Agenda Document Pack - Audit, Performance and Risk Committee - 30/06/2022
Moray Council · 30 June 2022
Back to Audit, Performance and Risk Committee — 30 June 2022 and its agenda
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Audit, Performance and Risk Committee Thursday, 30 June 2022 remote locations via video conference NOTICE IS HEREBY GIVEN that a Meeting of the Audit, Performance and Risk Committee, remote locations via video conference, on Thursday, 30 June 2022 at 14:00 to consider the business noted below. AGENDA 1. Welcome and Apologies 2. Declaration of Member's Interests 3. Minute of Meeting of 31 March 2022 3 - 6 4. Action Log of Meeting of 31 March 2022 7 - 8 5. Quarter 4 Performance Report 9 - 52 6. Internal Audit Completed Projects 53 - 60 7. Strategic Risk Register Report 61 - 92 8. Internal Audit Annual Report 2021-22 93 - 102 Page 1
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MORAY INTEGRATION JOINT BOARD SEDERUNT Mr Sandy Riddell (Chair) Mr Derick Murray (Voting Member) Councillor John Divers (Voting Member) Councillor Scott Lawrence (Voting Member) Mr Sean Coady (Member) Mr Steven Lindsay (Member) Ms Jane Mackie (Member) Simon Bokor-Ingram (Member) Jeanette Netherwood (Member) Mr Neil Strachan (Member) Clerk Name: Tracey Sutherland Clerk Telephone: 07971 879268 Clerk Email: committee.services@moray.gov.uk Page 2
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MINUTE OF MEETING OF THE AUDIT, PERFORMANCE AND RISK COMMITTEE Thursday, 31 March 2022 To be held remotely in various locations, PRESENT Ms Tracey Abdy, Simon Bokor-Ingram, Mr Steven Lindsay, Ms Jane Mackie, Mr Derick Murray, Mr Sandy Riddell APOLOGIES Councillor Frank Brown, Mr Sean Coady, Councillor Theresa Coull, Mr Neil Strachan IN ATTENDANCE Also in attendance were Corporate Manager, Internal Audit Manager and Tracey Sutherland, Committee Services Officer. Maggie Bruce, Audit Scotland was also in attendance. 1. Welcome and Apologies Sandy Riddell as Chair of the meeting welcomed everyone and apologies were noted. 2. Declaration of Member's Interests There were no declarations of Members' Interest in respect of any item on the agenda. 3. Thanks The Committee joined the Chair in thanking Tracey Abdy, Chief Financial Officer, for her hard work, assistance and guidance during her time as Chief Financial Officer. Ms Abdy leaves her post on 31 March 2022. 4. Minute of Meeting of 6 December 2021 Item 3. Page 3
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The minute of the meeting of 6 December 2021 was submitted and approved. 5. Action Log of Meeting of 6 December 2021 The Action Log of the meeting dated 6 December 2021 was considered and updated accordingly. 6. Performance Report - Quarter 3 A report by the Chief Financial Officer updated the Audit, Performance and Risk Committee on performance as at Quarter 3 (October to December 2021). The Corporate Manager updated the Committee to confirm that for future reports, waiting times at Accident and Emergency will be included in the figures provided. The Chair sought information on the actions being taken within NHS Grampian and Moray Council to help relieve the pressures on staff within the organisations be included in future reports. Following further consideration, in which Officers answered questions regarding D2A, mental health services and Social Care staff recruitment and the pressures on staff across the organisation, the Committee agreed to note: i) the performance of local indicators for Quarter 3 (October to December 2021) as presented in the Performance Report at Appendix 1; ii) the analysis of the local indicators that have been highlighted and actions being undertaken to address performance that is outside of acceptable target ranges as detailed in Appendix 1; and iii) the introduction of management dashboards using the Pentana Risk software to enable managers to monitor performance (an example is at Appendix 2). 7. Internal Audit - Completed Projects A report by the Chief Internal Auditor provided an update on audit work completed since the last meeting of the Committee. Following consideration the Committee agreed to note this audit update. 8. Strategic Risk Register A report by the Chief Officer provided an overview of the current strategic risks, along with a summary of actions which are in place to mitigate those risks, updated in March 2022. Following consideration the Committee agreed to: i) note the updated Strategic Risk Register included in appendix 1; and ii) note the Strategic Risk Register will be further refined to align with the transformation and redesign plans as they evolve. Page 4
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9. Internal Audit Plan 2022-23 A report by the Chief Internal Auditor provided the Committee with information on the proposed internal audit coverage for the 2022/23 financial year. Following consideration the Committee agreed the proposed audit coverage. 10. Civil Contingencies Resilience Standards Report A report by the Corporate Manager informed the Committee of progress against NHS standards and provided an overview of the work of the Health and Social Care Moray (HSCM) Civil Contingencies Group. Following consideration the Committee agreed: i) to note progress to date and contents of this report alongside the HSCM Civil Contingencies Group Action Plan (Appendix 1); and ii) request that an annual assurance report to this Committee from the HSCM Civil Contingencies Group. 11. External Review of Commissioned Services A report by the Chief Officer informed the Committee of the outcome of an external review of the Health and Social Care (HSCM) commissioning service. Following consideration the Committee agreed: i) to request that an external review is commissioned through an external audit organisation as a paid for commission. ii) to note the findings of the external review included in Appendix 1. Page 5
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MEETING OF MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE THURSDAY 31 MARCH 2022 ACTION LOG Item No. Title of Report Action Required Due Date Action By Update for 30/6/22 1. Action Log of Meeting dated 27 August 2020 Payment Verification Assurance Update – once through appropriate NHSG Governance route. June 2022 Sean Coady Payment verification has not yet resumed – update in CO report 30/6/22 2. G-OPES Reporting proposals from G-OPES to be considered by IJB. June 2022 CO HSCM Included in risk register report 3. Performance Report – Quarter 3 Information on actions being taken by NHS Grampian and Moray Council to help relieve pressures on staff within the organisations to be included in future reports. June 2022 Jeanette Netherwood Noted Both Moray Council and NHS Grampian have dedicated workstreams that cover all our employed staff and are managed by each organisation. 4. Civil Contingencies Annual Assurance Report from HSCM Civil Contingencies Group March 2023 Jeanette Netherwood scheduled Item 4. Page 7
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Item No. Title of Report Action Required Due Date Action By Update for 30/6/22 Resilience Standards Report 5. External Review of Commissioned Services External Review to be commissioned. Aug 2022 CO HSCM In process of procurement. Report scheduled for APR in August Page 8
