisors/managers had undergone the training recently. For effective and consistent application of the Policy, all managers with line responsibilities for staff should be encouraged to participate in the training delivered by the HR Service. A reminder should be issued to all supervisors/managers responsible for staff management to attend training on the Council's Health and Work Policy. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Head of People, Change & Community Strategy / Yes 31/01/2026 Health at Work training courses are regularly advertised to managers, however Page 105
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27 Executive Director Education, Housing & Communities (interim arrangement until the appointment of the responsible officer) other options to promote the training will be considered e.g. adding a link to the manager induction course. Additional numbers can be accommodated within the scheduled courses with improved attendance. Page 106
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28 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 8 Medium It is pleasing to note that senior officers from the Human Resources Service scrutinise a monthly listing of the 10 employees with the highest sickness absence within the Council to ensure appropriate management actions are being taken in compliance with the Health and Work Policy. This process also helps identify where additional support may be required for a service and/or where further employee wellbeing measures are needed. This is considered good practice and supports effective absence management across the Council. A review of these monthly reports noted that the same employees can appear over consecutive months. The need to review the absences of employees with the highest number of sick days is acknowledged. However, consideration could be given to expanding the current selection criteria to include analysis of absence patterns, which may help identify potential workplace or individual issues. Consideration should be given to expanding the selection criteria for the monthly overview undertaken by senior officers in the Human Resources Service, regarding absence management actions taken for employees with the highest number of sickness absence days. Page 107
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29 Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Head of People, Change & Community Strategy / Executive Director Education, Housing & Communities (interim arrangement until the appointment of the responsible officer) Yes 31/03/2026 Consideration will be given to expanding the selection criteria for monthly overview and the usefulness of this combined with the additional demands on a small central team required to produce the data. Page 108
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30 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 9 Medium As detailed previously, the Council has a contract with a company to provide an Occupational Health and Wellbeing Service (OH). The audit checked that procurement and processing of payments to this company is in compliance with Financial Regulations and Procurement Guidelines. The following points were noted: • Invoices payable to the OH company are issued at the beginning of the month, resulting in payments being made in advance of the service delivery. Financial Regulations state that advance payments for goods or services are only permissible with the prior written consent of the Chief Financial Officer. This had not been obtained. • A check was made to ensure that the payments made to the OH company were in accordance with the contract. It was found that a price increase had been incorrectly applied to monthly invoices from July 2024, resulting in an overpayment of £2,464. In accordance with Financial Regulations, invoices should be paid to the OH company only after the service has been delivered, or written consent obtained in writing from the Chief Financial Officer to authorise the advance payment. Payments to the OH company should be made in accordance with the contract. The overpayment identified during the audit should be recovered at the earliest opportunity. Page 109
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31 Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Head of People, Change & Community Strategy / Executive Director Education, Housing & Communities (interim arrangement until the appointment of the responsible officer) Yes 31/10/2025 Invoices are currently being processed at the end of the month they pertain to. Discussion with the provider will take place to ensure invoicing is in line with the conditions of the contract. Arrangements have been made for recovery of the overpayment. Page 110
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32 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 the Global Internal Audit Standards (GIAS). 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 111
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33 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 Service Manager Internal Audit and Risk (CAE). Page 112
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Appendix 2 1 Final Internal Audit Report Complex and Challenging Needs Service September 2025 Distribution: Service Manager Provider Services Team Manager/Consultant Practitioner Complex and Challenging Needs 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 1 Priority 2 6 Priority 3 5 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. Page 113
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Appendix 2 2 Contents Page Complex and Challenging Needs Service 1. Introduction & Scope 3 2. Key Issues 3-4 Detailed Report 3. Findings/Recommendations 5-18 4. Management Response 6-19 Appendices 1. Audit Terms of Reference and Definitions 2. Statement of Responsibility Page 114
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Appendix 2 3 1. Introduction and Audit Scope The annual Internal Audit plan for 2025/26 includes a review of the Complex and Challenging Needs Service. This Service supports individuals with complex care needs at purpose built facilities in Elgin and Lhanbryde, as well as within their own homes across Moray. At the time of the audit, the care facility in Elgin provided support to four adults. The accommodation consists of a large bungalow with shared living rooms, a communal kitchen and a garden. The facility in Lhanbryde serves as the administrative base for the Service and supports eight individuals in separate, purpose built accommodation, with access to a communal area used for social activities. The overall budget for delivering the Complex and Challenging Needs Service in 2024/25 was approximately £7.7 million. The scope of the audit was to review the systems and procedures for delivering and managing the Complex and Challenging Needs Service, specifically at the care facilities in Elgin and Lhanbryde. This was an audit of the administrative arrangements, rather than an assessment of the quality of care provided. The Care Inspectorate in Scotland, as the national regulatory body for care services, is responsible for ensuring that care services meet the required standards. The audit focused on reviewing policies, procedures, and operating practices in the administration of the Complex and Challenging Needs Service, particularly in relation to budget management and the arrangements for assisting people in managing their personal funds. However, the audit did include a check to ensure that Support Plans for individuals supported by the service were reviewed in accordance with agreed timescales. The audit was carried out in accordance with Global Internal Audit Standards (GIAS). 2. Key Issues • The Complex and Challenging Needs Service provides 24-hour support to individuals with specific care requirements. The audit found that the Service has a number of staff vacancies and as with other care sectors, is experiencing difficulties in recruiting officers. Analysis of payroll expenditure indicated that the majority of officers are working additional overtime hours each week. Random testing of overtime claims noted that some officers who are supporting individuals are often working more than 60 hours per week. The audit notes the demands on the Service and the commitment of officers to support the care needs of individuals; however, it does question the sustainability of current working arrangements. Page 115
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Appendix 2 4 • The Service also supports people at both care facilities in managing their personal funds. Officers assist individuals with payments for groceries, utilities and other living expenses. Separate records are maintained for each individual and any cash held on their behalf is stored securely. Documented guidelines outline the procedures for officers in administering these funds; however, these guidelines have not been reviewed or updated for several years. Consideration should be given to transitioning from a cash-based system to individual bank accounts, which would allow for the introduction of additional controls. • This audit focused on the financial administration of the Complex and Challenging Needs Service. However, it also included a check to confirm that the Support Plans of individuals at both care facilities had been reviewed in accordance with agreed timescales. The audit found that the majority of care packages sampled had not been reviewed for over a year. In accordance with Health & Social Care Moray Eligibility Criteria Policy, there is a requirement for a Social Worker/Community Care officer to undertake annual reviews where support is provided to meet eligible needs, or more frequently as a response to a significant change in circumstances. Page 116
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5 Findings/Recommendations - Complex and Challenging Needs Service 2025/26 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 1 High Officers of the Service support individuals with complex care needs at the care facilities in Elgin and Lhanbryde, as well as within their own homes. A review of the staffing complement at the time of the audit identified significant vacancies. As with other social care providers, the Service is experiencing difficulties in recruiting officers. An analysis of payroll costs found that the majority of officers employed within the Service are working more than their contracted hours each week. Approximately £750,000 was paid in overtime during 2024/25. Audit testing of individual overtime claims, undertaken to verify accuracy and compliance with Financial Regulations, revealed that some Support Workers are regularly working in excess of 60 hours per week. While the audit acknowledges the commitment of officers to meeting the needs of individuals supported by the Service, it also raises concerns about the sustainability of the current working arrangements. The ongoing recruitment campaign for officers within the Complex and Challenging Needs Service should be maintained. Consideration should also be given to exploring alternative approaches to reduce the significant levels of overtime currently worked by some officers. Page 117
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6 Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Service Manager (Provider Services) Yes Ongoing A short-life working group will be established to seek solutions and support the ongoing staffing challenges facing the Service. Since the audit, there has been a reduction in vacancies at Woodview from 19.1 FTE to 10.6 FTE (as of 1st October), and at Barlink from 4.49 FTE to 0.45 FTE for Support Workers and 1 FTE for a Keyworker (as of 1st October). While the appointment of new staff will not have an immediate impact on reducing overtime, due to the requirement for training and shadow shifts, it is expected that, over time, this will lead to a decrease in overtime usage. In addition, a review of staffing arrangements is ongoing to identify improvements in service delivery. The combination of recent staff recruitment and a review of current service delivery methods is expected to support a significant reduction in overtime in the future. This will be closely monitored by senior management. Page 118
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7 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 2 Medium The audit reviewed a random sample of officers overtime and travel/expenses claims to verify their accuracy and ensure correct authorisation in accordance with Financial Regulations. Testing identified one case where an officer had submitted an overtime claim for 13.75 hours and a travel/expenses claim for 27 miles in advance of the date the work was to be undertaken. Further investigation found that the officer had neither worked the planned additional hours nor incurred the mileage claimed, due to sickness absence. This is not in compliance with Financial Regulations. The officer has since reimbursed the overpaid amount and the mileage claimed. The audit also found that approximately one-third of all travel claims submitted by the Service were not dated at the time of signing, either by the submitting officer or the authorising officer. In accordance with Financial Regulations, officers within the Complex and Challenging Needs Service should be reminded that claims for overtime and travel/expenses must only be submitted after the hours have been worked or the mileage incurred. Additionally, all travel/expenses claims must be dated at the time they are signed by both the submitting and authorising officers. Page 119
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8 Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Assistant Managers (Woodview) Service Manager (Provider Services) Yes Yes 30/09/2025 31/03/2026 All staff are to be informed, in accordance with the Financial Regulations, of the correct procedure for completing and submitting travel and expense claims. In addition, these requirements will be reminded during Supervision and Team Meetings. Digital solutions will be explored with the Payroll Service for submitting expenses claims. Page 120
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9 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 3 Medium A review was undertaken of non-staffing expenditure made by the Complex and Challenging Needs Service. This involved testing a random sample of payments to suppliers of goods and services and checking to ensure compliance with Financial Regulations and Procurement Guidelines. The review found that mostly correct procurement and authorisation processes had been undertaken. However, an example was noted where Guidelines had not been followed in the procurement for the purchase and installation of a bicycle shed to the value of £25,000. Officers involved in the purchasing of goods and services should be reminded of the need to comply with Financial Regulations and Procurement Guidelines. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Team Manager/Consultant Practitioner Residential Complex and Challenging Needs Yes Implemented A grant was secured for the bike shed, and all work was completed within the £25,000 grant allocation. Staff have been reminded of the requirement to comply with the Council’s Procurement Guidelines. Page 121
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10 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 4 Low Analysis of the Financial Management System indicated that the overall budget for delivering the Complex and Challenging Needs Service in 2024/25 was £7.7 million, with the majority of expenditure related to staffing costs. It was found that the staffing budget is regularly reviewed to ensure accuracy and alignment with the needs of individuals supported by the Service. However, a number of other non staffing budget headings that is not material in value e.g. non domestic rates, utilities and ad- hoc repairs had a budget allocation which did not correspond to actual expenditure incurred. A financial “housekeeping” exercise should be undertaken to review and adjust the budget allocations for non-staffing costs to better reflect current expenditure. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Team Manager/Consultant Practitioner Residential Complex and Challenging Needs / Accountant Yes 31/03/2026 The Service, in consultation with the Accountancy Section, will review the non- staffing budget to ensure it is more closely aligned with actual expenditure. Page 122
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11 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 5 Medium The audit visit to the care facility in Lhanbryde found that funds are held in both cash and within a bank account of monies collected through fundraising activities and donations. These funds are intended for the benefit of the people supported by the Service. The administrations of these funds are similar to the requirements of a Private Fund within a School. The audit checked the income and expenditure activity of these funds and undertook a reconciliation to confirm the accuracy of the monies held to supporting documentation. It is pleasing to report that no discrepancies were noted. However, there are no operating guidelines to support officers in the administrative requirements in the management of these funds. Guidelines should be developed detailing the administrative requirements in the management and accounting arrangements of monies held from fundraising activities and donations. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Assistant Managers (Woodview) Yes 31/03/2026 A financial procedure will be developed for the management and administration of Page 123
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12 Service Manager (Provider Services) Yes 28/02/26 funds collected from events, donations, and fundraising, as well as the expenditures used to benefit individuals using the service. This will include the opening of a new bank account (where an admin fee is not charged). A management panel will be established to oversee and agree the allocation of funds. Page 124
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13 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 6 Medium The audit review noted that officers at the care facilities support individuals in the management of their personal monies. Cash sums are stored securely for individuals at the care facilities and are used for purchases such as groceries, day trips, utility bills and other living expenses. Operating arrangements for administering these funds are detailed within the Financial Guidelines developed by the Service. The audit reviewed these arrangements, including a reconciliation of supporting documents to the cash held for a sample of individuals. The following points were noted: • Resident funds are administered in cash. Records are maintained to evidence and reconcile individual balances against the monies held. However, it is considered that the amounts of cash stored at the care facilities for some individuals exceed routine weekly expenditure requirements. Consideration should be given to implementing alternative methods for managing the personal funds of individuals, such as individual banking arrangements. Page 125
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14 • The Financial Guidelines document detailing the administration arrangements for individuals’ funds has not been reviewed or updated since 2022. The Financial Guidelines document for administering individuals’ funds should be reviewed and updated as required. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Assistant Managers (Woodview) Service Manager (Provider Services)/ Service Manager (Learning Disability) / Chief Financial Officer (MIJB) Yes Yes 30/09/2025 31/03/2026 The Financial Guidelines document for administering individuals’ funds will be reviewed and updated. A request will also be submitted to Community Finance for weekly cash uplifts, thereby reducing the amount of funds held within the service A review will be undertaken to explore alternative methods for managing the personal funds of individuals, including consultation with guardians, social work, and Finance. Page 126
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15 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 7 Low The audit visit to the care facility at Lhanbryde noted the provision of two petty cash accounts: an Adult Services account with an imprest amount of £250 and a Children’s and Young Persons account with an imprest amount of £120. The review found that the Adult Services account was well managed and operated in accordance with Financial Guidelines. However, further to discussions with officers indicated that greater use is now being made of the purchasing card. The Children’s and Young Persons petty cash account had not been used since 2022. This account was initially established to support a young person before they turned 18 and transitioned into Adult Services. Consideration should be given to closing both the Adult Services and Children and Young Persons petty cash accounts. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Assistant Mangers (Woodview) Yes Implemented Petty cash has now been closed for both services, and evidence of this closure has been submitted to Internal Audit. Page 127
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16 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 8 Medium The audit included a review to ensure that Support Plans for individuals at both care facilities had been updated to confirm that care and support continue to meet their needs and agreed outcomes. It was found that the majority of care packages sampled had not been reviewed for over a year. This finding has also been noted in other social care reviews to highlight the requirement for regular reviews of Support Plans for individuals receiving services. It is acknowledged that management at Health and Social Care Moray are aware of this issue and are progressing the necessary actions in accordance with the Eligibility Criteria Policy, which requires a Social Worker or Community Care Officer to undertake annual reviews where support is provided to meet eligible needs. Support Plans for users of the Complex and Challenging Needs Service should be reviewed at least annually in accordance with the agreed policy. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Service Manager (Learning Disability) Yes 31/12/2025 All out-of-date support plans to be updated. Page 128