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 30 JUNE 2022 SUBJECT: QUARTER 4 (JANUARY TO MARCH 2022) PERFORMANCE REPORT BY: CORPORATE MANAGER 1. REASON FOR REPORT 1.1 To update the Audit, Performance and Risk (APR) Committee on performance as at Quarter 4 (January to March 2022). 2. RECOMMENDATION 2.1 It is recommended that the APR Committee consider and note: i) the performance of local indicators for Quarter 4 (January to March 2022) as presented in the Performance Report at APPENDIX 1; ii) the analysis of the local indicators that have been highlighted and actions being undertaken to address performance that is outside of acceptable target ranges as detailed in APPENDIX 1; iii) the performance of the indicators reported to the Ministerial Strategic Group (MSG) for Health and Community Care (latest published data) as presented at APPENDIX 2; and iv) the performance of the Health and Social Care Integration: core indicators for the reporting year 2021/22 as presented at APPENDIX 3. 3. BACKGROUND 3.1 The purpose of this report is to ensure the Moray Integration Joint Board (MIJB) fulfils its ongoing responsibility to ensure effective monitoring and reporting on the delivery of services and on the programme of work as set out in its Strategic Plan. 3.2 APPENDIX 1 identifies local indicators for the MIJB and the functions delegated by NHS Grampian and Moray Council, to allow wider scrutiny by the Board. Item 5. Page 9
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3.3 APPENDIX 2 allows the AP&R committee to scrutinise the performance of HSCM against the six indicators used by the MSG to monitor progress of the MIJB ‘to realise the full potential of integration and ensure that the people of Scotland get the right support, in the right place, at the right time, no matter their care needs.’ 3.4 APPENDIX 3 is included for the first time to allow the AP&R committee to scrutinise performance against the national indicators (Health and Social Care Integration: core indicators) that Integration Authorities are required to use to measure progress towards the National Health and Wellbeing Outcomes. The latest available data are for the year 2019/20 for the ten outcome indicators and 2020/21 for the data indicators; the 2021/22 data are expected to be published in September 2022. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 Local Indicators are assessed on their performance via a common performance monitoring Red, Amber, and Green (RAG) traffic light rating system. RAG scoring based on the following criteria: GREEN If Moray is performing better than target. AMBER If Moray is performing worse than target but within agreed tolerance. RED If Moray is performing worse than target by more than agreed tolerance. 4.2 The detailed performance report for quarter 4 is attached in APPENDIX 1. Summary 4.3 Performance within Health and Social Care Moray (HSCM) as demonstrated by the agreed indicators up to the end of quarter 4 of the financial year 2021/22 is showing as variable. Three of the indicators are presenting as green, two are amber and five are red. This represents a reduced performance compared to both quarters 2 and 3 and is a reflection of the significant additional pressure placed on the service during quarter 4. 4.4 Figure 1 provides a summary and the historical trend by indicator since quarter 3 of year 2020/2021. A summary of performance for each of the 6 reporting categories is provided below. Two of these areas are presenting as green, while one is Amber and the other three are red. EMERGENCY DEPARTMENT - GREEN There has been no appreciable change in the rate per 1,000 this quarter from 20.0 to 20.2, meeting the target but still well above the number presenting at the same period last year. However, the rate in February had reduced to 18.1 and the figure for March reversed the trend of the previous 4 months. DELAYED DISCHARGES – RED The number of delays at the March snapshot was 46 (up from 39 at the end of the previous quarter), remaining well above the revised target of 10. The number of bed days lost due to delayed discharges was 1294 (up from 1142). Page 10
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EMERGENCY ADMISSIONS – RED There continues to be a steady increase each month in the rate of emergency occupied bed days for over 65s, as noted in previous reports. Since the end of quarter 4 last year the rate has increased from 1,773 to 2,140, exceeding the target of 2,037 per 1,000 population. The emergency admission rate per 1000 population for over 65s has reduced from 187.2 to 183 during quarter 4 and remains AMBER, while the number of people over 65 admitted to hospital in an emergency also reduced from 126.3 to 125.2 over the same period, and also remains AMBER. HOSPITAL RE-ADMISSIONS - GREEN Both indicators in this barometer remain green having continued the improvements noted in the previous 2 quarters. 28-day re-admissions are 8.0% and 7-day re-admissions are at 3.4%. MENTAL HEALTH – RED After achieving 100% for the 6 months from December 2020 through to June 2021 there has been a further reduction in performance during quarter 4 with 33.3% of patients being referred within 18 week, compared to 67% last quarter. STAFF MANAGEMENT – RED NHS employed staff sickness levels have reduced again to 4.7% from 5.5%, but remain above the target of 4%. Council employed staff sickness was 8.05% last quarter, remaining above the 4% target. Unfortunately, sickness within the Moray Council Human Resources team who deal with information management has meant the data for quarter 4 have not yet been published. Figure 1 – Performance Summary Q4 2021 Q1 2122 Q2 2122 Q3 2122 Q4 2122 New Target Previous Target Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar (from Q1 2122) (from Q1 2021 or earlier) AE Accident and Emergency AE-01 A&E Attendance rate per 1000 population (All Ages) 17.8 23.5 21.7 20.0 20.2 no change 21.7 G‚ DD Delayed Discharges DD-01* Number of delayed discharges (including code 9) at census point 17 20 30 39 46 no change 10 R DD-02 Number of bed days occupied by delayed discharges (including code 9) at census point 496 592 784 1142 1294 no change 304 R EA Emergency Admissions EA-01 Rate of emergency occupied bed days for over 65s per 1000 population 1773 1859 1934 2045 2140 2037 2107 R EA-02 Emergency admission rate per 1000 population for over 65s 174.8 185.9 190.4 187.2 183 179.9 179.8 A EA-03 Number of people over 65 years admitted as an emergency in the previous 12 months per 1000 population 119.3 124.1 126.7 126.3 125.2 123.4 124.6 A HR Hospital Readmissions HR-01 % Emergency readmissions to hospital within 7 days of discharge 5.0% 4.4% 4.1% 3.5% 3.4% no change 4.2% G‚ HR-02 % Emergency readmissions to hospital within 28 days of discharge 9.8% 9.2% 8.4% 8.4% 8.0% no change 8.4% G‚ MH Mental Health MH-01 % of patients commencing Psychological Therapy Treatment within 18 weeks of referral 100% 100% 100% 67% 33.0% no change 90% R SM Staff Management SM-01 NHS Sickness Absence (% of hours lost) 3.1% 4.2% 6.0% 5.5% 4.7% no change 4% R Health and Social Care Moray Performance Report Code Barometer (Indicator) RAG Page 11
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AREAS NOT MEETING TARGETS Delayed Discharge 4.5 As predicted in the previous report the two indicators shown under the Delayed Discharge heading (DD-01 and DD-02) continue to be red and remain well above the new targets set at the end of quarter 3 of 2020/21. The reasons for the above target levels remain the same; there as an additional demand from the increase in COVID-19 cases linked to the Omicron variant during the first few weeks of the quarter, along with the previously reported increased frailty and more complex needs of patients. Staff absences due to sickness (COVID-19, self-isolation and non-COVID-19 related illnesses) remained high for Council staff during quarter 4, and lower, but above target, for NHS staff. External providers of care within Moray were also experiencing similar high levels of staff as were care homes. This significantly limited the ability to meet the demand for care at home. Although the availability of beds in care homes increased during quarter 4 there continued to be insufficient beds available to meet demand. 4.6 At the end of quarter 4 four of the 14 care homes were at ‘Red’ status for COVID-19 and unable to receive residents, and the remaining 10 were ‘Green’. This represents a turnaround from the situation reported at the end of last quarters when 7 care homes were ‘Red’ and 7 ‘Amber’. This was caused by the impact of COVID and a diarrhoea and vomiting virus on staffing levels and impact of measures implemented to reduce the spread to those in the home. 4.7 The measures outlined in previous report have had some effect in reducing the number of delayed discharges. However, the number of people delayed each day on average was over 40 during quarter 4, and the indications are that it is reducing very slowly (Figure 1). Figure 1: Average Number of Delayed Discharge Patients in Moray per Week 4.8 Figure 1 indicates how much higher the numbers of patients are each day who face a delayed discharge from hospital compared to last winter, illustrating the scale of the task faced by health and social care teams. While the trend is showing a reduction in the number of people affected it is a very gradual reduction and represents a significant loss of bed–capacity for other medical procedures, for example, and an additional unplanned burden on hospital and social care staff. There are considerable efforts being made across the system to move people to the most appropriate place to meet their needs as quickly as possible, but during quarter 4 there was restricted flow Page 12
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due to the impacts being felt across all teams due to staff absences caused by COVID-19. Emergency Admissions 4.9 Emergency Admission rates for the over 65s (EA-02) have reduced during quarter 4, continuing the trend observed in the previous quarter. Note that the rate of 183 per 1,000 population remains above the target based on the 2019 average of 179.9 per 1,000 population. Similarly, the number of people admitted as an emergency over 65 years old (EA-03) has followed a similar trend. This indicator was showing a consistent downward trend but between February and July 2021, the trend reversed and increased rapidly. Since August 2021 the number of emergency admissions for this age group levelled- off and in quarter 4 the rate reduced to 125.2 per 1,000 population, just above the target of 123.4 per 1,000 population (also based on the 2019 average). Note that the Emergency Occupied Bed Days for over 65s (EA-01) has been increasing steadily since the start of 2021 and continued to increase each month during quarter 4 reaching a rate of 2,140 bed-days per 1,000 population, exceeding the target of 2,037 per 1,000 population. 4.10 While the rate per 1,000 population presenting at ED is meeting the required performance level the proportion of patients seen within the 4-hour target time has dropped significantly since May 2021 (Figure 2). Prior to March 2020 over 95% of attendees at ED were seen within 4 hours, generally reducing to 90% in the winter months. Since May 2021 this rate has dropped to around 80%, and in January 2022 (the latest available data) the rate was 80.3%. Performance is below target and has deteriorated during 2021/22. Figure 2 – Percentage of patients seen within 4 hours (all ages) – (PHS, A&E Datamart) Mental Health 4.11 There was a reduction in the percentage of patients receiving psychological therapy treatment within 18 weeks (MH-01) for the second successive quarter from 67% to 33% at the end of March 2022. This reduction is in contrast to the first 6 months of 2021 when the percentage meeting the 18-week timescale was consistently 100%. This is due to capacity issues in the team and an increase in referrals. 4.12 For information, a workshop will be held on 29 June 2022 for all staff delivering psychological therapies in Moray to look at how the position can be improved. Staff Management Page 13
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4.13 The number of cases of COVID-19 being reported across Scotland peaked in mid-March 2022 and by the end of quarter 4 the number for Moray was 704 cases (equivalent to 737 per 100,000 population), virtually identical to the national rate of 742 per 100,000 population. 4.14 At the end of quarter 4 Moray vaccination rates for all residents aged 12 years old and over were less than the Scottish average rates for 1st and 2nd dose vaccinations at 89.6% and 85.2% respectively (compared to 93.3% and 87.3% for Scotland)1. In Moray 72.8% of the population have had a third vaccination, almost identical to the national rate of 72.9%. There was a marked rise in hospital admissions in Scotland during the middle part of quarter 4 significantly higher than the previous spikes observed during the pandemic. Although the numbers started to reduce during the final 2 weeks of the quarter the figure of 235 admissions per day remains high (Figure 3). Admissions to ICU, however, remained at relatively low levels with the end of quarter 7-day average of 6.43 being almost half the figure of 11.86 recorded in September 2021 and almost one-third of the 16.43 recorded in January 2021.2 Figure 3 - Hospital admissions 1 April 2020 to 31 March 2022 (PHS Data) 4.15 The average absence due to sickness for all Moray Council staff since May 2020 was 6.9% at the end of quarter 4. This is just above the Scottish average of 6.1% for the same period and above the pre-pandemic levels. The rising level of absence reported in the previous 2 quarters continued into quarter 4 reaching 10.5%. Over the same period NHS staff absences due to sickness reduced from 5.5% in quarter 3 to 4.7%. 4.16 Although the quarter 4 absence percentage for Moray Council employed Health and Social Care staff is not available, the locally collected data for Provider Services provides an illustration of the magnitude of the difficulties facing managers (Figure 4). Since the second week in March 2022 there was a steady reduction in absences from over 17% to 7.25% at the end of April. Since then, the percentage has risen steadily each week and by 1 June 2022 (admittedly outside the scope of this report) it had risen to 11.6%. 1 https://coronavirus.data.gov.uk/details/vaccinations?areaType=nation&areaName=Scotland Data to 31 March 2022. 2 Data for this measure is not available for individual local authorities. Page 14