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17 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 9 Low The care facility at Lhanbryde has one dedicated pool car that officers use to support individuals within the community. It was noted that the annual mileage used for this vehicle was approximately 7,000 miles in 2024/25. A previous audit of pool cars noted that best value is obtained when comparing the cost of purchasing and use of a pool car is achieved when mileage in excess of 12,000 a year is undertaken. Analysis of mileage claimed by officers of the Service when using their personal vehicles noted a cumulative total of approximately 17,000 in 2024/25. Increasing the use of the pool car may provide a financial saving to the Service. Consideration should be given to increasing the use of the available dedicated pool car by officers of the Service. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Assistant Managers (Woodview) Yes 31/01/2026 A review of the current pool car arrangements will be carried out, and a more proactive approach will be implemented for its use during care and support visits outside of Woodview, which currently incur a mileage charge. Page 129
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18 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 10 Low The care home facility at Lhanbryde operates a closed-circuit television (CCTV) system as an additional security measure for the property. The use of CCTV requires compliance with Data Protection Legislation, including the completion of a Data Protection Impact Assessment (DPIA). A DPIA is a structured process that systematically analyses the data protection risks associated with CCTV systems. It was found that no DPIA had been completed. Additionally, officers operating the CCTV at the facility had not undertaken the necessary training provided by the Council. It was also noted that the location of the CCTV monitor within the property is in an accessible area, which is not in accordance with Data Protection Legislation. . A Data Protection Impact Assessment (DPIA) should be completed for the care home facility at Lhanbryde. All officers operating CCTV must complete the Council’s CCTV training module. The location of the CCTV monitor within the property in Lhanbryde should also be relocated to ensure that footage can only be viewed by trained officers who require access as part of their duties. Page 130
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19 Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Assistant Managers (Woodview) Assistant Managers (Woodview) Yes Yes Implemented Implemented DPIA for the CCTV system at Woodview has been completed and approved. Training has been completed for all staff with access to the CCTV system at Woodview. In addition, access to the CCTV monitor at Woodview is now restricted. Page 131
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20 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 Global Internal Audit Standards (GIAS). 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 132
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21 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 Service Manager Internal Audit and Risk. Page 133
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Appendix 3 1 Final Internal Audit Report Procurement and Creditor Payments (Moray Integration Joint Board) January 2026 Distribution: Head of Service Health & Social Care (MIJB) Head of Service & Chief Social Work Officer Head of Education (Chief Education Officer) Team Manager Business Support Service Manager Finance Operations Social Work Service Manager Children & Families & Criminal Justice Social Work Interim Community Care Finance Manager Locality Manager West 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 2 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. Page 134
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Appendix 3 2 Contents Page Procurement and Creditor Payments (MIJB) 1. Introduction & Scope 3 2. Key Issues 3-4 Detailed Report 3. Findings/Recommendations 5-15 4. Management Response 6-15 Appendices 1. Audit Terms of Reference and Definitions 2. Statement of Responsibility Page 135
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Appendix 3 3 1. Introduction and Audit Scope The annual audit plan for 2025/26 includes coverage of the Council’s core systems. A review has been undertaken of payments made to suppliers of goods and services processed through the Council’s Financial Management System (FMS), but under the direction of the Moray Integration Joint Board (MIJB). The objectives of the audit review were not only to provide assurance over a key function of the FMS in the accurate processing and recording of expenditure, but also to test a sample of payments to confirm compliance with the Council’s Financial, Authorisation, Procurement, and Creditor Payment Processing Policies and Regulations. The findings from this review will be used to support the Service Manager Internal Audit and Risk in forming the annual opinion on the Moray Integration Joint Board’s internal control systems. The testing approach was developed using the Chartered Institute of Public Finance and Accountancy’s Control Matrices, in addition to consultation with the External Auditor. The audit reviewed a six-month period of non-payroll expenditure. During the sample period, total expenditure to suppliers of goods, works and services processed through the Financial Management System (FMS) was approximately £30 million. Data analytical software called IDEA was used to randomly select individual payments, stratified by financial value parameters, for testing. In addition, the audit analysed payments to identify any potential duplicate payments for further investigation. . The audit was carried out in accordance with Global Internal Audit Standards (GIAS). 2. Key Issues • The audit review confirmed that expenditure had been accurately recorded and processed through the Financial Management System (FMS). However, examples were noted where payments had been made in advance of services being delivered, without the required approval of the Council’s Chief Financial Officer. In addition, errors in the treatment of Value Added Tax (VAT) were noted, requiring recovery of the outstanding amount from His Majesty’s Revenue and Customs (HMRC). • The audit checked the sample period for potential duplicate payments. Using IDEA software, a report was generated to identify payments made to the same payee for identical amounts. It was noted that the majority of these related to recurring payments to social and educational care Page 136
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Appendix 3 4 providers. However, audit testing found a significant duplicate payment had been made to an educational care provider, for which recovery of the overpayment is now required. Further enquiries noted this had occurred due to an administrative error. Page 137
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5 Findings/Recommendations – Procurement and Creditor Payments (MIJB) Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 1 High Data analytical software called IDEA was used to review non-payroll expenditure made under the direction of the Moray Integration Joint Board (MIJB). This included the random selection of invoices for testing based on their financial value, as well as the identification of potential duplicate payments where the same amount was paid to the same individual, company, or organisation. Analysis of these potential duplicate payments found that the majority of identical payments made to the same payee related to recurring expenditure for the delivery of social and educational care. However, audit testing identified that a duplicate payment of £23,355 had been made in error to an educational care provider for the same service. Further investigation found this was the result of an administrative error, where a duplicate invoice had been processed incorrectly. In addition, the incorrect invoice number was recorded in the Financial Management System when processing the duplicate invoice, which resulted in the Officers responsible for administering the payment of invoices within Children and Families Services should be reminded of the correct procedures for processing and authorising payments and if required, further training should be provided. Action should be taken as soon as possible to recover the duplicate payment identified in this finding. Page 138
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6 transaction not being identified for further investigation. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Team Manager, Business Support Yes Implemented The duplicate payment has been recovered from the care provider and staff have been reminded of the importance of following the correct procedure when processing and authorising invoices for payment. Team Leader, Business Support will manage this going forward to ensure processes are adhered to for all future payments. Page 139
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7 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 2 Medium The audit checked a random sample of payments to verify the correct accounting treatment for Value Added Tax (VAT). No discrepancies were found in the majority of invoices reviewed; however, two paid invoices that included VAT, with a cumulative value of £9,274, had not been reclaimed from His Majesty’s Revenue and Customs (HMRC). Further enquiries found that this was due to an administrative error where the expenditure had not been correctly allocated between the financial codes for the budget cost centre and VAT within the Financial Management System. The Payments Section has been advised to correct the VAT error identified in the finding. Further instruction, and training if required, should be provided to the administrative officers who processed the invoices detailed within the finding to ensure the future correct accounting treatment of VAT. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Assistant FMS & Banking Manager Yes 30/11/2025 This has been corrected and the monies reclaimed from HMRC. A reminder has been issued to the administrative officer involved to ensure that VAT is treated correctly in future. Page 140
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8 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 3 Low The audit review noted cumulative payments totalling £30,000 to a charity in respect of grant match funding for a project supporting children and young people in Moray. Further investigation found this was part of a three‑year programme from 2022 to 2025. The importance of the funding objectives is recognised; however, payments had been made in advance of service delivery. While it is appreciated that there may have been operational requirements, Financial Regulations state, ‘expenditure shall not extend to making payments in advance of delivery of goods or services or completion of works or approved stages of works unless prior permission is obtained in writing from the Chief Financial Officer (CFO).’ Permission had not been obtained from the CFO. The nature of this expenditure is noted; however, in accordance with Financial Regulations, authorisation from the Council’s Chief Financial Officer is required if a payment is to be made in advance of the services being delivered. Page 141
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9 Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Social Work Service Manager, Children & Families & Criminal Justice Social Work Head of Education (Chief Education Officer) Yes Implemented Prior written approval will be sought from the Chief Financial Officer for any future purchases which require payment in advance. Page 142
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10 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 4 Low The review found during audit testing that some invoices from care providers and organisations contained personal and sensitive information about individuals receiving services, including names, dates of birth and home addresses. Data Protection Legislation requires organisations to ensure proportionality in the personal information they hold about individuals. Invoices should therefore include only the personal details necessary for legal, tax, or business purposes. Audit concerns regarding personal and sensitive information detailed on invoices received from some care providers and organisations have been raised with the Head of Service. It is acknowledged that invoices must clearly describe the services being procured. However, consideration should be given to contacting care providers and organisations to agree on greater use of unique reference numbers, thereby reducing the need to include personal and sensitive information about individuals on invoices. Page 143
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11 Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Interim Community Care Finance Manager Yes 05/12/2025 All care providers and organisations will be notified that only CareFirst numbers are to be used on invoices as opposed to client names and personal information and that if they do not have the CareFirst number it will be provided on request. Page 144
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12 Ref Risk Ratings for Recommendations Audit Finding Audit Recommendation 5 High A random sample of payments, based on financial value, was reviewed to ensure compliance with Financial Regulations and to confirm that expenditure had been correctly authorised and allocated to the appropriate financial code within the Financial Management System. The sample included a payment to a Care Provider in February 2025 and the audit confirmed that the expenditure had been correctly authorised and coded. The payment related to an out-of-area placement at a Care Facility and had been made gross of any financial deductions for personal care contributions. This is in accordance with agreed procedures; however, the individual had already been in the Care Facility for approximately 12 months. Further enquiries with officers noted that difficulties had been experienced in obtaining the required financial information from the individual to enable the determination of their personal financial contribution. Once the financial assessment has been completed, any personal financial contributions for an individual are recovered from future payments made to Authorisation of expenditure must be in compliance with the Council’s Financial Regulations. Recovery action should also be undertaken in the recovery of the personal financial contribution from the individual detailed within this finding. Page 145
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13 the Care Provider. The Care Provider will then recover this deduction from the individual at the Facility. In February 2025, the Community Care Finance Service completed the financial assessment for the individual and calculated a total cumulative contribution of £15,817 from the date of their entry into the Care Facility. In accordance with agreed arrangements, this amount was deducted from the total payment made to the Care Provider in February 2025. However, the Care Provider disputed this arrangement and the Interim Community Care Finance Officer/Support Manager, in consultation with the Team Manager- Community Care agreed to refund the total value of the personal contribution, in addition to the personal contributions due from the individual up to June 2025. An amount of £20,517 was repaid to the Care Provider in June 2025. The Team Manager was aware that this had been agreed and actioned through Community Care Finance and highlighted it to the Locality Manager, West. It is understood that officers have been in discussion with the individual at the Care Facility to agree arrangements for the payment Page 146
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14 of their personal financial contribution toward their care. It is appreciated that officers face significant challenges when supporting individuals with complex care needs. However, the Council’s Financial Regulations state that “where the need for expenditure for which there is no budgetary provision arises from emergency situations, the Head of Service should consult with the Chief Financial Officer”. As the payment was made to refund the Care Provider for the personal financial contribution due from an individual, consideration should have been given to seeking the Head of Service's approval to authorise the expenditure. For information, an audit review undertaken earlier this year of out-of-area placements for individuals with care requirements highlighted a need for administrative improvements. Management Response Responsible Officer Accepted (Yes/ No) Timescale for Implementation (Date Required) Agreed Management Action/Management Comment Locality Manager, West Yes 31/03/2026 Any financial authorisation must comply with financial regulations and approval sought from the Head of Service and Chief Page 147
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15 Financial Officer ensuring governance and financial regulations are adhered to. This is monitored through resource allocation where any financial package over a set amount is deferred to the High Cost Panel. Team Managers are required to follow due process however where this deviates from normal operating standards referral should be made in the first instance to the appropriate line manager. A process is underway to recover the debt and Social Work are working through this. Health and Social Care Moray will revise the process for such authorisations which may result in utilising the High Cost Panel. This will ensure that authorisation is provided at the correct level within the organisation for all future payments. Page 148
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16 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 Global Internal Audit Standards (GIAS). 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 149
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17 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 Service Manager Internal Audit and Risk (CAE). Page 150
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT PERFORMANCE AND RISK COMMITTEE ON 26 FERUARY 2026 SUBJECT: UPDATE ON THE DELIVERY OF THE UNPAID CARERS STRATEGY BY: SERVICE MANAGER, PROVIDER SERVICES 1. REASON FOR REPORT 1.1 This report provides Committee with an update on the progress in delivering the Moray Unpaid Carers Strategy highlighting key activities, developments, and outcome achieved during the reporting period. 1.2 The report aims to inform the Committee of the work undertaken to date in delivering on the strategic objectives and to outline ongoing and planned actions. 2. RECOMMENDATION 2.1 It is recommended that Committee: i) notes the progress made to date in delivering the objectives of the Unpaid Carers Strategy; and ii) considers the findings of the evaluation of the Maryhill Practice Unpaid Carer Project (Appendix A). 3. BACKGROUND 3.1 Unpaid carers are integral to the delivery of health and social care in Moray, providing essential support to individuals who would otherwise be unable to manage independently. It is estimated that around 16,200 individuals in Moray undertake an unpaid caring role for a partner, family member, friend or neighbour. 3.2 The Moray Carers Strategy sets out the partnership’s commitment to identifying, supporting, and valuing unpaid carers of all ages in line with the Carers (Scotland) Act 2016. Activity continues across key priority areas, including early identification, awareness-raising, workforce development, and the strengthening Item 9. Page 151
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of support pathways. This report provides an update since the previous reporting cycle. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 Consultation on the new Carer Aware branding has commenced via the Moray Engage HQ platform. The survey closed on 31 January 2026, and feedback will inform final branding decisions and the implementation plan for wider roll-out. The branding will be used across Moray for Carer Aware cards and badges, and by businesses, health, social care, and education settings participating in carer-aware initiatives. 4.2 The Unpaid Carers Survey is currently live on the Moray Engage HQ platform. Promotion is underway through commissioned providers, social media, and direct communication channels. The survey explores carers’ experiences of support, including initial contact with carer support services, support planning, and perceptions of recognition, value, and support. Findings will inform future workforce planning and support initiatives and provide a baseline for annual benchmarking. 4.3 A staff survey for health, social care, and education colleagues has been developed and is due to be distributed via the Moray Engage HQ platform. The survey will establish a baseline of staff knowledge and experience in identifying and referring unpaid carers, alongside training experience and development needs. This information will inform service delivery and the 2026 training programme. 4.4 The first Unpaid Carers Professionals’ Newsletter was issued in November 2025, with a second edition published in early February 2026. These publications provide updates and promote awareness of unpaid carers across health, social care, and education. Work is underway to develop a newsletter for adult and young unpaid carers, due for publication in the coming weeks. 4.5 The collaborative Maryhill Practice Unpaid Carer Project has now been evaluated. The evaluation highlights: • Improved early identification and recording of unpaid carers. • Strengthened referral pathways; and • Increased carer engagement within primary care. The full evaluation report is provided at Appendix A. 4.6 The Young Carers Statement (YCS) has been refreshed to adopt a more outcome-focused approach. Two age-appropriate versions have been developed: • A primary-aged version using simplified language and visual supports; and • A secondary-aged version with a more detailed outcomes framework These updates support consistency across education, social work, and partner agencies. The revised templates will be trialled with a sample of young carers to gather feedback and to further refine the documents, ensuring young carers have a sense of ownership over their YCS. Page 152