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Figure 4: Provider Services staff absence rate since 26 January 2022 (service collated data) 4.17 The recruitment cell continues to give excellent support to Provider Services working with locality managers to highlight the team and their role. Not only is there a steady supply of recruits to the care teams the cell also is taking some of the pressure off the workload Provider Services managers, for instance by carrying out interviews of potential recruits, developing locality specific adverts, promoting the care profession and networking with Moray College UHI to access training. The Recruitment cell is creating their team plan for the remainder of the year and will be focussing on localities with their next recruitment drive to target areas where there are low numbers of Social Care Assistants (SCAs). 4.18 Due to projects and other commitments Care Officers have not been able to provide the usual level of support to SCAs and it has not been possible to backfill these posts. Action is being taken by Care at Home which should rectify this situation. 4.19 The profile of the role of SCAs has been raised through Social Media showing possible career progression paths and also to show the high regard the SCAs are held in by the service users. Links are included to the videos placed on social media, including a video made by the DYW with support from school pupils: • https://m.facebook.com/watch/?v=1368388736919899&_rdr • https://www.facebook.com/watch/?v=379061773356751 • https://www.youtube.com/watch?v=vJgpPg9TaPI 4.20 Managers continue to be faced with daily challenges to find staff to allocate to rosters and to maintain the delivery of their services, and to prioritise the services being provided. For example, within both Community nursing teams and community hospitals all teams are supporting each other, where possible, to cover sickness and vacancies. There is a national shortage of trained District Nurses and this is reflected in the Moray workforce. However, with the agreement of City and Shire colleagues we are offering 3 trainee opportunities this year, as opposed to the 2 we normally offer. Although it will take 2 years to reap the full benefits at least it is someway in addressing the shortfall within this workforce. Recruitment of staff continues to be challenging but we have Page 15
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opportunities and areas where we can support New Graduate Nurses and by September, hope to have at least 3 in post within both community nursing and community hospitals. 4.21 There are 2 District Nurse Team leaders seconded until December and March which has a domino effect and as a result there are 3 other District nurses seconded in to cover these roles. This comes with its own challenges of trying to work creatively to ensure safe working and safe patient care with limited resources. 4.22 The HSCM team has been supported since January 2022 by Moray Council HR to identify ways of redeploying and recruiting additional staff to provide adequate cover to meet demand. An internal request for support for Council staff to redeploy to support HSCM had limited impact. Of the dozen or enquiries, only 1 person matched with administration work; nothing further came of the exercise as the key requirement was the need for caring work and volunteers were not willing to undertake such tasks. 4.23 The other support provided by HR included training, recruitment, and retention. The Moray Council Social Work Training Team were ready to respond as required, matching needs of recruits with training requirements as well as arranging and delivering the training. An open advert for Social Care Assistants (SCAs) was successful in encouraging people to apply for posts. In March there were 4 or 5 interviews a week in response to the advert with recruits coming from other care providers as well as from outwith the care sector. Since then, there has been a continuing stream of applicants. 4.24 Additionally, the HR team has worked with local partners to identify other ways of recruiting staff into the HSCM team. The Department for Work and Pensions (DWP) now promote current vacancies to all work coaches in Moray to raise the profile of care work. Moreover, an HSCM manager was the guest speaker at the end of January at a meeting with work coaches to promote the vacancies, explore the possibility of a Sector Base Academy initiative and to review our work experience agreement with the DWP. Developing the Young Workforce Moray have bene given access to promotional equipment and are working with the service on a campaign for encouraging young people into the care sector. 4.25 Job adverts have been placed with the local military organisations to encourage spouses and partners to consider care roles. Managers have attended job fairs in Inverness and Buckie but these were of limited value. 4.26 In order to understand why people leave the service there have been discussions with a small group of SCAs who were able to air their concerns. Exit interview forms do not provide much information other than the common theme of poor communication. The report last quarter highlighted the reduction on working hours as people were looking for ways to balance their work and domestic commitments. This has continued, and requests are generally supported as there is a risk of losing the employee altogether and it considered to be a better option to retain staff, albeit working fewer hours, to have some availability to cover shifts. However, a more planned approach is in place as it is not possible to cover the number of hours required to meet the demand if there is an increased reliance on those on zero hours contracts Page 16
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rather than those with confirmed contractual hours. Requests for reducing hours from staff are now closely managed and there have been discussions with unions about the approach being taken. 4.27 Burn-out amongst staff, supervisors and managers caused by continuing high levels of absence and the constant crisis management to cover shifts on a daily basis threatens the long-term ability of the service to meet demand. The report on Unmet Need in Health and Social Care Moray, approved by the Moray Integration Joint Board at their meeting held on 31 March 2022 (item 9 of the minutes refers) noted the conclusion of a study published in November 2021 that found COVID-19 stress was a significant independent predictor of a decline in the mental wellbeing of health and social staff in Scotland.3 Furthermore, pressure on the system remains high with levels of unmet need and number of people experiencing delayed discharge above pre-pandemic levels. Demand is likely to increase as the population of Moray continues to age, as reported to the Moray Integration Joint Board Clinical and Care Governance Committee at the meeting held on 26 May 2022 (agenda Item 9). 4.28 Due to the continued and increasing pressures on staffing across HSCM focussed effort is being put into collation and identification of potential staffing pressures across HSCM services, especially when there are high levels of community transmission of Covid. The key staffing information regarding annual leave, sickness absences, covid related absences and vacancies in order to obtain the necessary management information to inform decisions regarding the allocation of staff resources. This was instigated in January 2022 and is being overseen by SMT. A short daily response huddle of service managers has been instigated and meets at 9:00am weekdays to review immediate pressures and look for solutions or provision of support where possible. MINISTERIAL STRATEGIC GROUP (MSG) FOR HEALTH AND COMMUNITY CARE 4.29 The six MSG indicators provide an indication of the progress being made to realise the full potential of integration and the data are collated and circulated by Public Health Scotland (APPENDIX 2). Performance can be summarised as follows, but the advice is to treat with caution, as the response to the pandemic and the unusual nature of the past 2 years have had an incalculable impact on integration activities. 4.30 Emergency Admissions There were 1,907 emergency admissions in quarter 4, the lowest quarterly figure during 2021/22. The average number of admissions in each quarter of 2021/22 was 2,054, which compares with pre- pandemic averages. Numbers of emergency admissions dropped by about 25% during the Quarter 1 2020/21, which was the first quarter after the lockdown measure were introduced, but since then the monthly figure has been between 600-700 (approximately). Performance can be summarised as stable. There were 1,448 admissions from the Emergency Department (ED) in quarter 4, down from 1,596 in quarter 3. Prior to the Covid-19 pandemic there 3 Cogan, N., Kennedy, C., Beck, Z., McInnes, L., MacIntyre, G., Morton, L., Kolacz, J., & Tanner, G. (2021). ENACT project: understanding the risk and protective factors for the mental wellbeing of health and social care workers in Scotland: adapting to the challenges and lessons learned. Poster session presented at NHS Research Scotland Mental Health Annual Scientific Meeting 2021, Online, United Kingdom. Page 17