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Collaborative working with education settings is underway to support completion of the initial sections of the YCS in partnership with young carers’ named person or school-based young carer champions, where appropriate. Education settings will also be part of the refinement of the YCS and feedback will be obtained from those who have supported the completion of the document. 4.7 Engagement continues with schools across Moray to strengthen awareness-raising and early identification of young carers. Schools are being supported to embed carer-aware practice. • Carer Champions have been identified in five schools, providing a dedicated leadership and points of contact for young carer support. • Further expansion of the Carer Champion model is planned. 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 2019 – 2029” Supporting unpaid carers to maintain their health, wellbeing, and educational and economic potential is central to achieving the ambitions of the Moray Integration Joint Board Strategic Plan Moray Partners in Care 2019–2029, the Corporate Plan, and the Local Outcomes Improvement Plan (LOIP). The strategy contributes to delivery of National Health and Wellbeing Outcome 6. The approach aligns with the principles of Realistic Medicine and EPiC, placing people at the centre of decisions about their care and support. (b) Policy and Legal The Moray Unpaid Carers Strategy fulfils the statutory duties placed on the Moray IJB under the Carers (Scotland) Act 2016. It supports carers’ rights to: • Access a local information and advice services. • Be included in the hospital discharge planning for the person they are caring for. • Request and Adult Carer Support Plan (if over the age of 18) or a Young Carer Statement (if under aged 18 or younger) • Access Support where eligible needs are identified. • Be consulted on services affecting them and the person they care for. (c) Financial implications Annual Carer Act funding is in place to support delivery of the strategy. Actions within the Strategy and Action Plan, including commissioning of information and advice services, will be delivered within existing resources and through additional funding streams where available. (d) Risk Implications and Mitigation Page 153
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Implementation of the Act contributes to effective risk management across the Health and Social Care Partnership. Demand for support is expected to increase as more carers are identified. Local eligibility criteria are in place to determine access to formal support. (e) Staffing Implications Delivery of the strategy relies on partnership working between the workforce, unpaid carers, communities, and third and independent sector organisations. Survey findings will inform future workforce planning and development. (f) Property None arising directly from this report. (g) Equalities/Socio Economic Impact Unpaid carers are more likely to experience poorer health outcomes and socio-economic disadvantage. The strategy seeks to reduce inequalities and enhance equality of opportunity for all carers, including young carers. (h) Climate Change and Biodiversity Impacts None arising directly from this report. (i) Directions No Direction required. (j) Consultations Consultations have taken place with the Young Carers Strategy Officer, Assistant SDS & Carers Officer, Service Manager Provider Services, GP Clinical Lead for Moray, Carers Strategy Oversight Group, Operational Management Team (OMT). 6. CONCLUSION 6.1 This report outlines progress in delivering the Moray Unpaid Carers Strategy and highlights ongoing work to improve recognition, support, and outcomes for unpaid carers across Moray. Author of Report: Michelle Fleming, Self-Directed Support & Unpaid Carers Team Manager (SDS & Carers Lead Officer) Appendix A: HSCM EHC GP Project Evaluation - Nov 2025 Background Papers: Ref: Page 154
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APPENDIX A The Unpaid Carers Team, Health & Social Care Moray In Partnership With Maryhill Group Practice – Elgin Health Centre Whole Practice Approach to the Identification of Unpaid Carers 2024/2025 Pilot Project Evaluation Contents 1. Project Overview ....................................................................................................................... 2 2. Key Activities ............................................................................................................................ 2 3. Achievements .......................................................................................................................... 2 4. Challenges ............................................................................................................................... 3 5. Learning ................................................................................................................................... 3 6. Next Steps for Elgin Health Centre ............................................................................................. 4 7. Conclusion ............................................................................................................................... 5 8. Next Steps for HSCM ................................................................................................................. 5 Appendix 1 ................................................................................................................................... 7 Page 155
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Page 2 of 8 Pilot GP Practice Project Evaluation Report HSCM Unpaid Carers Team Report Approved by Dr R Lockhart & M Fleming – 27/11/25 1. Project Overview • Objectives: o to increase awareness of unpaid carers to support early identification o consistent recording of unpaid carers on patient records o ensure unpaid carers can access the support they require in a timely manner • Setting: Elgin Health Centre, (Maryhill Group Practice) Elgin • Size of Practice: over 20,000 patients • Links to Unpaid Carer Strategy Implementation Plan Actions: Ref: 1.1.11, 1.1.12, 1.1.13 • Timeline: April 2024 to June 2025 • Project Leads: Dr Robert Lockhart, Clinical GP Lead for Moray, Michelle Fleming, Self-Directed Support & Unpaid Carers Team Manager (HSCM) 2. Key Activities • Unpaid Carer Awareness Raising: o Staff awareness training on recognising and identifying unpaid carers. • Patient Record Enhancement: o Updates to electronic patient records to include a single identifier for unpaid carers. o Staff guidance on coding unpaid carers within patient records. • Support Pathway Development: o Creation of a GP Practice Unpaid Carer Support Pathway, including signposting to the local carer support service. 3. Achievements • Quantitative Measures: o 63.4% increase in recorded unpaid carers on the GP practice records (from start to end of the project) • Qualitative Improvements: o Reception staff have reported an increased awareness of unpaid carers and how to recognise and identify them. o At the outset of the project, a comprehensive data cleanse was undertaken. This process streamlined multiple unpaid carer identifiers into a single, standardised identifier. Page 156
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Page 3 of 8 Pilot GP Practice Project Evaluation Report HSCM Unpaid Carers Team Report Approved by Dr R Lockhart & M Fleming – 27/11/25 o The unique unpaid carer identifier has since been formally established within GP practice records and is now applied consistently. 4. Challenges • Staff availability and competing priorities: The demands of a busy GP practice meant that the designated link staff were not always available, which occasionally led to rescheduled meetings and slower progression of planned actions. • Dissemination of training materials: Circulation of the training booklet took longer than anticipated, which limited timely access. • Time pressures across the team: Clinical and administrative responsibilities naturally took precedence, which impacted staff availability for training and feedback. • Lack of feedback mechanisms: It was not feasible to request staff to complete feedback on the training, which hindered the ability to evaluate its effectiveness and gather insights for improvement. • Measuring training outcomes: Without structured follow-up, it was difficult to assess whether the training led to increased awareness among reception staff regarding the identification and support of unpaid carers. • Data inconsistencies: Establishing an initial baseline for the number of unpaid carers identified within the Practice was challenging due to variations in how unpaid carers were recorded. However, this challenge prompted a thorough data cleanse, which not only resolved the inconsistencies but also enabled the creation of a reliable baseline figure. 5. Learning At the outset of the campaign, it was agreed that the initial focus would centre specifically on reception staff rather than the wider practice team. This targeted approach recognised the pivotal role receptionists play as the first point of contact for patients and their potential to identify unpaid carers during routine interactions. By concentrating efforts on this group, the project aimed to build foundational awareness and establish practical recording and signposting processes This strategy allowed for more manageable implementation within a busy practice environment and provided valuable insights into frontline engagement with carer support pathways. • Importance of dedicated time and role clarity: The availability of a key link person is crucial for maintaining momentum. Future initiatives may benefit from clearer role definitions and protected time for project-related responsibilities to avoid delays and missed opportunities for progress. • Timely resource distribution matters: Delays in circulating training materials can hinder staff engagement and reduce the overall impact of awareness efforts. Early planning and streamlined distribution channels are essential to ensure resources reach staff when needed. • Staff engagement requires flexibility: Competing priorities in a busy practice environment mean that staff may not be able to participate in feedback or training activities. Offering flexible formats (e.g., short sessions, digital feedback tools) could improve uptake and responsiveness. Page 157
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Page 4 of 8 Pilot GP Practice Project Evaluation Report HSCM Unpaid Carers Team Report Approved by Dr R Lockhart & M Fleming – 27/11/25 • Feedback mechanisms are vital for evaluation: Without structured feedback, it is difficult to assess the effectiveness of training or changes in staff awareness. Embedding simple, low- effort feedback tools into the training process can help capture valuable insights. • Data consistency is foundational: Establishing accurate baseline data is critical for measuring progress and evaluating impact. Completing a data cleansing exercise prior to establishing the baseline number of recorded unpaid carers proved highly valuable, as it eliminated inconsistencies and ensured that identifiers could be standardised across records. • Reception staff play a pivotal role: While their awareness is difficult to measure without feedback, reception staff are often the first point of contact and can be instrumental in identifying unpaid carers. Future campaigns might consider tailored engagement strategies for this group. • Adaptability to practice pace is essential: It was clear that the practice operates under significant time pressures and competing priorities. The project had to adapt to the pace and capacity of the team, highlighting the need for realistic timelines and flexible delivery models. • Staff turnover impacts continuity: The resignation of the original key link person prior to the evaluation phase required reconnection with a new contact. This transition affected the depth and continuity of feedback, limiting the ability to conduct a more comprehensive evaluation of the project’s outcomes. 6. Next Steps for Elgin Health Centre Strengthen Internal Coordination • Maintain a dedicated carer lead with protected time to oversee carer-related initiatives. Improve Training Delivery and Evaluation • Embed simple feedback mechanisms (e.g., quick surveys or verbal check-ins) to assess training impact and staff awareness. Enhance Staff Engagement • Offer brief refresher sessions or carer-awareness prompts during team meetings or development days. Standardise Carer Identification and Recording • Provide clear guidance on how and when to record unpaid carer status in patient records. Monitor and Evaluate Progress • Set measurable goals for carer identification and support (e.g., increase in recorded carers, referrals made). Strengthen External Signposting and Partnerships • Build links with carer organisations to facilitate referrals and joint initiatives. Page 158
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Page 5 of 8 Pilot GP Practice Project Evaluation Report HSCM Unpaid Carers Team Report Approved by Dr R Lockhart & M Fleming – 27/11/25 7. Conclusion The unpaid carer project within Elgin Health Centre has laid a valuable foundation for improving carer identification, recording, and support. By focusing initially on reception staff, the project targeted those most likely to engage with carers at first contact, helping to build awareness and introduce practical tools for signposting. Despite the challenges of a busy practice environment and changes in key personnel, the initiative demonstrated adaptability and commitment to progressing at a pace that worked for the team. The project’s alignment with NHS priorities—particularly around personalised care and reducing health inequalities—underscores its strategic relevance. It has helped to highlight the often-hidden role of unpaid carers and the importance of identifying and supporting them within primary care. With continued momentum, strengthened systems, and broader staff engagement, the practice is well- positioned to build on this work and further embed carer support into its everyday operations. The project formally concluded on 10 June 2025, during Carers Week, with a photograph taken at Elgin Health Centre featuring Dr Lockhart, Michelle Fleming, and Ivan Augustas (IJB unpaid carer representative). This moment marked the completion of the project and acknowledged the collaborative efforts between the GP practice and HSCM. The photograph was featured in a Health and Social Care Moray (HSCM) news article, helping to publicly celebrate the achievements of the project and raise awareness of the importance of unpaid carer support. 8. Next Steps for HSCM Rollout Plan for Other GP Practices within Moray Develop a Replicable Toolkit • Create a standardised campaign pack including: o Briefing document outlining aims, benefits, and alignment with NHS priorities* o Training booklet tailored for reception staff o Carer support pathway guide o Template for recording unpaid carers in patient records o Feedback forms or digital survey links *See appendix 1 Page 159
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Page 6 of 8 Pilot GP Practice Project Evaluation Report HSCM Unpaid Carers Team Report Approved by Dr R Lockhart & M Fleming – 27/11/25 Engage Practice Leadership Early • Present the campaign to practice managers and GP leads, highlighting: o Alignment with NHS priorities (personalised care, reducing health inequalities) o Minimal disruption to clinical workflows o Evidence from the pilot practice • Secure buy-in and identify a carer link person within each practice Tailor to Practice Capacity • Offer flexible implementation timelines • Allow practices to start with reception staff and expand gradually • Provide options for digital or in-person training delivery Provide Light-Touch Support • Assign a local coordinator or carer support liaison to: o Check in periodically o Help troubleshoot recording issues o Encourage feedback collection • Offer short virtual drop-ins for reception staff to ask questions Monitor and Evaluate Progress • Ask practices to submit: o Number of carers recorded before and after implementation o Staff feedback on training and confidence levels o Examples of successful signposting to support services • Use this data to refine the toolkit and share success stories Page 160
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Page 7 of 8 Pilot GP Practice Project Evaluation Report HSCM Unpaid Carers Team Report Approved by Dr R Lockhart & M Fleming – 27/11/25 Appendix 1 Supporting Unpaid Carers in Primary Care Unpaid carers in Scotland make up a workforce larger than the combined paid health and social care sectors. They play a vital role in delivering quality care and are often uniquely positioned to understand and advocate for the needs, rights, and preferences of the individuals they support. While caring can be deeply rewarding, it also presents significant challenges. Many carers routinely prioritise the wellbeing of the person they care for over their own health and wellbeing needs. Unpaid Carers in Moray There are an estimated: 16,200 carers in Moray Carers legislative rights are enshrined by the Carers (Scotland) Act 2016 which recognises that preventative support at an early stage can reduce the risk of carers coming to crisis and help them to continue to manage their caring role. What’s the Aim of the Campaign? To improve identification and support for unpaid carers by: • Raising awareness among reception staff • Embedding carer identification and recording into daily practice • Strengthening signposting to local support services What’s Included? Each practice receives a campaign toolkit: • GP Practice Briefing • Reception Staff Training Booklet • Carer Support Pathway Guide • Recording Templates and Coding Tips Page 161
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Page 8 of 8 Pilot GP Practice Project Evaluation Report HSCM Unpaid Carers Team Report Approved by Dr R Lockhart & M Fleming – 27/11/25 • Feedback and Evaluation Forms • Access to support and guidance from members of the Health & Social Care Moray Unpaid Carer Team. Why It Works Aligns with NHS priorities on personalised care and reducing health inequalities Flexible delivery tailored to busy practice environments Builds on pilot project learning Strengthens links with local carer support services What’s Expected? • Identify a carer link person • Share baseline and follow-up unpaid carer data (numbers only) • Circulate training materials to reception staff • Encourage use of the support pathway • Provide light touch feedback Ready to Join? Whether you're just starting or already supporting unpaid carers, this campaign offers practical tools and guidance to make a difference. To get started or request the toolkit, contact: Unpaid Carers Team, Health & Social Care Moray. Email: UnpaidCarers@Moray.gov.uk Page 162
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 26 FEBRUARY 2026 SUBJECT: MORAY INTEGRATION JOINT BOARD DRAFT STRATEGIC RISK REGISTER BY: CHIEF OFFICER 1. REASON FOR REPORT 1.1 To present the Committee with the updated Draft MIJB Strategic Risk Register, providing a clear overview of current strategic risks, their assessments, and mitigating actions. This supports informed decision-making, strengthens strategic planning, and reinforces effective risk governance aligned with the Strategic Plan. 2. RECOMMENDATION 2.1 It is recommended that the Board: i) scrutinise the Board Strategic Risk register; and ii) review whether the mitigating controls and assurance arrangements are adequate, and identify any areas where further assurance is required. 3. BACKGROUND 3.1 The Risk Management Framework review was approved by the Moray Integration Joint Board (MIJB) at their meeting on 25 June 2020 (para 9 of the minute refers). Risk Appetite Statements are included in Appendix 1. 3.2 Risk scores are determined using the MIJB Risk Policy (Section 5), based on likelihood and impact. 3.3 As agreed at Audit, Performance and Risk Committee 26 October 2023 (para 8 of the minute refers), the reporting frequency was amended from quarterly to biannually unless significant changes arise. Item 10. Page 163
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3.4 The MIJB Internal Auditor issued a ‘Limited Assurance’ rating for MIJB for 2024/25 to the meeting of Audit, Performance and Risk Committee on 19 June 2025 (para 8 of the minute refers), reflected within Strategic Risk 8. 3.5 As agreed at MIJB meeting 25 September 2025 (para 11 of minute refers), the Board agreed that future iterations of the Strategic Risk Register should be presented in draft to the Audit, Performance and Risk Committee, prior to submission to the Board for final approval, and this report reflects that agreed approach to strengthen governance and ensure risks receive appropriate scrutiny and assurance before Board approval. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 The updated Strategic Risk Register incorporates feedback from the October 2024 hybrid session with Board members, ensuring alignment with strategic priorities and operational realities. 4.2 The approved Risk Appetite Statements guide decision making and balance innovation with compliance and continuity. 4.3 This report does not present and changes to the level of risks within the Board Risk Register, but provides some updates to the mitigations and assurances: 4.4 Risk 2 (Financial Sustainability) remains assessed as Very High. This continues to reflect significant exposure arising from the Quarter 3 financial forecast, slippage in the 2025/26 savings programme, increasing demand pressures, and high cost care packages with no additional budget. 4.5 The Senior Management Team continues to oversee and monitor grip and control measures, with structured challenge of spending decisions through established governance routes. 4.6 Financial pressures remain escalated to the Chief Executives of Moray Council and NHS Grampian, with ongoing dialogue through the tri-partite meetings. 4.7 Additional financial and operational pressures are noted across all service areas, including increasing demand in adult and children’s services, high cost complex care packages, and escalating unavoidable spend across out of area provision due to lack of service provision with Grampian 4.8 The organisational Review of Health and Social Care Moray structures, referenced under Risk 6, is progressing. This work is intended to realise the full integration of Children’s, Families and Justice services. It is also intended to ensure the organisation is aligned and equipped to meet current and future service pressures and transformation requirements. 5. SUMMARY OF IMPLICATIONS Page 164