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were around 1,100 admissions from ED each quarter, but this figure has now been consistently around 1,500 during 2021/22. Performance appears to have stabilised, but at a higher level than before the pandemic. 4.31 Unscheduled hospital bed days - The number of unscheduled hospital days for acute specialities (all ages) was 11,972 in quarter 4, down from 13,191 in quarter 3, and 25% lower than the highest recorded figure of 16,013 bed days in quarter 1 2018/19. The quarter 4 figures were lower than usual due to the untypically low number of unscheduled bed days in January 2022 (3,030) and if the March figure (4,688) is repeated in coming months then next quarter is likely to be back to more typical. The reason for the reduced number in January is not clear but it did coincide with the rise in the number of cases of the Omicron variant. Performance is probably stable, albeit at a lower level than before the pandemic. 4.32 A&E (now known as ED) attendance - The graph of ED attendance numbers mirrors the various phases of the COVID-19 outbreak. After the initial lockdown in March 2020 the number of patients presenting at the ED roughly halved from their typical figure of over 2,000 per month. Numbers were back at typical levels over the summer of 2021, reducing to 1,900 per month in the autumn. But as the Omicron variant arrived in Moray ED attendance reduced in February 2022. Consequently, for quarter 4 there were 4,903 attendees at ED, 900 fewer than in quarter 3. Long-term performance won’t be clear for a few quarters, but there are indications that if the March 2022 monthly figure is repeated, then performance has reduced from pre- pandemic levels. However, more data are required before this assessment can be made with any certainty. 4.33 On the other hand, it is clear that the 4-hour ED waiting time target is not being met, as described at paragraph 4.10 previously. 4.34 Delayed Discharges - The number of delayed discharge bed-days also mirrors the peaks and troughs of the pandemic, but with 1,201 bed-days recorded in January 2022 (the latest available data) performance is similar to pre-pandemic levels. 4.35 End of life care - In 2020/21 (the latest available data) 91.7% of residents spent the last 6 months of their life in a community setting4, 5% were in a large hospital, and 3.2% were in a community hospital. The proportion in a community setting has increased gradually from 88.8% in 2013/14 while those in a large hospital has reduced from 7% over the same period. Community hospital figures have remained close to 4%. 4.36 The balance of care across institutional and community services - The most recent published data relates to 2019/20 which show that the majority (98.1%) of people are able to live unsupported in their own homes. 1.1% are supported in their homes, 0.5% in care homes and the remainder in hospital, community hospitals or hospice/palliative care. The breakdown between these settings has remained virtually unchanged since 2013/14. 4 Community includes care home residents as well as those living in their own home. Page 18
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NATIONAL HEALTH AND SOCIAL CARE INTEGRATION; CORE INDICATORS 4.37 The core indicators have been developed to measure progress that IJBs are making towards meeting the National Health and Wellbeing Outcomes and are being reported to this committee for the first time. The figures are published annually for the data indicators and biennially for the ten outcome indicators (APPENDIX 3). The 2021/22 figures for the outcome indicators have recently become available, but not yet for the data indicators. However, the 2020/21 data indicators are included for information. 4.38 In 2021/22 performance across Scotland reduced for all 9 of the reported outcome indicators compared to 2019/20. Moray mirrored the national performance apart from recording a small improvement in the percentage of carers who feel supported to continue in their caring role. However, it should be noted that the sampling method used for data gathering means the results have a degree of uncertainty, so changes or differences of 1% or 2% are likely to be statistically insignificant. 4.39 The comparison for each indicator is as follows: • Exceeding or equalling Scottish average: o Percentage of adults able to look after their health very well or quite well (Moray 93%; Scotland 91%) o Percentage of adults supported at home who agreed they are supported to live as independently as possible (Moray 79%; Scotland 79%), and o Percentage of carers who feel supported to continue in their caring role (Moray 32%; Scotland 30%), • Below Scottish average: o Percentage of adults supported at home who agreed that they had a say in how their help, care or support was provided (Scotland 71%; Moray 70%) o Percentage of adults supported at home who agreed that their health and social care services seemed to be well co-ordinated (Scotland 66%; Moray 62%) o Percentage of adults receiving any care support who rate it as excellent or good (Moray 68%; Scotland 75%). o Percentage of people with positive experience of care at their GP practice (Scotland 67%; Moray 60%), o Percentage of adults supported at home who agree that their services and support had an impact on improving or maintaining their quality of life (Scotland 78%; Moray 73%), and o Percentage of adults supported at home who agree they felt safe (Scotland 80%; Moray 72%). No data has been published for the indicator that measures whether staff would recommend their workplace as a good place to work. 4.40 In 2020/21 for the ten data indicators that have published data Moray was performing better than Scotland for 7, and marginally below the overall Scottish performance for the other 3. Page 19
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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” Performance management reporting is a legislative requirement under section 42 of the Public Bodies (Joint Working) (Scotland) Act 2014. In addition to publishing an Annual Performance Report, the Moray Integration Scheme requires that the MIJB will “monitor the performance of the delivery of integrated services using the Strategic Plan on an ongoing basis” (para 5.2.2 of the Moray Integration Scheme refers). (b) Policy and Legal None directly associated with this report. (c) Financial implications None directly associated with this report. (d) Risk Implications and Mitigation There are no risk issues arising directly from this report. The long-term impact of the COVID-19 on the Health and Social Care system are still unknown and performance measurement will remain flexible to enable the service to be prepared and react to any future developments. (e) Staffing Implications None directly associated with this report. (f) Property None directly associated with this report. (g) Equalities/Socio Economic Impact An Equality Impact Assessment is not required for the Performance Framework because there will be no impact, as a result of the report, on people with protected characteristics. (h) Climate Change and Biodiversity Impacts No climate change or biodiversity implications have been determined for this policy/activity. It should be noted that extreme weather events, such as the recent storms, are expected to occur more frequently and with greater ferocity in future years. In the longer-term there are likely to be issues with the reduction in availability and increases in costs of fossil fuels that will pose challenges for the delivery of care services to people living in rural areas. (i) Directions There are no directions arising from this report. (j) Consultations For Health and Social Care Moray the Chief Officer, Corporate Officer and Service Managers in relation to respective areas have been consulted as has Tracey Sutherland, Committee Services Officer, Moray Council and their comments are incorporated in the report. Page 21