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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” The MIJB requires effective governance arrangements for those services and functions delegated to it and Risk Management systems are integral to this. (b) Policy and Legal As set out in the terms of reference, the Board has responsibility to provide assurance of the adequacy of the risk management framework. There are no legal implications arising from this report. (c) Financial implications There are no direct financial implications arising from this report however, the Board should note the failure to manage risks effectively could have a financial impact for the MIJB. (d) Risk Implications and Mitigation This report forms part of the governance arrangements for identifying and managing strategic risks of the MIJB. The risks are outlined in the body of the report in section 4. Without appropriate funding, the organisation may be required to reduce or discontinue services in Moray to meet financial targets. This could result in unmet community needs, reputational damage, and failure to deliver the strategic objectives set by the Board. (e) Staffing Implications There are no additional staffing implications arising from this report. (f) Property There are no property implications arising from this report. (g) Equalities/Socio Economic Impact An Equalities Impact Assessment is not required because there are no service, policy or organisational changes being proposed. However, Impact Assessments will be core to any decision making process. (h) Climate Change and Biodiversity Impacts There are no impacts arising from this report. (i) Directions None arising from this report. (j) Consultations Consultation on this report has taken place with the Board members, and Senior Management Team. 6. CONCLUSION Page 165
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6.1 The updated Strategic Risk Register demonstrates a collaborative and embedded approach to risk management. It aligns with strategic priorities and operational realities. The Board is asked to approve the updated register, reaffirming its commitment to robust governance. Author of Report: Sonya Duncan, Corporate Manager Background Papers: held by HSCM Ref: Page 166
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IJB RISK REGISTER SUMMARY – November 2025 APPENDIX 1 Risk Assessment Table – Multiply likelihood score by impact score to determine the risk rating (score). Risk No Risk Risk Owner Previous Risk Rating Last Reviewed Chang e Current Rating 1 There is a risk that the MIJB does not function as set out within the Integration Scheme, Strategic Plan and in-line with its Governance Framework and fails to deliver its objectives or expected outcomes. Chief Officer Contributor: Senior Leadership Team Error! Referenc e source not found. September 2025 Medium 2 The MIJB must operate within the resources allocated to it by the partner bodies and it is good financial practice to set a balanced budget at the start of each financial year. There is a risk that financial pressures being experienced by the funding partners will directly impact the MIJB’s strategic planning of services and its decision-making Chief Officer Contributor: Chief Finance Officer/ Heads of Service/ Chief Nurse Very High January 2026 Very High 4 There is a risk that the MIJB is unable to operate effectively as a Public Body. Chief Officer Contributor: Corporate Manager/ Chief Finance Officer Medium September 2025 Medium 5 There is a risk that the MIJB does not comply with the necessary legislative and regulatory requirements in which it operates. Chief Officer Contributor: Senior Leadership Team Medium September 2025 Medium 6 There is a risk that the MIJB’s strategic aspirations are not sufficiently transformative and as a result, that it is unable to deliver outcomes for people in a sustainable way. Chief Officer Contributor: Senior Leadership Team Medium September 2025 Medium 7 There is a risk that the MIJB is unable to exert influence on services delegated but hosted within another organisation. Chief Officer Contributor: Heads of Service Medium September 2025 Medium 8 There is a risk that the MIJB’s internal control and governance arrangements are not sufficiently robust, as evidenced by the 2024/25 Internal Audit opinion of ‘limited assurance’ Chief Officer Contributor: Senior Leadership Team Medium September 2025 Medium Page 167
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Risk 1: There is a risk that the MIJB does not function as set out within the Integration Scheme, Strategic Plan and in-line with its Governance Framework and fails to deliver its objectives or expected outcomes. Consequence: Legal and Regulatory Implications, Reputational Damage, Loss of Stakeholder Trust, Resource Challenges, Service Disruption, Failure to deliver Health Outcomes Risk Rating: Medium Risk Appetite: Moderate-High Risk Movement: Historical Risk Rating: Medium September 2025 Rationale for Risk Appetite as reflected by MIJB in Appendix 2: • Strategic Priorities require innovative approaches to integration that may involve governance development • Outcomes depend on our ability to make timely decisions through efficient governance structures • The board recognises that complete risk aversion would prevent necessary transformation of services • A Moderate appetite allows for controlled governance exploration while maintaining core statutory compliance Rationale for Risk Rating: The risk remains Medium because, although core governance elements (Integration Scheme, Governance Framework, Scheme of Administrations, Members Induction and Standards training) are in place and routinely used, the breadth of delegated functions and ongoing structural change still create exposure to governance variance across services. Risk scoring before mitigations/controls Mitigations / Current controls in place Risk scoring after mitigations/controls 4 5 20 1. Integration Scheme approved March 2023. 2. Consultation with legal representative for all reports to committees and attendance at committee for key reports. 3. Induction sessions are held for new MIJB members. 4. Conduct and Standards training held for MIJB Members in June 2022, and February 2024 provided by Legal Services. 5. Regular Senior Management Team (SMT) and Operational Management Team (OMT) meetings to provide direction and support to managers and teams, with agreed focus and priorities aligned to the Strategic Delivery Plan 6. Implementation of HSCM Internal Audit Process providing assurance and escalation process to SMT 2 3 6 Untreated Likelihood Untreated Impact Untreated Score Current Likelihood Current Impact Current Score Page 168
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Assurances: • MIJB Scheme of Integration • Programme of Development Sessions held throughout the year with all MIJB members and Officers • Audit, Performance and Risk Committee (APR) provides quarterly scrutiny of governance compliance with minutes to the Board. • Internal Audit conducts reviews with formal recommendations and monitoring to APR • Budget Savings Oversight Group monitors financial governance monthly with escalation pathways to SMT and MIJB. • Service Reporting to Board for strategic decisions and updates. • The Moray Transformation Board and Strategic Planning and Commissioning Group provides oversight of planned business across HSCM. • Budget Savings Oversight Group on monthly basis. • Monthly Tri-partite partnership performance meetings with partner CEOs, Finance Directors and Chair/Vice Chair of MIJB • Care Inspectorate assessment of services, including governance impact on service delivery. • Annual governance statement for external audit. • Strategic Delivery Plan (approved June 2025) incorporates the work being driven across all areas of the MIJB’s Strategic Plan priorities and will be reported regularly to AP&R Committee Gaps in Assurance: As part of HSCM structural review, mapping of the delegated Children’s, Families and Justice services will take place to ensure the statutory governance requirements and those of MIJB are robust. Current Performance: • The Scheme of Administration is updated as required. • The Governance Framework was approved by MIJB on 28 January 2021. • Re-appointment of Standards Officer agreed by MIJB 28 March 2024. • Members Handbook updated and circulated to 100% of members in June 2022 • Quarterly performance to APR including benchmarking and targets. • All committees submitted required reports on schedule in 2024/25 • 100% of new members received induction on appointment • Standards training was delivered to all members in February 2024 with an update during MIJB Development session in August 2025 • Development sessions: 5 planned and delivered in 2025/26. Further Controls Required Further Controls Owner Complete integration of Children’s, Families and Justice. Organisational Review and Change process underway. HoS/CO August 2026 Review of MIJB Members Handbook Required – delayed from December 2025 due to competing priorities Corporate Manager/Legal Services April 2026 Target Date Page 169
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Risk 2: The MIJB must operate within the resources allocated to it by the partner bodies and it is good financial practice to set a balanced budget at the start of each financial year. There is a risk that Financial pressures being experienced by the funding partners will directly impact the MIJB’s strategic planning of services and its decision-making. Consequence: Inability to deliver strategic priorities, potential statutory service cuts. Reduced service capacity, financial instability, compromised care delivery Risk Rating: Very High Risk Appetite: Moderate (as per Appendix 2) Risk Movement: Historical Risk Rating: Very High January 2026 Rationale for Risk Appetite (as detailed in Appendix 2) • Willing to accept moderate financial risks in pursuit of strategic objectives • Conservative approach to core budget management • Higher tolerance for innovative projects with clear benefits • Low tolerance for financial decisions that could threaten long-term sustainability Rationale for Risk Rating: The risk remains rated at Very High due to in year pressures, savings slippage and recurrent cost growth outpacing available funding, including high-cost care packages and demand growth in adults and children’s services. Prescribing movements, shortfalls (eNIC) and savings slippage underline uncertainty. While the grip/control, oversight and escalation processes are in place, residual exposure to overspend and delivery risk remains high. Managing the risk - Current controls in place 5 5 25 1. Medium Term Financial Framework (MTFF) approved by MIJB on 30th March 2025. 2. Additional resource to support the Budget Savings Delivery has been extended to March 2026. 3. Tri-partite partnership performance meetings with partner CEOs, Finance Directors and Chair/Vice Chair of MIJB. 4. Operational financial monitoring undertaken by Chief Finance Officer (CFO), Heads of Service (HOS) and Budget Managers. 5. Budget Savings Oversight Group chaired by Chief Officer, attended by HOS, CFO and Service Managers as appropriate. 6. Monitoring of MIJB Strategic Delivery Plan ensuring all projects are aligned with savings plans. 7. Extended Resource Management Group – including financial recovery action plan. 8. SMT are actively monitoring and responding to the grip and control measures as they arise, ensuring robust oversight and challenge, ensuring that no critical issues are overlooked. 9. Financial pressures have been escalated to the Chief Executives of Moray Council and NHS Grampian, discussions continue as per the tri-partite arrangements. 3 5 15 Untreated Likelihood Untreated Impact Untreated Score Current Likelihood Current Impact Current Score Page 170
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Assurances: • Quarterly Budget monitoring reporting to MIJB • Financial Reporting through MIJB, NHS Grampian and Moray Council • The Project Management Office continues to support the Budget Savings Delivery as part of the budget setting for 2026/27 onwards. • Ongoing Financial Development Sessions with MIJB members. • Internal Audit quarterly reporting to APR • External Audits presented to MIJB/ Committees as appropriate. • Six weekly Tri-partite partnership performance meetings with partner CEOs, Finance Directors and regular meetings with the Chair/Vice Chair of MIJB • Strategic Delivery Plan (approved June 2025) incorporates the work being driven across all areas of the MIJB’s Strategic Plan priorities and will be reported regularly to AP&R Committee. • Finance workshop with IJB in December and another to scheduled for Feb 2026. • Risk 2 presented to MIJB in January 2026 with Q3 report. Gaps in Assurance: • Slippage in savings programme for 2025/26 presented to MIJB January 2026. • Unprecedented growth and demand across adults and childrens services, adding significant pressure to all budgets and delivery of savings previously identified. Current Performance: The Revenue Budget Outturn for 2024/25 was presented and a balanced budget for 2025/26 was agreed by MIJB on 27 March 2025 A Financial Savings Plan for 2025/26 was agreed by MIJB on 27 March 2025. Quarter 1 budget monitoring report presented to MIJB on 25 September 2025. Approved Audited accounts for 2024/25 presented and approved by APR committee 29 October 2025 and MIJB 30 October 2025. Quarter 2 budget monitoring reported presented to MIJB on 27 November 2025. Quarter 3 budget monitoring report planned for presenting to MIJB 29 January 2026. APR committee presented with biannual update on Strategic Delivery Plan October 2025. Comments: Further Controls Required Further Controls Owner Target Date Review Date Review Notes / Decisions Risk 3: There is a risk that the MIJB’s workforce strategy is not delivered impacting the quality of paid and unpaid Health & Social Care. Consequence: Service disruption and reduced capacity, Increased Workload and staff burnout, Significant Financial impact, Deteriorating Staff and Unpaid Carers Morale and Engagement, Compromised Patient Safety and Care Quality, Negative Public Perception and Reputation Damage Risk Rating: Medium Risk Appetite: Moderate (as per Appendix 2) Risk Movement: Page 171
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Historical Risk Rating: Medium November 2025 Rationale for Risk Appetite (as detailed in Appendix 2) MIJB will only accept minimal risk to people accessing services, unpaid carers or staff when the comparative risk of doing nothing is higher than the risk of intervention. Safety risks inherent in Health and Social care services demand exceptional management and clinical care standards. The Board recognises that: • Individual safety is paramount • Person-centred care involves supporting informed decision-making, which may introduce nuanced risk scenarios A balanced approach is critical, considering both individual and community safety risks Rationale for Risk Rating: The risk remains Medium because recruitment and retention challenges, geography and housing constraints continue to affect capacity and service resilience. Residual risk remains until workforce plans are refreshed and resourced. Assurances: • Operational oversight by Moray Workforce Forum. Managing the risk - Current controls in place 5 5 25 1. Ongoing review of HSCM Structure to identify areas for consideration, development, reconfiguration. 2. Moray Council conducted an assessment of needs, including people working in the Health and Care sector. 3. Staff wellbeing is a key focus and there are many initiatives across both parent organisations offering information, support and access to activities. 4. Collaborative approaches with educational institutions e.g. intakes and programmes for future workforce development. 5. Professional Development and retention programmes; Incentives have been secured to attract additional NHS dentists and dental practices to Moray. The Scottish Dental Access Initiative includes Moray, with grants of £50,000 and above available to allow dental practices to be established or extended, provided there is a seven- year commitment to providing NHS treatment. A recruitment and retention bonus is also being offered to eligible new dentists in Moray. 6. GP sustainability Group and Primary Care Vison for the Future Groups now progressing across Grampian. 7. iMatter reports are an opportunity for staff’s opinions on the MIJB and wider organisation. 3 3 9 Untreated Likelihood Untreated Impact Untreated Score Current Likelihood Current Impact Current Score Page 172
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• The HSCM Response Group continues to focus on leadership around emerging issues and resolving them, including staffing. • The Carers Strategy extension was approved by MIJB June 2025, extending to March 2028. The focus is on developing support to the large, valued workforce of unpaid carers within Moray. • The Resource Management Group (RMG) considers all vacancies before being considered for external advertisement. • HSCM organisational review is cognisant of recruitment challenges and will be the consultation with staff will be key to developing any changes. Gaps in Assurance: • Further capacity will be required to develop and implement workforce plans to reflect updated delivery plans to reflect the financial savings required. Current Performance: Comments: Staffing issues are monitored by the Operational Management Team (OMT) working collaboratively to seek opportunities to make jobs more attractive where it has proven difficult to recruit in the past. There is the risk that staff move from one position to another within HSCM, as in unintended consequence creating a vacancy elsewhere in the system. This needs to be considered when fixed term contracts and secondments are planned; consideration needs to be given to the whole of HSCM and not services in isolation. Many of our staff may have transferrable skills and experience. Further Controls Required Further Controls Owner Target Date Review and update of the Workforce Plan – awaiting SG TBC TBC Review Date Review Notes / Decisions Page 173
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Risk 4: Inability to demonstrate effective governance and effective communication and engagement with stakeholders. Consequence: Suboptimal outcomes for people, Erosion of organisational trust and credibility, Increased legal and regulatory compliance risks. Workforce demotivation and disengagement, missed strategic opportunities and collaborative potential, reduced organisational responsiveness and adaptability Risk Rating: Medium Risk Appetite: Low-Moderate (as per Appendix 2) Risk Movement: Historical Risk Rating: Medium November 2025 Rationale for Risk Appetite (as detailed in Appendix 2) The Board acknowledges the critical importance of: • Robust stakeholder relationships • Effective collaboration and co-production • Adaptive partnership working • Recognising diverse stakeholder capacities and readiness for change Strategic principles guiding stakeholder engagement: • Maintaining constructive, transparent relationships • Balancing organisational objectives with collaborative dynamics • Ensuring inclusive and meaningful engagement processes • Protecting long-term partnership sustainability Continuous Improvement in communication processes Rationale for Risk Rating: The risk remains Medium because engagement and communications processes are variable across a complex landscape, and the current Communication & Engagement Strategy (2019) is being updated. Whilst SOCG locality work, and adoption of ‘Planning with People’ principles, and strengthened digital channels are in place, assurance on consistency and outcome capture needs to improve within the limited capacity. Assurances: • Oversight and scrutiny by Clinical and Care Governance Committee, Audit Performance and Risk Committee and MIJB Managing the risk - Current controls in place 4 4 16 • Refocus of Strategic Planning & Commissioning Group (SPCG) to support locality engagement. • Continued working with Community Planning colleagues to oversee the development of locality planning. • Grampian Joint Strategic Needs Assessment Group, including participation from community groups. • Engagement with diverse groups across Moray e.g. Alcohol & Drug Partnership, School Nurses. • ‘Planning with People’ principles adopted as per Healthcare Improvement Scotland (HIS) 3 3 9 Untreated Likelihood Untreated Impact Untreated Score Current Likelihood Current Impact Current Score Page 174