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6. CONCLUSION 6.1 This report provides the MIJB with an overview of the performance of specified Local and National indicators and outlines actions to be undertaken to improve performance in Section 4 and expanded on in APPENDIX 1. 6.2 In addition, this report provides the MIJB with an overview of performance against the indicators reported to the Ministerial Strategic Group for Health and Community Care (APPENDIX 2) and the National Health and Social Care Integration indicators (APPENDIX 3). Authors of Report: Jeanette Netherwood, Corporate Manager Carl Bennett, Senior Performance Officer Background Papers: Available on request Ref: Page 22
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Appendix 1 PERFORMANCE REPORT - SUPPORTING CHARTS QUARTER 4 2021/22 (1 JANUARY 2022 – 31 MARCH 2022) Item 5. Page 23
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Table of Contents Health and Social Care Moray - 1 - 2021-22 Quarter 4 Performance Report 1. TABLE OF CONTENTS 1. Table of Contents ............................................................................................................................. 1 1. Performance Summary .................................................................................................................... 2 Barometer Overview ........................................................................................................................... 2 2. Delayed Discharge - RED .................................................................................................................. 3 DD-01: Number of delayed discharges (including code 9, Census snapshot, at end of quarter) ....... 3 DD-02: Number of Bed Days Occupied by Delayed Discharges per quarter (inc code 9) per 1000 18+ population ........................................................................................................................................... 4 3. Emergency Admissions - AMBER ..................................................................................................... 5 EA-01: Rate of emergency occupied bed days for over 65s per 1000 population .............................. 5 EA-02: Emergency Admissions rate per 1000 population for over 65s .............................................. 6 EA-03: Number of people over 65 years admitted as an emergency in the previous 12 months per 1000 population .................................................................................................................................. 7 4. Emergency Department – GREEN .................................................................................................... 8 AE-01: ED Attendance rates per 1,000 population (All Ages) ............................................................. 8 5. Hospital Re-admissions - GREEN ...................................................................................................... 9 HR-01: Percentage of Emergency Re-admissions to hospital within 28 days - Moray Patients ......... 9 HR-02: Percentage of Emergency Re-admissions to hospital within 7 days - Moray Patients ......... 10 6. Mental Health - RED ...................................................................................................................... 11 MH-01: Percentage of patients commencing Psychological Therapy Treatment within 18 weeks of referral ............................................................................................................................................... 11 7. Staff Management - RED ............................................................................................................... 12 SM-01: NHS Sickness Absence % of Hours Lost ................................................................................ 12 SM-02: Council Sickness Absence (% of Calendar Days Lost) ............................................................ 13 Council STAFF Absence OVER TIME – SCOTLAND COMPARISON...................................................... 14 Appendix 1: Key and Data Definitions .................................................................................................. 15 RAG Scoring Criteria .......................................................................................................................... 15 Peer Group Definition ....................................................................................................................... 15 Appendix 2: Strategic Priorities............................................................................................................. 16 Appendix 3: National Health and Wellbeing Outcomes ....................................................................... 18 Page 24
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Performance Summary Health and Social Care Moray - 2 - 2021-22 Quarter 4 Performance Report 1. PERFORMANCE SUMMARY BAROMETER OVERVIEW Moray currently has 11 local indicators. Of these 3 are Green, 2 are Amber and 5 are Red. Figure 1 - Performance Summary Q4 2021 Q1 2122 Q2 2122 Q3 2122 Q4 2122 New Target Previous Target Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar (from Q1 2122) (from Q1 2021 or earlier) AE Accident and Emergency AE-01 A&E Attendance rate per 1000 population (All Ages) 17.8 23.5 21.7 20.0 20.2 no change 21.7 G‚ DD Delayed Discharges DD-01* Number of delayed discharges (including code 9) at census point 17 20 30 39 46 no change 10 R DD-02 Number of bed days occupied by delayed discharges (including code 9) at census point 496 592 784 1142 1294 no change 304 R EA Emergency Admissions EA-01 Rate of emergency occupied bed days for over 65s per 1000 population 1773 1859 1934 2045 2140 2037 2107 R EA-02 Emergency admission rate per 1000 population for over 65s 174.8 185.9 190.4 187.2 183 179.9 179.8 A EA-03 Number of people over 65 years admitted as an emergency in the previous 12 months per 1000 population 119.3 124.1 126.7 126.3 125.2 123.4 124.6 A HR Hospital Readmissions HR-01 % Emergency readmissions to hospital within 7 days of discharge 5.0% 4.4% 4.1% 3.5% 3.4% no change 4.2% G‚ HR-02 % Emergency readmissions to hospital within 28 days of discharge 9.8% 9.2% 8.4% 8.4% 8.0% no change 8.4% G‚ MH Mental Health MH-01 % of patients commencing Psychological Therapy Treatment within 18 weeks of referral 100% 100% 100% 67% 33.0% no change 90% R SM Staff Management SM-01 NHS Sickness Absence (% of hours lost) 3.1% 4.2% 6.0% 5.5% 4.7% no change 4% R Health and Social Care Moray Performance Report Code Barometer (Indicator) RAG Page 25