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• Strategic Planning & Commissioning Group (SPCG) • MIJB Audit, Performance and Risk Committee • 3rd Sector and Stakeholder Representatives on MIJB and committees • Local Outcome Improvement Plan (LOIP). • Community Planning • ADP • Locality Reporting to MIJB • Stakeholder Representative on GP Vision Board • Summary reports of MIJB submitted to Moray Council and NHSG committees. • The Programme Management Office ensures that all programmes of work incorporate appropriate engagement as standard business as usual practice. Gaps in Assurance: • Seek to improve the level of engagement across Moray. • Communication and Engagement Strategy was approved in 2019 and is currently being updated. • More systematic approach to stakeholder consultation required. • Establish a more robust process for youth representation pathways. Current Performance: • SPCG meets quarterly. • Locality Plans reviewed with the Strategic Delivery Plan • LOIP plans linked to MIJB Strategic Plan • Annual Performance Report for 2024/25 published in July 2025. • Community engagement in place for key projects areas such as Forres, Keith and Lossiemouth Comments: • Communications & Engagement will be factored into the ongoing structural review, providing a more systematic approach to engagement in localities. Further Controls Required Further Controls Owner Target Date Update Communication and Engagement Strategy Corporate Manager April 2026 Review Date Review Notes / Decisions Page 175
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Risk 5: There is a risk that the MIJB does not comply with the necessary legislative and regulatory requirements in which it operates. Consequence: Significant reputational impact and potential resource allocation challenge and possible financial and operational strain, potential impact on communities and staff, potential compromise of statutory Category One Response obligations, reduced organisational resilience Risk Rating: Medium Risk Appetite: Moderate (as per Appendix 2) Risk Movement: Historical Risk Rating: Medium November 2025 Rationale for Risk Appetite (as detailed in Appendix 2) The MIJB has minimal tolerance of harm happening to people as a result of its actions, recognising the need to balance the risk of doing nothing and the risk of action or intervention. The Moray Integration Joint Board (MIJB) recognises the statutory obligations under the Civil Contingencies Act 2004, including Category 1 Responder responsibilities (since March 2021) Rationale for Risk Rating: The risk remains Medium as regulatory requirements span multiple domains (performance, finance, resilience, decision making), and system pressures raise the likelihood of standards not being met at times. Controls exist (learning loops, statutory reporting, resilience planning), but full assurance depends on Business Continuity planning being complete and visible across both parent bodies. Assurances: • Quarterly reporting to Clinical and Care Governance and Audit, Performance and Risk Committees • Annual Performance Report – published July 2025 • Chief Social Work Officer’s Report Managing the risk - Current controls in place 5 5 25 1. Continuous emergency preparedness awareness with partners in Grampian Local Resilience Partnership (GLRP) – including exercises and debriefs. 2. Learning from Inspection Reports, Adverse Events, Complaints, actions plans and performance measures monitored by Clinical Risk Management (CRM), Clinical and Care Governance Group (CCGG) and Operational Management Team (OMT) with oversight by SMT. 3. HSCM Civil Contingencies group review specific risks and action plans to mitigate, developing plans and testing arrangements in partnership with NHSG and Council. 4. Annual review of internal resilience and emergency processes with Senior Managers on Call. 5. Timetable of statutory reporting across the financial year. 6. Implementation of regular progress reports on audit at OMT, with oversight at SMT. 3 3 9 Untreated Likelihood Untreated Impact Untreated Score Current Likelihood Current Impact Current Score Page 176
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• Internal and External Audits • Senior Management Meetings fortnightly • Joint meeting of MIJB Chief Officer with two Partner Body Chief Executives. • Annual report on MIJB activity developed and reported to Moray Council and NHSG • All Inspection reports reported to APR Committee with action plans developed and monitored Gaps in Assurance: Business Continuity (BC) Planning – work is underway to ensure HSCM has a register of all plans and timescales – to be monitored by OMT and escalations to SMT. Current Performance: There are Resilience and Business Continuity processes in place, and these are reviewed regularly. Annual Performance Report for 2024/25 was approved by the MIJB and published in July 2025. Audited annual accounts October 2025. Category One Responder duties incorporated in the role of Corporate Manager. Comments: Structure review of HSCM to mitigate the governance risk of services not meeting standards and adequate service delivery. The Manchester Arena and Grenfell Inquiry has resulted in a focus on Category 1 responders’ responsibilities, together with an increase of additional policies/procedures to be developed, implemented and exercised with no additional resource. Implementation plan for new Scottish Government Resilience Standards will be required once received. Further Controls Required Further Controls Owner Target Date Business Continuity Planning Senior Management Team April 2026 Review Date Review Notes / Decisions Page 177
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Risk 6: There is a risk that the MIJB’s strategic aspirations are not transformative and as a result, we are unable to deliver outcomes for people in a sustainable way. Consequence: Persistent health inequalities, erosion of public trust and organisational reputation, potential legal challenges, significant reputational damage to MIJB, potential long-term negative impacts on community health outcomes, reduced effectiveness of healthcare resource allocation Risk Rating: Medium Risk Appetite: Moderate (as per Appendix 2) Risk Movement: Historical Risk Rating: Medium November 2025 Rationale for Risk Appetite (as detailed in Appendix 2) The Moray Integration Joint Board (MIJB) faces significant challenges in maintaining service delivery across its delegated services from NHS Grampian and Moray Council. These challenges stem from three key areas: Resource Constraints Budgetary pressures are leading to reduced staffing resources, affecting service delivery capacity and quality. This situation requires careful management to maintain essential services while operating within financial constraints. System Pressures The healthcare system continues to experience significant strain from high levels of unplanned admissions and delayed discharges. While teams across the care pathway are working collaboratively to address these issues, the complexity of the situation, combined with limited community care availability, makes sustainable improvement challenging. Service Redesign The financial recovery plan necessitates fundamental service redesign to deliver outcomes more efficiently. While the aim is to enhance service quality through these changes, public expectations may need to adjust to align with what is deliverable within budget constraints. This requires careful management of both service transformation and stakeholder expectations. The Moray Integration Joint Board (MIJB) is committed to: • Maintaining exemplary standards of governance • Balancing innovative approaches with robust regulatory compliance • Proactively managing emerging risks in a dynamic healthcare landscape • Prioritisation of Moray’s unique community needs Regulatory risks will only be considered with: 1. Comprehensive consultation with relevant regulatory bodies 2. Clearly defined and documented defensible risk mitigation strategies 3. Transparent decision-making processes 4. Thorough impact assessments MIJB will only take regulatory risks knowingly, following consultation with the relevant regulatory body and where we have clear risk mitigation in place. Potential impacts to the wide range of services in NHS Grampian and Moray Council commissioned by the MIJB arising from reductions in available staff resources as budgetary constraints impact. Page 178
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Unplanned admissions and delayed discharges place additional cost and capacity burdens on the service. The level of delayed discharges has remained challenging, reflecting the sustained pressure in the system and the lack of availability of care in the community. There are sustained focussed and collective efforts by all those working in the pathway. However, this is a complex area and will require continued effort to realise reductions and maintain them. The financial recovery plan will require some service redesign to meet outcomes in alternative ways. It is hoped that this will always provide an improved service, but it must be recognised that public expectations may differ to what can be delivered within budget. The Moray Integration Joint Board (MIJB) faces significant challenges in maintaining service delivery across its commissioned services from NHS Grampian and Moray Council. Rationale for Risk Rating: The risk remains at a Medium rating due to persistent system pressures, including high levels of unplanned admissions, delayed discharges, and constrained community capacity, all of which limit the Partnership’s ability to progress transformation at the intended pace. Significant financial constraints and limited workforce capacity continue to impact the feasibility and timing of redesign work. Public expectations also remain higher than what can be delivered within current resources. Although strong governance arrangements, performance oversight, and collaborative work across the pathway are in place, these structural challenges continue to create a sustained risk that the MIJB may be unable to deliver all strategic aspirations in a sustainable way. Managing the risk - Current controls in place 5 4 20 1. Clinical and Care Governance (CCG) oversight is provided through the CCG Committee, supported by the Clinical and Care Governance Group, Clinical Risk Management (CRM) and Practice Governance structures, ensuring professional standards are monitored and risks escalated appropriately. 2. HSCM Clinical Risk Management (CRM) Group and NHS Grampian CRM Group review High and Very High operational health service risks. 3. Annual Performance Reports 4. Regular Internal and External scrutiny is provided through inspections. 5. Internal/External Inspection reports are scrutinised by appropriate operational groups with actions tracked and monitored through the appropriate governance groups. 6. Care Home Collaborative Support Group provides oversight, ensuring risks in care homes are monitored and mitigated through partnership working. 3 3 9 Untreated Likelihood Untreated Impact Untreated Score Current Likelihood Current Impact Current Score Page 179
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Assurances: Audit, Performance and Risk and Clinical and Care Governance Sub- Committees oversight and scrutiny. The Clinical and Care Governance Framework was refreshed and presented to CCG Committee in November 2023. The Strategic Delivery Plan was approved by MIJB June 2025 Gaps in Assurance: Process for highlighting recurring themes or strategic expectations from external inspections requires further development to ensure Committee has sight of significant issues. Current Performance: External inspection reports are scrutinised and actions arising are allocated to responsible officers. A summary of inspections is included in the Annual Performance report. Risk Management session delivered for managers in HSCM in September 2023, by the NHSG Risk Advisor. Comments: No major concerns identified for HSCM services in any audits or inspections during 2023/24. An inspection of Childrens Services commenced in August 2023, the final report was presented to the board and a Service Improvement plan commenced and reported to APR on a quarterly cycle. The current financial pressures will impact HSCM’s ability to deliver on the priorities set out in the strategic plan and requires a level of transformation to match this. Further Controls Required Further Controls Owner Target Date Review Date Review Notes / Decisions 7. Children and Adult Protection Committees provide specialist scrutiny and ensure statutory safeguarding duties are met. 8. Robust governance arrangements such as SMT, OMT and daily operational huddles ensure regular oversight, co-ordinated decision aking and early escalation of system pressures. 9. Organisational Review of HSCM structures is underway to strengthen strategic capacity and ensure the organisation is equipped to deliver transformation and ability to respond to increasing demands across the system. Page 180
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Risk 7: There is a risk that the MIJB is unable to exert influence on services delegated but hosted within another organisation. Consequence: Legal challenge from Moray citizens and staff, potential intervention or censure from Scottish Government, systemic service failures, particularly in areas such as IT, Human Resources, Legal and compliance services Risk Rating: Medium Risk Appetite: Moderate (as per Appendix 2) Risk Movement: Historical Risk Rating: Medium November 2025 Rationale for Risk Appetite (as detailed in Appendix 2) Extremely low tolerance for: • Systemic support service failures • Potential compromise of organisational effectiveness • Risk of legal and regulatory non-compliance • Diminished service delivery capacity Low tolerance in relation to not meeting requirements. Rationale for Risk Rating: The risk remains Medium because hosted services are subject to partner governance, financial constraints and workforce pressures outside MIJB’s direct control. The tri-partite working forums improve visibility and influence but cannot fully eliminate dependency risks. Parent organisations experiencing: • Significant financial constraints • Staffing challenges • Potential resource allocation limitations The projected overspend in hosted services sits within each MIJB and HSCM is one of the partners who can influence decisions. Assurances: These largely come from the systems, process and procedures put in place by NHS Grampian, which are still being operated, along with any new processes which are put in place by the lead MIJB. North East System Wide Transformation Group (Officers only) led by the 4 pan- Grampian chief executives. The aim of the group is to develop real top-level leadership to drive forward the change agenda, especially relating to the delegated hospital-based services. The CEO group and the Chairs/Vice Chairs group meet quarterly. The meetings are evenly staggered between groups, giving some six weeks between them, allowing progressive work / iterative work to be timely between the forums. The Managing the risk - Current controls in place 5 4 20 1. Chief Officer regularly meets with Chief Officers of Aberdeen City Health and Social Care Partnership and Aberdeenshire Health and Social Care Partnership. 2. Significant changes to service delivery are discussed across all three HSCP’s. 3. Agreement that proposals regard significant service changes are presented to all three MIJB’s for approval. 4. Internal Audit of MIJB Hosted Services 3 3 9 Untreated Likelihood Untreated Impact Untreated Score Current Likelihood Current Impact Current Score Page 181
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Portfolio approach and wider system approach demonstrates closer joint working across the 3 Health and Social Care Partnerships and the Acute Sector. Gaps in Assurance: Ongoing implementation of internal audit recommendations. Current Performance: Officers are currently implementing the recommendations from the Audit on Hosted Services. Standardised service templates have been implemented and sent to all hosted services and information is being gathered in preparation to presenting proposals to the Chief Officers, MIJB’s and NHS Grampian. Comments: Further Controls Required Further Controls Owner Target Date Review Date Review Notes / Decisions Page 182
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Risk 8: There is a risk that the MIJB’s internal control and governance arrangements are not sufficiently robust to provide full assurance, as evidenced by the 2024/25 Internal Audit opinion of ‘Limited Assurance’ Consequence: • Weaknesses in internal controls may lead to financial mismanagement, service delivery failures, reputational damage, and non-compliance with statutory duties. • Delays in implementing audit recommendations may result in prolonged exposure to known risks and inefficiencies. • A continued ‘limited assurance’ position may reduce stakeholder confidence in the MIJB’s governance and oversight arrangements. Risk Rating: Medium Risk Appetite: Moderate (as per Appendix 2) Risk Movement: Historical Risk Rating: Medium November 2025 Rationale for Risk Appetite (as detailed in Appendix 2) • The MIJB recognises the importance of strong internal controls and governance to support safe, effective, and sustainable service delivery. • While some risk is accepted in the pursuit of transformation, assurance processes must be timely, transparent, and responsive to audit findings. Rationale for Risk Rating: The risk remains Medium because the 2024/25 Internal Audit Annual Report concluded ‘Limited Assurance’ with delays in recommendations and weaknesses noted in contract management, digital and tracking arrangements. Controls have strengthened (end to end audit tracking, SMT engagement, governance statement) but residual risk persists until audit actions are closed and key enablers are delivered. Assurances: • Internal Audit Annual Report presented to APR Committee (June 2025). • Internal Audit Quarterly reporting of audit progress and follow-up to APR Committee. • Oversight by SMT. • Internal audit process implemented, providing operational assurance to SMT as per agreed timescales. Gaps in Assurance: Delays previously experienced in implementing some audit recommendations. Updated Risk Policy framework is underway. Managing the risk - Current controls in place 4 5 20 1. ‘End to end’ process for agreeing, implementing and tracking audits is now established with regular OMT/SMT oversight. 2. Governance statement prepared in line with CIPFA/SOLACE guidance. 3. Internal audit attending regular SMT meetings to discuss audit plan work and any emerging risks. 4. Financial resource from HSCM to MIJB Internal Audit team to improve capacity for collaboration and oversight. 2 3 6 Untreated Likelihood Untreated Impact Untreated Score Current Likelihood Current Impact Current Score Page 183
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Current Performance: • Implementation of Adult Social Care Commissioning audit recommendations nearing completion. • Audit plan for 2025/26 includes follow-up reviews to verify progress. • Improved partnership working with Internal Audit and SMT. Comments: Further Controls Required Further Controls Owner Target Date • Continue to identify capacity to progress the Digital work stream, including digitalisation where possible. • Progress development of unified case recording system • HSCM Risk Framework (2022) being updated. CFO/HoS HoS SMT March 2027 March 2027 June 2026 Review Date Review Notes / Decisions Page 184
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MIJB Risk Appetite Statement The Moray MIJB recognizes that effective risk management is fundamental to achieving its strategic objectives in delivering integrated health and social care services. This statement defines the level and type of risk the MIJB is willing to accept in pursuit of achieving the outcomes defined in the strategic plan, Partners in Care 2022-2032. Moray MIJB adopts a balanced approach to risk-taking, acknowledging that transformation, innovation and service improvement often require managed risk-taking while ensuring the safety and wellbeing of its staff and the public remains paramount. Strategic Risk: MODERATE-HIGH • Higher appetite for strategic initiatives supporting integration • Willingness to innovate in service delivery • Acceptance of calculated risks in pursuit of transformation • Support for pilot projects with clear business case and evaluation criteria At this appetite level, the board is willing to accept some uncertainty in governance processes where: - Clear oversight mechanisms remain in place - Core statutory obligations continue to be met - Potential benefits to service delivery are significant - Learning opportunities from governance adjustments can be captured Financial Risk: MODERATE • Willing to accept moderate financial risks in pursuit of strategic objectives • Conservative approach to core budget management • Higher tolerance for innovative projects with clear benefits • Low tolerance for financial decisions that could threaten long-term sustainability Clinical Safety Risk: LOW • Minimal appetite for risks affecting patient/service user safety • Strong controls and monitoring required for all clinical activities • Zero tolerance for non-compliance with clinical governance standards • Comprehensive risk assessments required for any service changes • Operational Risk: MODERATE • Moderate tolerance for operational changes that improve efficiency • Willing to consider new service delivery models • Acceptance of short-term disruption for long-term benefits • Regular monitoring and review of operational changes Reputational Risk: LOW-MODERATE • Conservative approach to actions that could damage public trust • Proactive stakeholder engagement in major decisions • Low tolerance for activities that could undermine partnership working • Emphasis on transparent decision-making Page 185
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Workforce Risk: MODERATE • Moderate appetite for workforce development initiatives • Innovation in recruitment and retention strategies • Support for new ways of working • Low tolerance for risks affecting staff wellbeing Risk Governance • Regular review of risk appetite by the MIJB Board • Clear escalation procedures for risks exceeding appetite levels • Integration of risk appetite into decision-making processes • Regular reporting on risk profile against appetite Implementation • Risk appetite to be considered in all significant decisions • Regular training for staff on risk management • Clear communication of risk appetite across the organization • Annual review and update of risk appetite statement Monitoring and Review • Bi-annual review of risk register against appetite levels • Annual review of risk appetite statement • Regular reporting to Audit and Risk Committee • Adjustment of appetite levels based on changing context This statement will be reviewed annually and updated as required to reflect changes in the operating environment and strategic priorities. Page 186