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Delayed Discharge - RED Health and Social Care Moray - 3 - 2021-22 Quarter 4 Performance Report 2. DELAYED DISCHARGE - RED Trend Analysis The number of delays at snapshot (46) and number of bed days lost due to delayed discharges (1294) have both increased since Q3 2021/22. Prior to March 2021 both figures had been reducing. It had been hoped that with the third wave reaching a peak during quarter 3 the number of people facing a delay in being discharged from hospital would have shown a reduction during quarter 4. However, the Omicron variant reversed any improvements that had been made and the number of people being delayed from being discharged from hospital was at the highest level recorded since January 2019. Bed-days lost to delayed discharge are over 4 times the target that has been set. DD-01: NUMBER OF DELAYED DISCHARGES (INCLUDING CODE 9, CENSUS SNAPSHOT, AT END OF QUARTER) Purpose Reliably achieving timely discharge from hospital is an important indicator of quality and is a marker for person centred, effective, integrated, and harm free care. Strategic Priority 2: HOME FIRST Linked Indicator(s) DD-02 National Health & Wellbeing Outcomes 2, 3, 5, 7 Figure 2 – Delayed Discharges Indicator Trend – Increasing Despite some volatility in numbers from month to month the underlying trend for the number of people experiencing Delayed Discharge has been steadily increasing since the end of Quarter 4 2020/21. Source Public Health Scotland Page 26
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Delayed Discharge - RED Health and Social Care Moray - 4 - 2021-22 Quarter 4 Performance Report DD-02: NUMBER OF BED DAYS OCCUPIED BY DELAYED DISCHARGES PER QUARTER (INC CODE 9) PER 1000 18+ POPULATION Purpose This monitors the number of people delayed in hospital once medically fit for discharge. Longer stays in hospital are associated with increased risk of infection, low mood, and reduced motivation. Strategic Priority 2: HOME FIRST Linked Indicator(s) DD-01 National Health & Wellbeing Outcomes 2, 3, 5, 7 Figure 3 – Delayed Discharge Bed-days Indicator Trend – Increasing The number of bed-days are over 4 times the target number of days and have shown no sign of reducing during 2021-22. Source Public Health Scotland Page 27
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Emergency Admissions - RED Health and Social Care Moray - 5 - 2021-22 Quarter 4 Performance Report 3. EMERGENCY ADMISSIONS - RED Trend Analysis Since March 2021 there has been a steady increase each month in the rate of emergency occupied bed days for over 65s and the rate increased during quarter 4 from 2,045 to 2,140 in March 2022. However, the emergency admission rate per 1000 population for over 65s has reduced from 187.2 to 183 over the same period, while the number of people over 65 admitted to hospital in an emergency also reduced from 126.3 to 125.2. EA-01: RATE OF EMERGENCY OCCUPIED BED DAYS FOR OVER 65S PER 1000 POPULATION Purpose EA-01, EA-02, and EA-03 are all interconnected and provide a narrative when viewed together of whether emergency admissions and bed days are within tolerance and indicate where potential risks could arise. Strategic Priority 1: BUILDING RESILIENCE Linked Indicator(s) EA-02, EA-03 National Health & Wellbeing Outcomes 1, 2, 3, 5 Figure 4 – Emergency Occupied Bed-days (Over 65s) Indicator Trend – Increasing This indicator was on a downward trend for most of 2020, but since the start of 2021 has been increasing and has now exceeded the reduced target that has been set for 2 consecutive quarters. Source Health Intelligence Page 28
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Emergency Admissions - RED Health and Social Care Moray - 6 - 2021-22 Quarter 4 Performance Report EA-02: EMERGENCY ADMISSIONS RATE PER 1000 POPULATION FOR OVER 65S Purpose EA-01, EA-02, and EA-03 are all interconnected and provide a story when viewed together of whether emergency admissions and bed days are within tolerance and indicate where potential risks could arise. Strategic Priority 1: BUILDING RESILIENCE Linked Indicator(s) EA-01, EA-03 National Health & Wellbeing Outcomes 1, 2, 3, 5 Figure 5 – Emergency Admissions (Over 65s) Indicator Trend – Reducing At the start of 2021 the trend had been rapidly increasing, but since August there has been a steady and sustained reduction, albeit above the target of 179.9 admissions per 1,000 population. Source Health Intelligence Page 29
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Emergency Admissions - RED Health and Social Care Moray - 7 - 2021-22 Quarter 4 Performance Report EA-03: NUMBER OF PEOPLE OVER 65 YEARS ADMITTED AS AN EMERGENCY IN THE PREVIOUS 12 MONTHS PER 1000 POPULATION Purpose EA-01, EA-02, and EA-03 are all interconnected and provide a story when viewed together of whether emergency admissions and bed days are within tolerance and indicate where potential risks could arise. Strategic Priority 1: BUILDING RESILIENCE Linked Indicator(s) EA-01, EA-02 National Health & Wellbeing Outcomes 1, 2, 3, 5 Figure 6 – Number of Over 65 People Emergency Admissions Indicator Trend – Reducing This indicator was showing a consistent downward trend until February 2021, since when the trend reversed and increased rapidly. As with Figure 4 the rate levelled off in August and remains above target with a figure of 125.2 per 1,000 population. Source Health Intelligence Page 30
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Emergency Department – GREEN Health and Social Care Moray - 8 - 2021-22 Quarter 4 Performance Report 4. EMERGENCY DEPARTMENT – GREEN Trend Analysis There has been a very slight increase in the rate per 1,000 this quarter from 20.0 to 20.2, meeting the target but almost double the number presenting in April 2020. Since June 2021 the trend had been reducing in gradual steps until March 2022. AE-01: ED ATTENDANCE RATES PER 1,000 POPULATION (ALL AGES) Purpose A greater system-wide understanding of how people access emergency care, and why certain choices are made, will allow local health systems to develop intelligence about avoidable attendances at emergency departments and target their responses. Strategic Priority 3: PARTNERS IN CARE Linked Indicator(s) HR-01, HR-02 National Health & Wellbeing Outcomes 1, 2, 3, 5 Figure 7 – ED Attendance Rate Indicator Trend – Stable During quarter 3 the attendance rate per 1,000 population has remained stable, below the target level. However, the attendance rate is almost double the rate experienced at the end of April 2020. Source Health Intelligence Page 31
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Hospital Re-admissions - GREEN Health and Social Care Moray - 9 - 2021-22 Quarter 4 Performance Report 5. HOSPITAL RE-ADMISSIONS - GREEN Trend Analysis Both indicators in this barometer remain green. 28-day re-admissions are 8.0% and 7-day Re- admissions are at 3.4%. HR-01: PERCENTAGE OF EMERGENCY RE-ADMISSIONS TO HOSPITAL WITHIN 28 DAYS - MORAY PATIENTS Purpose Re-admissions are often undesirable for patients and have also been shown to be associated with the quality of care provided to patients at several stages along the clinical pathway, including during initial hospital stays, transitional care services and post-discharge support. (This measure lags by a month due to the time required for a potential 28 day discharge to occur) Strategic Priority 1: BUILDING RESILIENCE Linked Indicator(s) HR-02, AE-01 National Health & Wellbeing Outcome 1, 2, 3, 5 Figure 8 – 28-dayEmergency Readmissions Indicator Trend – Stable 28-day Hospital Re-admissions have remained around the target of 8.4% this quarter. Source Health Intelligence Page 32