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Likelihood – What is the likelihood of the risk occurring? Assess using the criteria below. Rare (1) Unlikely (2) Possible (3) Likely (4) Almost Certain (5) Don’t believe this event would happen Will only happen in exceptional circumstances Not expected to happen but definite potential exists Unlikely to occur May occur occasionally Has happened before on occasions Reasonable chance of occurring Strong possibility that this could occur Likely to occur This is expected to occur frequently/ in most circumstances more likely to occur than not Impact – What could happen if the risk occurred? Assess for each category and use the highest score identified. The impact scale is from an organisational level perspective. It reflects the key areas that if impacted could prevent the organisation achieving its priorities and objectives. The scale is a guide and cannot cover every type of impact therefore judgement is required. Category Negligible (1) Minor (2) Moderate (3) Major (4) Extreme (5) Patient or Service user Experience Reduced quality patient experience/clinical outcome not directly related to delivery of clinical care Unsatisfactory patient experience/clinical outcome directly related to care provision – readily resolvable Unsatisfactory patient experience/ clinical outcome, short term effects – expect recovery less than 1wk Unsatisfactory patient experience /clinical outcome, long term effects - expect recovery over more than 1week Unsatisfactory patient experience/clinical outcome, continued ongoing long term effects Objectives/ Project Barely noticeable reduction in scope/quality/ schedule Minor reduction in scope/quality/schedule Reduction in scope/quality/project objectives or schedule Significant project overrun Inability to meet project/corporate objectives, reputation of organisation seriously damaged Injury /illness (physical and psychological) to Adverse event leading to minor Minor injury or illness, first aid treatment required Agency reportable, e.g. Police (violent and aggressive acts) Major injuries/long term incapacity /disability (e.g. loss of limb), Incident leading to death(s) or major permanent incapacity Page 187
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patient/service user/visitor/staff/carer injury not requiring first aid Significant injury requiring medical treatment and/or counselling requiring, medical treatment and/or counselling Complaints/Claims Locally resolved verbal complaint Justified written complaint peripheral to clinical care Justified complaint involving lack of appropriate care Claim above excess level. Multiple justified complaints Multiple claims or single major claim Complex Justified complaint Service/ Business Interruption Interruption in a service which does not impact on the delivery of patient care or the ability to continue to provide service Short term disruption to service with minor impact on patient care/service provision Some disruption in service with unacceptable impact on patient care Temporary loss of ability to provide Service. Sustained loss of service which has serious impact on delivery of patient care resulting in major contingency plans being invoked Permanent loss of core service/ facility Disruption to facility leading to significant “knock on” effect -- to function Staffing and Competence Short term low staffing level temporarily reduces service quality (less than 1 day) Short term low staffing level (>1 day), where there is no disruption to patient care Ongoing low staffing level reduces service quality Minor error due to lack of/ ineffective training/ implementation of training Late delivery of key objective/service /care due to lack of staff Moderate error due to lack of/ ineffective training / implementation of training Ongoing problems with staffing levels Uncertain delivery of key objective/service/care due to lack of staff Major error due to lack of/ ineffective training / implementation of training Non-delivery of key objective/ service/care due to lack of staff. Loss of key staff Critical error due to lack of/ ineffective training/ implementation of training Financial (including Damage/Loss/Theft/ Fraud Negligible organisational/ personal financial loss up to £1k Minor organisational/ personal financial loss of £1-10K Significant organisational/personal financial loss of £10- 100k Major organisational/personal financial loss of £100k- 1m) Severe organisational financial loss of more than £1m Page 188
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Inspection/ Audit Small number of recommendations which focus on minor quality improvement issues Recommendations made which can be addressed by low level of management action Challenging recommendations that can be addressed with appropriate action plan Improvement Notice Enforcement/prohibition action Low Rating Critical report Prosecution Zero rating Severely critical report Adverse Publicity/ Reputation Rumours, no media coverage Little effect on staff morale Local media coverage – short term. Some public embarrassment Minor effect on staff morale/public attitudes Local media – long term adverse publicity Significant effect on staff morale/public perception of the organisation National media adverse publicity less than 3 days Public confidence in the organisation undermined Use of services affected National/International media/ adverse publicity, more than 3 days MSP/MP/SEHD concern (Questions in Parliament) Court Enforcement/Public Enquiry/FAI Risk Scoring Consequences/Impact Likelihood Negligible Minor Moderate Major Extreme Almost Certain Medium High High V High V High Likely Medium Medium High High V High Possible Low Medium Medium High High Unlikely Low Medium Medium Medium High Rare Low Low Low Medium Medium Review Timescales – When a risk rating has been assigned the criteria below should be used to assess the review timescales. Very High or High Requires monthly monitoring and updates. Medium Requires quarterly monitoring and updates. Low Requires 6 monthly monitoring and updates. Page 189
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 26 FEBRUARY 2026 SUBJECT: INTERNAL AUDIT PLAN YEAR ENDING 31 MARCH 2027 BY: CHIEF INTERNAL AUDITOR 1. REASON FOR REPORT 1.1 To provide the Committee with information on the proposed internal audit coverage for the 2026/27 financial year. 2. RECOMMENDATION 2.1 It is recommended that the Committee: i) note the proposed internal audit coverage for the 2026/27 financial year; and ii) seek clarification on any matters arising from the report or from the proposed Internal Audit Plan for 2026/27 attached as Appendix 1. 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 organisations achieve their objectives by applying a systematic, disciplined approach to evaluate and enhance the effectiveness of risk management, control, and governance processes. 3.2 The Internal Audit Plan determines the priorities of the internal audit activity and how these align with the wider goals of the Moray Integration Joint Board (MIJB). Internal Audit adopts a risk-based approach to annual audit planning, with all areas that may be subject to review included within an ‘audit universe.’ This audit universe is continuously reviewed and updated to encompass all significant activities and systems that contribute to achieving the MIJB’s priorities and objectives. . Item 11. Page 191
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3.3 The Internal Audit Plan outlines the areas Internal Audit expects to review during the year, assuming stability in the resources available to the Section. Time allocations for all audits have been determined on the basis that the systems under review are adequately documented, including details of the controls implemented by management, and that testing confirms compliance with these controls. However, if this is not the case, additional time may be required, which could impact the review of planned areas and the overall achievability of the plan. 3.4 The proposed Internal Audit Plan for 2026/27 is attached in Appendix 1. The Plan has been updated to reflect the Global Internal Audit Standards (GIAS), which came into effect on 1 April 2025, replacing the Public Sector Internal Audit Standards. GIAS requires a more prescriptive Internal Audit Charter that clearly defines the internal audit function’s mandate, independence, and authority within the organisation. The Internal Audit Charter has been updated and is included as part of the Internal Audit Plan. 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 the Global 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. Page 192
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(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 2026/27. Author of Report: Dafydd Lewis, Chief Internal Auditor Background Papers: Internal Audit Files Ref: mijb/ap&rc/ Page 193
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APPENDIX 1 MORAY INTEGRATION JOINT BOARD INTERNAL STRATEGY AND AUDIT PLAN 2026/27 Page 194
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1.1 In June 2015, the Scottish Government’s Integrated Resources Advisory Group (IRAG) issued the “Guidance for Integrated Financial Assurance” to support the Public Bodies (Joint Working) (Scotland) Act 2014. This guidance requires Integration Joint Boards (IJBs) to seek assurance that their resources are sufficient to enable them to carry out their functions, assess associated risks, and establish adequate and proportionate internal audit arrangements for reviewing risk management, governance and control of delegated resources. 1.2 The guidance requires that a risk-based audit plan be developed by the Chief Internal Auditor of the IJB and approved by the IJB or an appropriate 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 provides independent and objective assurance and consulting services that add value and enhance the operations of the Moray Integration Joint Board (MIJB). By applying a systematic and disciplined approach, it supports the MIJB in achieving its objectives through improved risk management, control and governance processes. This strategy sets the direction for the Internal Audit Service, ensuring alignment with the MIJB’s priorities and compliance with Global Internal Audit Standards for the UK public sector. The Service aims to strengthen MIJB’s ability to create and protect value by delivering risk-based assurance, advice and insight; fulfilling its mandate under the Internal Audit Charter; being recognised for professionalism and expertise. It will deliver audit engagements sufficient to support an annual opinion on MIJB’s control environment, align the Audit Plan with strategic objectives and risks and maintain robust knowledge and skills within the Internal Audit Section. The Internal Audit Service for the Moray Integration Joint Board (MIJB) is delivered by Moray Council’s Internal Audit Section. In addition, assurance is supplemented by reviews undertaken by NHS Grampian’s Internal Audit Provider on NHS systems that support the delivery of MIJB’s delegated services. 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 195
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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 Audit’s approach to annual audit planning is risk-based, with the areas identified for potential review contained within an “audit universe.” This audit universe is continuously reviewed and updated to include all significant activities and systems. 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 196
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2.3 The audit universe is risk-assessed annually to help determine the Internal Audit Plan and ensure that sufficient time and resources are allocated to reviewing the most significant areas of risk. . 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 service demands to ensure proportionate audit coverage across the MIJB. While the audit universe is a key factor, it is not the sole consideration when determining the audit plan. Senior management and the Chair of the Audit, Performance and Risk Committee have also been consulted during the preparation of the Internal Audit Plan for 2026/27. 2.6 These sources enable the Chief Internal Auditor to meet the requirement of providing an annual internal audit opinion on the adequacy and effectiveness of internal control systems for inclusion in the Annual Governance Statement published with the MIJB’s annual accounts. A review of internal audit plans from other IJBs has also been undertaken, based on committee reports available online. This offers an opportunity to understand issues faced by other IJBs and to identify potential 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 . Delivering an internal audit programme that provides sufficient and appropriate coverage will enable a well-informed and comprehensive year-end internal audit opinion. . 2. Internal Audit Plan: Approach Page 197
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Conformance with the Global 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 Global Internal Audit Standards (GIAS) developed by standard setters, including the Chartered Institute of Public Finance and Accountancy and the Chartered Institute of Internal Auditors. The GIAS, in their applicability to the public sector, must be considered along with the Application Note: Global Internal Audit Standards in the UK Public Sector, which has been produced to assist with interpretation. 2.9 The Global Internal Audit Standards (GIAS) require an annual self-assessment as part of a continuous quality assurance and improvement program to ensure the internal audit function complies with the Standards. Time has been allocated within the Council’s Internal Audit Plan to review the Internal Audit Section’s procedures and processes against the GIAS, identify areas for improvement, and inform a Quality Assurance and Improvement Plan (QAIP). The GIAS also introduced a requirement for “topical requirements” in the preparation of the Internal Audit Plan. These topical requirements represent critical risk areas for which the Standards provide guidance to ensure a minimum baseline and consistent, comprehensive criteria for assessing the design and implementation of governance, risk management, and control processes. Detailed below are the current topical requirements for consideration within the Internal Audit Plan, along with proposed actions for addressing these risk areas. Topical Requirement Description Proposed Audit Coverage Cybersecurity This Topical Requirement provides a consistent, comprehensive approach to assessing the design and implementation of cybersecurity governance, risk management, and control processes. A review of cybersecurity has been included in the Council’s Internal Audit Plan for 2026/27. . The Global Internal Audit Standards (GIAS) are designed to harmonise internal audit practices across the public sector worldwide and are mandatory for local authorities in Scotland. Internal auditors must apply topical requirements (TR) in conformance with the Global Internal Audit Standards. The purpose of TRs is to provide a benchmark on what good looks like when performing internal audit engagements over common high-risk areas of an organisation. 2. Internal Audit Plan: Approach Page 198
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3.1 The Internal 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 Internal Audit Plan also includes time to assist services in developing their controls and approach to improving compliance. This reflects the continued development of Internal Audit's more proactive, value-added approach to supplement its 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, Internal Audit may identify governance issues that are outside the stated scope of the review. GIAS requires 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”. Topical Requirement Description Proposed Audit Coverage Third-Party The term “third party” refers to vendors, suppliers, contractors, subcontractors, outsourced service providers, other agencies and consultants. This topical requirement intends to provide a consistent, comprehensive approach to assessing the design and implementation of third-party governance, risk management and control processes This is included in the Council’s Internal Audit Plan for 2026/27; however, it may require audit coverage of MIJB delegated services. . The Internal Audit Plan lists projects the Internal Audit Service will review to provide management and members with an independent opinion on whether the MIJB’s risk management, governance and internal control processes are operating effectively. The proposed 2026/27 plan is presented in Appendix 2. In addition, the Internal Audit Plan also details allocation of days to support the Service and development requirements within the Internal Audit Section. Established working practices allocate 80 days for audit work relating to the MIJB. The Council’s Internal Audit Plan, detailing this time allocation and proposed projects for review, will be reported to Moray Council’s Audit and Scrutiny Committee at its meeting on 25 March 2026. In addition to the reviews outlined in Appendix 2, reviews will also be undertaken of interest to the MIJB, including both payroll and creditor expenditure, which will also be reported to the Audit, Performance and Risk Committee. . 3. Internal Audit Plan 2025/26 Page 199
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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 deployment 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 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 in 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 of the review undertaken, as well as recommendations for improvements to 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 for a recommendation detailed in 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. 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 200
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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 governance, risk management and control framework. 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. 4,6 In accordance with the Global Internal Audit Standards (GIAS), the Chief Internal Auditor is required to disclose any responsibility for non-audit services to safeguard the independence and objectivity of the internal audit function. The Chief Internal Auditor is also the Council’s Service Manager Internal Audit and Risk (CAE), with responsibility for supporting the Council’s risk management and business continuity arrangements. These duties are carried out by a Business Continuity and Risk Management Officer within the Internal Audit Section. However, a clear separation is maintained between the duties of this post and the internal audit function, with different reporting arrangements and greater operational oversight exercised by the Council’s senior management. This structure is considered appropriate to preserve the Internal Audit Service’s independence and objectivity. 4. Internal Audit Reporting Page 201
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Appendix 1 Moray Council Internal Audit Section INTERNAL AUDIT CHARTER Date of Creation: September 2025 Owner (Service): Service Manager Internal Audit & Risk Reviewer Head of Service: Chief Governance Officer Approver Executive Director: Economy, Enterprise & Operations Date Approved: 16/10/2025- Corporate Leadership Team Approver (Committee): Audit and Scrutiny Committee Date Approved: 19/11/2025 Next Review Date: Annual Version History Version Date Author Changes Made Approved By 1.0 [Insert Date] [Insert Author – service title] Initial document [Insert Name] Page 202
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INTERNAL AUDIT CHARTER FOR THE MORAY COUNCIL Introduction 1.1 The Local Authority Accounts (Scotland) Regulations 2014 introduced a statutory requirement for all Scottish local authorities to have in place and 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 United Kingdom for all public sector internal audit providers, in-house, shared or outsourced, are the Global Internal Audit Standards (GIAS). The GIAS, in their applicability to the public sector, must be considered along with the Application Note: Global Internal Audit Standards in the UK Public Sector, which has been produced to assist with the interpretation of the GIAS. 1.2 The GIAS contain requirements to support 15 guiding principles associated with and expected to be operating within the Internal Audit function across 5 key domains: Purpose, Ethics and Professionalism, Governing, Managing and Performing, these domains and the 15 guiding principles are outlined in the images below. Page 203
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1.3 In accordance with the Global Internal Audit Standards (GIAS), all local authorities in Scotland must produce an Internal Audit Charter (Charter). The Charter is required to detail the purpose, mission, authority, independent reporting relationships and scope of responsibilities of the internal audit function. The GIAS refers to the head of an internal audit service as the Chief Audit Executive and within the Moray Council, this is the Service Manager Internal Audit and Risk. The Internal Audit Section of the Moray Council also provides internal audit services to the Moray Integration Joint Board (MIJB) and the Grampian Valuation Joint Board (GVJB). The same professional standards defined in this Internal Audit Charter will apply to all work undertaken for the MIJB and GVJB. Page 204
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Purpose Statement of Internal Auditing– Domain I 2.1 As defined by the GIAS, the purpose of the Internal Auditing (IA) function is to strengthen the Council’s ability to create, protect and sustain value. This is achieved by providing the Audit and Scrutiny Committee and senior management with independent, risk-based and objective assurance, advice, insight and foresight. 2.2 The IA function enhances the Council’s: • Successful achievement of its objectives • Governance, risk management and control processes • Decision-making and oversight • Reputation and credibility with its stakeholders • Ability to serve the public interest 2.3 The Council’s IA function is most effective when: • Internal auditing is performed by competent professionals in conformance with the GIAS, which are set in the public interest • The IA function is independently positioned with direct accountability to the Audit and Scrutiny Committee • Internal auditors are free from undue influence and committed to making objective assessments 2.4 IA assurance is provided by delivering an annual programme of audit work that independently and objectively assesses the design and effectiveness of the controls established to manage the Council’s most significant risks. Commitment to Adhering to the Global Internal Audit Standards 2.5 The Council’s Internal Audit (IA) function will adhere to the Institute of Internal Auditors' International Professional Practices Framework, consisting of the GIAS and Topical Requirements as well as the Application Note: Global Internal Audit Standards in the UK Public Sector. When expressing conformance with standards, the Council’s IA function will be clear that it is conforming to the Global Internal Audit Standards in the UK Public Sector. The Service Manager Internal Audit and Risk (CAE) will report annually to the Audit and Scrutiny Committee and senior management on the IA function’s conformance with the GIAS, which will be assessed through a quality assurance and improvement programme. Page 205
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Internal Audit Mandate 2.6 In accordance with the GIAS, the Council’s Internal Audit (IA) function receives its mandate from the Council’s first-tier constitutional documents with particular reference to the Scheme of Delegation and Financial Regulations. These documents set out the authority, roles and responsibilities enabling the IA function to provide the Audit and Scrutiny Committee and senior management with independent, risk-based and objective assurances on the robustness of the Council’s internal control systems. 2.7 The IA function’s authority is also supported by its direct reporting relationship to the Audit and Scrutiny Committee and senior management. Such authority allows for unrestricted access to the Chief Executive, Chair of the Audit and Scrutiny Committee and the Council Leader. Independence, Organisational Position, and Reporting Relationships 2.8 The GIAS state that the Service Manager Internal Audit and Risk (CAE) should be positioned at a level in the Council that enables the Internal Audit (IA) Service to be performed without interference from management, thereby ensuring the independence of the IA function. 2.9 The CAE reports functionally to the Audit and Scrutiny Committee and administratively to the Chief Governance Officer (Monitoring Officer). This provides the organisational authority and status to bring matters directly to senior management and escalate matters to the Audit and Scrutiny Committee, when necessary, without interference and supports the internal auditors’ ability to maintain objectivity. 2.10 The CAE is required to confirm to the Audit and Scrutiny Committee, at least annually, the organisational independence of the IA function. If the governance structure does not support organisational independence, the CAE must document the characteristics of the governance structure limiting independence and any safeguards employed to achieve the principle of independence. The CAE must disclose to the Audit and Scrutiny Committee any interference internal auditors encounter related to the scope, performance, or communication of internal audit work and results. The disclosure will include communicating the implications of such interference on the IA function’s effectiveness and ability to fulfil its mandate. 2.11 To ensure that IA independence and objectivity are maintained for assurance services, IA will remain free from interference from anyone within the Council in relation to audit selection, scope, procedures, frequency, timing and report content. 2.12 Where IA also has responsibility for non-audit activities, the GIAS requires that appropriate arrangements be established to avoid conflicts of interest. Additionally, IA will not be permitted to audit any activities for which they have previously been responsible within a period of one year and will not engage in any other activity that may impair their judgment or independence. For advisory services, the IA role will be specifically restricted to providing guidance, views, and opinions. To comply with independence requirements, IA will not be involved in any aspects of operational decisions subsequently taken by management. Page 206
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2.13 The Service Manager for Internal Audit and Risk (CAE) is responsible for supporting the Council’s risk management and business continuity arrangements. These responsibilities are carried out within the Internal Audit Section by the Business Continuity and Risk Management Officer, who is also involved in preparing the Council’s Annual Governance Statement. The operational management of these duties is overseen by senior management, including the Chief Governance Officer, rather than by the Service Manager for Internal Audit and Risk (CAE). This approach helps to avoid impairments to the independence and objectivity of the IA function. Changes to the Mandate and Charter 2.14 The Audit Charter will be reviewed annually to ensure that it remains up to date. Any amendments will be approved by the Audit and Scrutiny Committee. Requirements to update the Internal Audit Charter may include: • A significant change in the Global Internal Audit Standards in the UK Public Sector. • A significant reorganisation within the Council • Significant changes to the Audit and Scrutiny Committee, and/or senior management Ethics & Professionalism– Domain II Demonstrate Integrity 3.1 The CAE will ensure that internal auditors: • Conform with the GIAS including the principles of Ethics and Professionalism: integrity, objectivity, competency, due professional care, confidentiality and the Seven Principles of Public Life • Understand, respect, meet, and contribute to the legitimate and ethical expectations of the Council and can recognise conduct that is contrary to those expectations • Encourage and promote an ethics-based culture in the Council • Report organisational behaviour that is inconsistent with the Council’s ethical expectations, as described in applicable policies and procedures Maintain Objectivity 3.2 The Service Manager Internal Audit and Risk (CAE) will ensure that the internal audit function remains free from all conditions that threaten the ability of internal auditors to carry out their responsibilities in an unbiased manner, including matters of engagement selection, scope, procedures, frequency, timing, and communication. If the CAE determines that objectivity may be impaired in fact or appearance, the details of the impairment will be disclosed to appropriate parties. Page 207
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3.3 Internal auditors will maintain an unbiased mental attitude that allows them to perform engagements objectively, such that they believe in their work product, do not compromise quality and do not subordinate their judgment on audit matters to others, either in fact or appearance. 3.4 Internal auditors will have no direct operational responsibility or authority over any of the activities they review. Accordingly, internal auditors will not implement internal controls, develop procedures, install systems, or engage in other activities that may impair their judgment, including: • Assessing specific operations for which they had responsibility within the previous year • Performing operational duties for the Council or its partner organisations • Initiating or approving transactions external to the IA function • Directing the activities of any employee that is not employed by the IA function, except to the extent that such employees have been appropriately assigned to IA teams or to assist internal auditors 3.5 Internal auditors will: • Immediately disclose impairments of independence or objectivity, in fact or appearance, to the Service Manager Internal Audit and Risk (CAE) • Exhibit professional objectivity in gathering, evaluating, and communicating information • Make balanced assessments of all available and relevant facts and circumstances • Take necessary precautions to avoid conflicts of interest, bias, and undue influence. Demonstrate Competency 3.6 The Service Manager Internal Audit and Risk (CAE) will hold an appropriate professional qualification in addition to relevant experience. Therefore, in considering whether a CAE is suitably qualified, an organisation must be looking for: • CMIIA, or a CCAB qualification, or an equivalent professional qualification which includes training on the practice of internal audit, and • Suitable internal audit experience 3.7 In addition, all staff who are on professional training programs must comply with their terms and conditions of practice and maintain the standards expected of the professional institute they belong to and other relevant requirements as outlined in this Charter. 3.8 All staff must maintain their continued professional development in accordance with their professional body on an annual basis and make the appropriate declaration where required. Exercise Due Professional Care 3.9 In completing planning activities and subsequent audit work internal auditors shall consider the: • Extent of work needed to achieve the engagement’s objectives Page 208
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• Relative complexity, materiality or significance of matters to which assurance procedures are applied • Adequacy and effectiveness of governance, risk management and control processes • Probability of significant errors, fraud, or non-compliance • Cost of assurance in relation to potential benefits Maintain Confidentiality 3.10 The GIAS set out the duty of internal auditors to be faithful custodians of the information they gather, sharing only in limited, defined, and controlled ways. GIAS describes the need for awareness of responsibilities in protecting information and demonstrating respect for the confidentiality, privacy and ownership of information. 3.11 While the duties under the GIAS mainly relate to restricting the sharing of information, auditors must also be aware of the circumstances under which sharing or publication of information will be required. They must be aware of the Council’s policies and procedures for the routine publication of certain information and where there are statutory obligations to share or publish information. Governing the Internal Audit Function – Domain III Authorisation by the Audit and Scrutiny Committee (Board) 4.1 Appropriate governance arrangements are essential to enable the Internal Audit (IA) function to be effective. This domain outlines the requirements for the Service Manager Internal Audit and Risk (CAE) to work closely with the Audit and Scrutiny Committee to establish the IA function, position it independently and oversee its performance. 4.2 In the United Kingdom, such arrangements are highly developed, particularly within local government, and are further supplemented by the CIPFA in the ‘Practical Guidance for Audit Committees for Local Authorities and Police 2022 edition’. In Moray, the Council’s Scheme of Delegation details the role of the Service Manager Internal Audit and Risk to act as the Chief Audit Executive for the delivery of internal audit services in accordance with GIAS. Positioned Independently – The Audit and Scrutiny Committee (Board) establishes and protects the internal audit function’s independence and qualifications 4.3 The Audit and Scrutiny Committee (Board) is responsible for enabling the independence of the Internal Audit (IA) function. Independence is defined as the freedom from conditions that impair the internal audit function’s ability to carry out its responsibilities in an unbiased manner. Page 209
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4.4 The Service Manager Internal Audit and Risk (CAE), who reports functionally to the Council’s Audit and Scrutiny Committee, is appropriately qualified and has the necessary experience. The Service Manager, Internal Audit and Risk (CAE), administratively reports to the Chief Governance Officer (Monitoring Officer) but has access to the Chief Executive, Chair of the Audit and Scrutiny Committee and the Council Leader. This both maintains independence and positions the Service Manager Internal Audit and Risk (CAE) within the Council to discharge the function of internal audit and its responsibilities without interference. Overseen by the Audit and Scrutiny Committee (Board) – The Board oversees the internal audit function to ensure the functions effectiveness. 4.5 The Audit and Scrutiny Committee (Board) oversight is essential to enable the overall effectiveness of the Internal Audit (IA) function. Achieving this principle requires collaboration and interactive communication between the Board and the Service Manager Internal Audit and Risk (CAE), as well as the Board’s support in ensuring the IA function obtains sufficient resources to fulfil the internal audit mandate. 4.6 To establish, maintain, and ensure that Moray Council’s IA function has sufficient authority to fulfil its duties, the Audit and Scrutiny Committee will, if required: • Discuss with the CAE and senior management the appropriate authority, role, responsibilities, scope, and services (assurance and/or advisory) of the IA function • Ensure the CAE has unrestricted access to and communicates and interacts directly with the Audit and Scrutiny Committee, including in private meetings with or without senior management present, where that is required • Discuss with the CAE other topics that should be included in the internal audit charter, where appropriate • Approve the IA function’s charter, which includes the internal audit mandate and the scope and types of internal audit services • Review the internal audit charter periodically with the CAE to consider changes affecting the Council such as the employment of a new CAE or changes in the type, severity and interdependencies of risks to the organisation; and approve the internal audit charter on an annual basis.(A copy of the internal audit charter will be included for approval with the audit plan) • Approve the risk-based audit plan and any strategy on which it is based and monitor completion of the plan, in accordance with any performance indicators set annually • Through discussion with the CAE be satisfied that the IA function’s human resources, administration and budgets are sufficient to complete the audit plan and provide an annual opinion • Through discussion with the CAE determine if they are satisfied that the service has appropriate levels of skills to fulfil its ability to complete the audit plan • Ensure that the CAE has adequate competencies and qualifications in conformance with the GIAS • Receive communications from the CAE about the IA function including its performance relative to its plan. These will be in accordance with the Page 210
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Committee’s scheduled timetabling of meetings as outlined in the Council’s meetings calendar • Ensure a quality assurance and improvement programme has been established and review the results annually and every five years for the external review to ensure that any deficiencies identified and opportunities for improvement contain an action plan and timeline for addressing these issues, together with monitoring progress • Make appropriate enquiries with the CAE to determine whether scope or resource limitations are inappropriate Managing the Internal Audit Function – Domain IV 5.1 The Service Manager Internal Audit and Risk (CAE) is responsible for managing the Internal Audit (IA) function in compliance with the internal audit charter and GIAS. This responsibility includes strategic planning, obtaining and deploying resources, building relationships, communicating with stakeholders, and ensuring and enhancing the performance of the function. 5.2 The CAE is expected to conform with the GIAS, whilst the CAE may delegate appropriate responsibilities to other qualified professionals in the delivery of the IA function. Plan Strategically 5.3 Planning strategically requires the Service Manager Internal Audit and Risk (CAE) to understand the internal audit mandate and organisational governance, risk management and control processes. A properly resourced and positioned IA function helps develop and implement a strategy to support the organisation’s success. 5.4 The CAE will develop and produce an internal audit strategy to support the requirements of the GIAS and the annual audit plan. The strategy and resulting audit plan will be subject to ongoing monitoring and updated where deemed appropriate. 5.5 The Council’s IA Service will have appropriate supporting methodologies (processes and procedures) in place via the Internal Audit Manual to provide clear directions to staff on expected practices which must be followed to achieve the wider requirements within the GIAS and UK applications. Manage Resources 5.6 The Service Manager Internal Audit and Risk (CAE) manages resources to implement the internal audit function’s strategy and achieve its audit plan and mandate. The CAE must develop a budget that enables the successful implementation of the audit plan, this will include training, technology and day-to- day activities. 5.7 The Council has an established and documented process for developing budgets and resources that will be needed to cover the work of the IA function. As part of the annual budget planning process, the internal audit function will consider its needs, which will include, but not be limited to, staffing, training, travel, and other associated costs. If the CAE has concerns regarding the level of internal audit resources to meet the auditing Page 211
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requirements of the Council or partner organisations, this should initially be raised with senior management for resolution before it is reported to the Audit and Scrutiny Committee. 5.8 Appropriately qualified staff will be engaged to provide services within the IA function, together with appropriate training and continued professional development. Communicate effectively 5.9 The Service Manager Internal Audit and Risk (CAE) guides the IA function to communicate effectively with its stakeholders, building relationships, establishing trust and enabling stakeholders to benefit from the results of the internal audit services. 5.10 The Council’s IA function has clear and documented processes for engagement with its stakeholders, which are documented in its internal audit manual. This process includes but is not limited to accurate, objective, clear, concise, constructive, complete and timely reporting of its fundings. 5.11 The Council’s IA function, through the CAE, will update the Audit and Scrutiny Committee (Board) on the completion of the audit plan and any significant revisions. In addition, the Board will be informed when there is an inability to agree on a recommendation with management, and where the IA function believes it is critical or high risk in relation to a control weakness that could put the Council at risk. In the event that other risks are identified that do not meet the threshold of being critical or high risk, acceptance of the risk will be noted in the action plan contained within the report. Enhance quality 5.12 The Service Manager Internal Audit and Risk (CAE), is responsible for ensuring the IA function’s conformance with the GIAS and for continuous performance improvement where required. Appropriate and independent internal quality assessments will be required by self-assessment annually and externally every five years. Findings of any quality assessments undertaken will be reported to senior management and the Audit and Scrutiny Committee. Performing Internal Audit Services - Domain V Plan Engagement Effectively 6.1 The Service Manager Internal Audit and Risk (CAE) will submit an annual audit plan to the Audit and Scrutiny Committee for review and approval, which is designed to support the provision of an evidence-based assessment of the robustness of the Council’s internal control systems. This annual audit plan will be developed, based on a risk-based prioritisation of the audit universe from a range of key stakeholders, including Members, Chief Executive, Corporate Leadership Team and Heads of Services. Page 212
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6.2 The scope of internal audit activities also encompasses, but is not limited to, objective examinations of evidence to provide independent assurance and advisory services to the Audit and Scrutiny Committee and senior management on the adequacy and effectiveness of governance, risk management, and control processes for the Council and partner organisations. However, the nature of evolving risks makes it likely that the audit assignments included in the audit plan may be subject to change. Consequently, the audit plan will be reviewed by the Service Manager Internal Audit and Risk (CAE) on an ongoing basis and any proposed changes will require the approval of the CAE and the Audit and Scrutiny Committee. Conduct Engagement Work 6.3 The Service Manager Internal Audit and Risk (CAE) must consider the effect on the opinion work before accepting consultancy work or management requests over and above the contingency allowed for in the internal audit plan. Such consultancy work will only be undertaken where resources permit, without impacting on the annual assurance process, and where there is no direct or perceived conflict of interest or eroding of the independence and objectivity of the internal audit function. The CAE will inform the Audit and Scrutiny Committee of any significant unplanned consultancy work undertaken. 6.4 The nature, objectives and scope of advisory services may be agreed with the party requesting the service, provided the IA function does not assume management responsibility. Opportunities for improving the efficiency of governance, risk management, and control processes may be identified during advisory engagements. These opportunities will be communicated to the appropriate level of management. Communicate Engagement Conclusions and Monitor Action Plans 6.5 Findings from audit reviews undertaken will be communicated to the Audit and Scrutiny Committee and senior management effectively, along with the significance and prioritisation, including limitations of scope, where applicable, and conclusions in relation to governance, risk management, and internal controls. The Council’s IA function will make all such communications in line with the GIAS and will be reflected in the internal audit manual. 6.6 Appropriate follow-up and monitoring of recommendations will be undertaken by the IA function and this will be reported to the Audit and Scrutiny Committee and senior management. 6.7 The GIAS requires the Service Manager Internal Audit and Risk (CAE) to coordinate with internal and external assurance providers to consider relying on their work and minimise duplication of effort. This may be achieved via a shared risk assessment with the Council’s external auditors and other sources of external assurance, where relevant. 6.8 The GIAS recognises that there are various relevant outside assurance providers whose authority flows from separate legal or regulatory sources beyond the control or influence of the CAE, and it may not have any ability to access the work of those assurance providers or gain insight into the scope and timing of their work. Under these circumstances, the CAE must consider whether it is possible or practical to coordinate. Page 213
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Handling Information 6.9 The GIAS set out the duty on internal auditors to be faithful custodians of the information they gather, sharing only in limited, defined and controlled ways, and describes the need for awareness of responsibilities in protecting information and demonstrating respect for the confidentiality, privacy and ownership of information. Fraud and Corruption 7.1 In accordance with the Council’s Policy to Combat Fraud, Theft, Bribery and Corruption, management is responsible for the prevention and detection of fraud or corruption. The Internal Audit Section will assist management in fulfilling this responsibility. 7.2 Audit procedures alone cannot guarantee that all fraud or corruption will be detected. Internal Audit will, however, exercise an appropriate level of professional scepticism during audit work and be alert to risks and exposures that could allow the opportunity for fraud or corruption to occur. 7.3 In support of the Council's counter fraud arrangement, the Service Manager Internal Audit and Risk (CAE) will consider including a counter fraud review of the Council’s systems and procedures to minimise the risk and impacts of fraud from internal and external threats. Glossary Board - refers to the Council’s Audit and Scrutiny Committee which has delegated responsibility for overseeing the work of the Internal Audit Service Chief Audit Executive (CAE) - refers to the Service Manager Internal Audit and Risk Page 214
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Appendix 2 Internal Audit Annual Work Programme- 2026/27 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 INTERNAL AUDIT PLAN Auditable Area Audit Scope Strategic Risk Register (Control Assurance) Allocated Days Self-Directed Support Option 1 This audit will assess the effectiveness of governance, financial controls and monitoring arrangements for Self-Directed Support Option 1, where individuals receive a direct payment to arrange their own care. The review will examine eligibility assessments, support planning, payment processing, and oversight of fund usage to ensure compliance with relevant legislation and policies. Delivery of objectives or expected outcomes and Legislative and Regulatory 25 Moray Integration Joint Board- Financial Sustainability The review will assess the robustness of Moray IJB’s financial planning and governance arrangements, including the adequacy of its medium and long-term financial strategies, alignment of resources with strategic priorities and the effectiveness of its risk management Financial 25 Page 215
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in addressing funding pressures. The audit will also consider the clarity and transparency of financial reporting to Moray Council and NHS Grampian. Block Contracts This audit will assess the effectiveness of governance, procurement, and contract management arrangements for block contracts within social care services. It will review how contracts are awarded, monitored, and evaluated to ensure value for money, service quality and compliance with relevant legislation and Council policies and regulations. Delivery of objectives or expected outcomes and Financial 30 INTERNAL AUDIT SECTION ONGOING SERVICE REQUIREMENTS (Allocation of days included within the Moray Council Internal Audit Plan) Category Scope Allocated Days Global Internal Audit Standards The Global Internal Audit Standards (GIAS) require an annual self- assessment as part of a continuous quality assurance and improvement program to ensure that the internal audit function conforms to the standards. This assessment will involve reviewing the Internal Audit Section’s procedures and processes against the GIAS to identify areas for improvement and to inform a Quality Assurance and Improvement Plan (QAIP). 30 Audit Planning for 2027/28 (Includes Council/ MIJB & GVJB) Develop and consult on proposed coverage for the Internal Audit Annual Plan 2027/28. 10 Page 216
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Critical Friend Consultancy In its ‘critical friend’ role, provide internal challenge and quality assurance on projects involving significant 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. 30 Follow-Up Monitor progress with implementation of Internal Audit recommendations. 80 Page 217
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT PERFORMANCE AND RISK COMMITTEE ON 26 FEBRUARY 2026 SUBJECT: PAYMENT VERIFICATION BY: HEAD OF SERVICE / DEPUTY CHIEF OFFICER 1. REASON FOR REPORT 1.1 The purpose of this report is to provide an update on the review of the Payment Verification (PV) Assurance Service provided by National Services Scotland (NSS) Practitioner Services Divisions (PSD), on behalf of NHS Grampian. 2. RECOMMENDATION 2.1 It is recommended that the Committee note: i) the arrangements in place in Grampian for the management of the payment verification process; and ii) the actions already taken to address outstanding issues, with plans for future action to include an update on progress to this Committee annually. 3. BACKGROUND 3.1 NHS Grampian has statutory responsibility for monitoring contracts with Family Health Service (FHS) providers covering General Medical services (GMS), Dental, Pharmacy and Optometry. 3.2 Contracts with independent practitioners for the delivery of FHS, ie General Medical, General Pharmaceutical, General Dental and Ophthalmic services, are mainly subject to nationally agreed terms and conditions, with some exceptions that allow for local agreement on enhanced services. 3.3 NHS Boards are the accountable bodies for the delivery of FHS and are required to ensure that payments made to independent practitioners are valid, timely and accurate and in line with agreed contractual arrangements. The responsibility for Item 12. Page 219
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the planning and delivery of FHS was delegated by NHS Grampian to the three Grampian Integration Joint Boards (IJB’s) with effect from 1 April 2016. Moray Integration Joint Board (MIJB) hosts the Primary Care Contracts Team (PCCT) on behalf of all three IJBs. 3.4 As part of the NHS Grampian Audit process, the PV Assurance Group implements and oversees management arrangements covering pre and post verification of payments across all independent medical, dental, pharmaceutical and ophthalmic primary care practitioners. PV is regulated through the protocols set out in the (NHS) Chief Executive’s Letter (CEL) DL (2023) 24 issued in August 2023. 3.5 NHS Grampian’s PV Assurance Group is chaired by the Service Manager for Primary Care Contracts (PCC). Membership includes Health & Social Care Partnerships (HSCP), Primary Care Leads, Finance Manager, Clinical and Planning Leads, representatives from the PCCT and Practitioners Services Division (PSD). Links are maintained with NHS Grampian Finance Department 3.6 Whilst the majority of PV will be undertaken by PSD, there may be instances where it is more appropriate for PV to be undertaken by the NHS Board. Consequently, there is an onus on PSD and the NHS Board to agree the annual payment verification programme. 3.7 Formal Medical, Pharmacy, Dental and Ophthalmic PV Assurance Meetings are held quarterly, to agree the programme of visits and to ensure appropriate management oversight of the process. PV issues are dealt with on an ongoing basis, as they arise during the course of the year, and are fed through a number of performance and management groups across all contractor areas and within local HSCP performance management structure. 3.8 The majority of visits are proposed to be carried out virtually. However, face to face remains an option if absolutely required. 3.9 A report presented to this Committee on 26 September 2024 (para 11 of minute refers) provided a general update on the PV process when it was agreed that the report was to be shared with Aberdeen City and Aberdeenshire IJBs (complete). A progress update was presented to this Committee in January 2025 (para 10 of the minute refers). 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 Difficulties were experienced in receiving updates on progress for the improvement of PSD/PV outcomes prior to COVID-19 pandemic. 4.2 There are no longer significant delays in the system. 4.3 NHS Grampian had identified lack of consultation on the process in general plus clear governance channels, particularly with respect to NSS PV Reference Groups. This had been escalated via both the national FHS Finance Execs and Primary Care Management Lead groups. Page 220
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4.4 The above is progressing with dialogue ongoing at a national level, and progress has been made to the extent that governance transparency has improved and, whilst both groups referenced in 4.3 remain alert to the situation, it is now dealt with by exception only. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” The MIJB requires effective governance arrangements for those services and functions delegated to it. Such governance arrangements include systems for managing risks. (b) Policy and Legal There are no legal implications arising from this report. (c) Financial implications There are no financial implications arising directly from this report. (d) Risk Implications and Mitigation There is a risk that assurance cannot be provided to NHS Grampian that Payment Verification is being carried out appropriately. (e) Staffing Implications There are no staffing matters arising directly as a result of this report. (f) Property There are no implications in terms of Council or NHS property directly arising from this report. (g) Equalities/Socio Economic Impact An Equality Impact Assessment is not required because there are no service, policy or organisational changes proposed in this report. (h) Climate Change and Biodiversity Impacts There are no matters arising directly as a result of this report. (i) Directions There are no directions directly as a result of this report. (j) Consultations Consultation has taken place with the Head of Service, Service Manager Primary Care Contracts and Finance Manager regarding this report. 6. CONCLUSION 6.1 It is encouraging to note governance of the PV process nationally has improved Page 221
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6.2 Updates will be brought back to this Committee annually. Author of Report: Peter Maclean, Service Manager, Primary Care Contracts Background Papers: DL (2023) 24 - Revised Payment Verification Protocols Ref: Page 222
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 26 FEBRUARY 2026 SUBJECT: UNSCHEDULED CARE – HOME ASSESSMENT PATHWAY BY: HEAD OF SERVICE 1. REASON FOR REPORT 1.1 To inform Committee of the successful bid to implement a Moray Home Assessment Pathway, highlighting how this development supports the delivery of Moray Integration Joint Board’s (MIJB’s) strategic priorities as outlined in the Strategic Plan, as well as contributing to the nine national Health and Wellbeing Outcomes. 1.2 This new pathway aims to maintain a strong focus on transformational change, enabling services to be delivered sustainably within the resources available. 2. RECOMMENDATION 2.1 It is recommended that the Board: i) consider and note the content of the report; and ii) agree that the pathway aligns with and supports the aspirations of the MIJB’s Strategic Plan in relation to Home First. 3. BACKGROUND 3.1 In August 2025, Moray Health and Social Care Partnership (HSCP) submitted a successful bid to the Scottish Government (SG) to enhance and embed a Home Assessment Pathway within existing services that supports people to leave hospital as soon as they are clinically able and help avoid hospital admission where appropriate. The incorporation of a flexible, dynamic, multi-disciplinary and collaborative pathway will allow for people to be assessed at home, in the environment which they will continue to live, ensuring they are safe and as independent as possible, for as long as possible. 3.2 The programme aims to: Item 13. Page 223
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o Reduce avoidable hospital admissions by providing timely, community- based interventions. o Enhance frailty management within primary care and at the Front Door to improve patient independence and quality of life, aligned with Frailty at Front Door work. o Enable timely and effective hospital discharges, reducing bed occupancy and improving patient outcomes, linking with the Discharge Without Delay planned date of Discharge works. o Strengthen collaboration between general practice, community teams, and secondary care to ensure seamless transitions. o Increase primary care capacity to manage complex patients within the community, reducing reliance on acute care. o Improve efficiency by optimising resource use and reducing service duplication. o Ensure alignment with the NHSG GP Vision programme, Home First and Discharge Without Delay frameworks, focusing on innovation, workforce development, and sustainable models of care. 3.3 The pathway will enable proactive interventions that prevent unnecessary hospital admissions, support improved discharge planning, and ensure that frail and elderly patients receive the right care, in the right place, at the right time. Strengthening primary and inpatient capacity will reduce pressure on secondary care services and support more efficient, patient-centred care. 3.4 The model supports integration between general practice, community health services, and social care, ensuring a seamless healthcare experience for patients, underpinned by the Getting It Right for Everyone (GIRFE) principles, the NHSG GP Vision programme, supporting Moray HSCP’s Discharge Without Delay and Unscheduled Care Frameworks and reinforcing the commitment to Home First. 3.5 The pathway considers all elements of support including medication reviews, care facilitation, telecare and technological aids, proportionate care, volunteers, equipment and social support, such as third sector befriending services. 3.6 Collaboration will be central to the pathway. This is about optimising and enhancing the services to increase capacity and coordination. The current criteria for Discharge to Assess (D2A) and Community Response Teams will be removed, eliminating barriers and supporting people to remain safely at home. The only criteria will be the service’s capacity to meet the needs of the person. 3.7 Assessment at home requires a culture shift by the HSCP’s staff across community and secondary care services and the requirement to update and inform the public. 3.8 The model consists of 4 pathways: Page 224
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3.9 Timescale Phase 1 Launch Jan 2026 Phase 2 Expansion Mar 2026 KPI Review Quarterly Final Evaluation Mar 2027 3.10 Budget Total Estimated Cost: £1,391,682 Includes staffing (£1.3M), equipment (£60K), and contingency (£100K). The funding is recurring, (performance based), and is subject to enhanced reporting to SG as part of the Unscheduled Care Improvement Programme. The bid was successful and Moray HSCP have received the full allocation. 3.11 Governance o Oversight: Home First Steering Group, Unscheduled Care Improvement Board. o Reporting: Operational Management Group, Senior Management Team, Moray IJB, and SG. Reporting occurs weekly to the Unscheduled Care Board and monthly to the SG. o Evaluation: Regular reviews for sustainability, quality, and satisfaction. Page 225
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3.12 Progress to Date Recruitment As of January 2026, the majority of posts have now been successfully recruited to. 3.13 Slippage spends Moray HSCP have been supported to access slippage funds from across Grampian with Unscheduled Care (USC) funding in Moray until end of March 2026, this has funded: o Surge beds are open in two of the community hospitals with bank nurse staff providing Senior Charge Nurse backfill. This has allowed movement of patients from acute settings into the community. o Care homes – funding for four interim beds to support discharge flow. o Purchasing telecare equipment such as medication dispensers and prompt devices, enabling reduced home care packages and supporting independence. o Additional nursing capacity within Community Response Teams, including a nurse on call service until 2000hrs. Enabling improving targeted triage and support. Enabling available care to be directed to the right people. 3.14 Discharge Without Delay The National Discharge Without Delay Programme continues to be developed concentrating on 4 priority areas. These are: o Frailty at the Front Door o Planned Day of Discharge Setting and Pilots (PDD) o Community Hospital / Step Down Rehabilitation Units (national) o Discharge To Assess (D2A)/ Home First (local) 3.15 Frailty at the Front Door As part of their separate unscheduled care funds bid, Dr Gray’s made a successful bid for enhanced Allied Health Professional (AHP) cover at the front door (Occupational Therapy and Physiotherapy), as well as for a discharge hub. Moray HSCP are collaborating with Dr Gray’s on all programmes. 3.16 Predicted Date of Discharge (PDD) Moray is taking part in a PDD pilot to improve the planning of discharge. Compliance is in the 90-95% bracket and the HCSP are looking at use of the discharge tab in Trak to facilitate better discharge with the most up to date and reliable information across its entire Multi-Disciplinary Team staffing. 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. This report supports the strategic objectives. b) Policy and Legal There are no new policy or legal implications arising directly from this report. Page 226
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The report is consistent with existing statutory duties and governance arrangements. c) Financial implications There are no direct financial implications associated with this report as new recurring funding is being provided by SG. However, performance insights may inform future resource planning and monies received from SG. d) Risk Implications and Mitigation While there are no immediate risks arising from this report, at present, please note the risks listed in paragraph 5. If performance is not met, SG will reduce or remove funding and the permanent staff will be at the expense of NHSG. NHSG have recognised this risk. e) Staffing Implications While there are no direct staffing implications arising from this report, it is important to acknowledge the ongoing challenges with recruitment across health and social care services. Any staffing implications will be considered under the relevant policy. f) Property There are no property implications directly associated with this pathway as utilising buildings already in use. g) Equalities/Socio Economic Impact An Equality Impact Assessment (EIA) is not required for this report, as it does not introduce or amend any policy or service that would directly affect individuals with protected characteristics. However, performance data may be used to inform future service improvements that promote equity and inclusion. h) Climate Change and Biodiversity Impacts There are no direct climate or biodiversity implications arising from this report. However, it is recognised that extreme weather events and rising energy costs may increasingly impact service delivery, particularly in rural areas. These factors will be considered in any future design work. i) Directions No new directions are required as a result of this report. j) Consultations This report was in collaboration with the Home Assessment Oversight Group. 5. CONCLUSION 5.1 The Committee is asked to recognise the significant contribution of staff across all sectors that have supported the development of this challenging yet transformative pathway. The collective efforts have enabled the creation of a model that enhances patient experience, strengthens system Page 227
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integration, and supports delivery of the Board’s strategic priorities. The Home Assessment Pathway represents a major step forward in embedding sustainable, person centred care in Moray and will be instrumental in driving improved outcomes for the population. Author of Report: Sean Coady, Deputy Chief Officer, Moray HSCP Background papers: On request Page 228