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Hospital Re-admissions - GREEN Health and Social Care Moray - 10 - 2021-22 Quarter 4 Performance Report HR-02: PERCENTAGE OF EMERGENCY RE-ADMISSIONS TO HOSPITAL WITHIN 7 DAYS - MORAY PATIENTS Purpose Re-admissions are often undesirable for patients and have also been shown to be associated with the quality of care provided to patients at several stages along the clinical pathway, including during initial hospital stays, transitional care services and post-discharge support. Strategic Priority 1: BUILDING RESILIENCE Linked Indicator(s) HR-01, AE-01 National Health & Wellbeing Outcome 1, 2, 3, 5 Figure 9 – 7-day Emergency Readmissions Indicator Trend – Stable 7-day Hospital Re-admissions have remained below the target of 4.2% this quarter. Source Health Intelligence Page 33
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Mental Health – RED Health and Social Care Moray - 11 - 2021-22 Quarter 4 Performance Report 6. MENTAL HEALTH – RED Trend Analysis After 24 months below target and a year at around 20% this measure was at 100% for the 6 months from December 2020 through to June 2021. However, quarter 3 has shown a rapid reduction with 67% of patients being referred within 18 weeks during December 2022. MH-01: PERCENTAGE OF PATIENTS COMMENCING PSYCHOLOGICAL THERAPY TREATMENT WITHIN 18 WEEKS OF REFERRAL Purpose Timely access to healthcare is a key measure of quality and that applies equally in respect of access to mental health services. Strategic Priority 3: PARTNERS IN CARE Linked Indicator(s) National Health & Wellbeing Outcome 1, 2, 3, 5 Figure 10 – Psychological Therapy Treatment within 18 Weeks Indicator Trend – Reducing Having been at 100% for four quarters in a row this measure has remained below target during quarter 4, and reduced significantly compared to quarter 3. Source Health Intelligence Page 34
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Staff Management - RED Health and Social Care Moray - 12 - 2021-22 Quarter 4 Performance Report 7. STAFF MANAGEMENT - RED Trend Analysis Sickness absence for NHS employed staff rose to 6.4%, one and a half times greater than the target of 4%, during quarter 3, before reducing to 5.5%. It’s too early to identify a trend, but this may indicate the peak is over. Council employed staff sickness has risen again from 7.8% to 8.05%, which is above the figure for the same period in the previous year. The rate of increase has decreased sharply during quarter 3. SM-01: NHS SICKNESS ABSENCE % OF HOURS LOST Purpose Attendance at work of all employees is essential in the interests of the effective and efficient operation of services. Strategic Priority 1: BUILDING RESILIENCE Linked Indicator(s) SM-02 National Health & Wellbeing Outcome 8 Target (+10%) Q3 20/21 Q4 20/21 Q1 21/22 Q2 21/22 Q3 21/22 Q4 21/22 4% 3.6% 3.1% 4.2% 6.0% 5.5% 4.7% Figure 11 – NHS Sickness Absence Indicator Trend – Reducing This indicator had been increasing over recent quarters but met the target of 4% for 2 months this quarter before increasing once more in March 2022. Source Health Intelligence Page 35
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Staff Management - RED Health and Social Care Moray - 13 - 2021-22 Quarter 4 Performance Report SM-02: COUNCIL SICKNESS ABSENCE (% OF CALENDAR DAYS LOST) Purpose Attendance at work of all employees is essential in the interests of the effective and efficient operation of services. Strategic Priority 1: BUILDING RESILIENCE Linked Indicator(s) SM-01 National Health & Wellbeing Outcome 1, 2, 3, 5 Target Q3 20/21 Q4 20/21 Q1 21/22 Q2 21/22 Q3 21/22 Q4 21/22 4% 6.2% 6.2% 6.95% 7.8% 8.05% N/A Figure 12 – Moray Council Sickness Absence Indicator Trend – Increasing This indicator continues to rise, remaining above target although it is significantly lower than the figure of 9% recorded in quarter 4 2019/20 when it reached a peak. Due to staff absences within the Council HR team the quarter 4 data are not yet available Source Council HR Page 36
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Staff Management - RED Health and Social Care Moray - 14 - 2021-22 Quarter 4 Performance Report COUNCIL STAFF ABSENCE OVER TIME – SCOTLAND COMPARISON Chart provided by the Improvement Service using data from the from weekly SOLACE council returns. This update captures data from the week ending 27 May 2022. Figure 13 – Moray Council Sickness Absence Compared to National Average Page 37
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Staff Management - RED Health and Social Care Moray - 15 - 2021-22 Quarter 4 Performance Report APPENDIX 1: KEY AND DATA DEFINITIONS RAG SCORING CRITERIA GREEN If Moray is performing better than target. AMBER If Moray is performing worse than target but within specified tolerance. RED If Moray is performing worse than target but outside of specified tolerance. ▲ − ▼ Indicating the direction of the current trend. PEER GROUP DEFINITION Moray is defined as being in Peer Group 2 in the Local Government Benchmarking Framework Family Group 1 Family Group 2 Family Group 3 Family Group 4 East Renfrewshire East Dunbartonshire Aberdeenshire Edinburgh, City of Perth & Kinross Aberdeen City Shetland Islands Orkney Islands Moray Stirling East Lothian Angus Scottish Borders Highland Argyll & Bute Midlothian Falkirk Dumfries & Galloway Fife South Ayrshire West Lothian South Lanarkshire Renfrewshire Clackmannanshire Eilean Siar Dundee City East Ayrshire North Ayrshire North Lanarkshire Inverclyde West Dunbartonshire Glasgow City Page 38
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Staff Management - RED Health and Social Care Moray - 16 - 2021-22 Quarter 4 Performance Report APPENDIX 2: STRATEGIC PRIORITIES Page 39
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Staff Management - RED Health and Social Care Moray - 17 - 2021-22 Quarter 4 Performance Report •EA-01: RATE OF EMERGENCY OCCUPIED BED DAYS FOR OVER 65S PER 1000 POPULATION •EA-02: EMERGENCY ADMISSIONS RATE PER 1000 POPULATION FOR OVER 65S •EA-03: NUMBER OF PEOPLE OVER 65 YEARS ADMITTED AS AN EMERGENCY IN THE PREVIOUS 12 MONTHS PER 1000 POPULATION •HR-01: PERCENTAGE OF EMERGENCY RE-ADMISSIONS TO HOSPITAL WITHIN 28 DAYS -MORAY PATIENTS (DR GRAY’S) •HR-02: PERCENTAGE OF EMERGENCY RE-ADMISSIONS TO HOSPITAL WITHIN 7 DAYS -MORAY PATIENTS (DR GRAY’S) •SM-01: NHS SICKNESS ABSENCE % OF HOURS LOST •SM-02: COUNCIL SICKNESS ABSENCE (% OF CALENDAR DAYS LOST) BUILDING RESILIENCE •DD-01: NUMBER OF DELAYED DISCHARGES (INCLUDING CODE 9, CENSUS SNAPSHOT, AT END OF QUARTER) •DD-02: NUMBER OF BED DAYS OCCUPIED BY DELAYED DISCHARGES PER QUARTER (INC CODE 9) PER 1000 18+ POPULATION •UN-01: NUMBER OF LONG-TERM HOME CARE HOURS UNMET AT WEEKLY SNAPSHOT •UN-02: NUMBER OF PEOPLE WITH LONG-TERM CARE HOURS UNMET AT WEEKLY SNAPSHOT HOME FIRST •OA-01: NUMBER OF REVIEWS OUTSTANDING AT END OF QUARTER SNAPSHOT •MH-01: PERCENTAGE OF PATIENTS COMMENCING PSYCHOLOGICAL THERAPY TREATMENT WITHIN 18 WEEKS OF REFERRAL •AE-01: A&E ATTENDANCE RATES PER 1000 POPULATION (ALL AGES) PARTNERS IN CARE Page 40
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Staff Management - RED Health and Social Care Moray - 18 - 2021-22 Quarter 4 Performance Report APPENDIX 3: NATIONAL HEALTH AND WELLBEING OUTCOMES 1 - PEOPLE ARE ABLE TO LOOK AFTER AND IMPROVE THEIR OWN HEALTH AND WELLBEING AND LIVE IN GOOD HEALTH FOR LONGER. 2 - PEOPLE, INCLUDING THOSE WITH DISABILITIES OR LONG-TERM CONDITIONS, OR WHO ARE FRAIL; ARE ABLE TO LIVE, AS FAR AS REASONABLY PRACTICABLE, INDEPENDENTLY AT HOME, OR IN A HOMELY SETTING IN THEIR COMMUNITY. 3 - PEOPLE WHO USE HEALTH AND SOCIAL CARE SERVICES HAVE POSITIVE EXPERIENCES OF THOSE SERVICES, AND HAVE THEIR DIGNITY RESPECTED. 4 - HEALTH AND SOCIAL CARE SERVICES ARE CENTRED ON HELPING TO MAINTAIN OR IMPROVE THE QUALITY OF LIFE OF PEOPLE WHO USE THOSE SERVICES. 5 - HEALTH AND SOCIAL CARE SERVICES CONTRIBUTE TO REDUCING HEALTH INEQUALITIES. 6 - PEOPLE WHO PROVIDE UNPAID CARE ARE SUPPORTED TO LOOK AFTER THEIR OWN HEALTH AND WELLBEING, INCLUDING TO REDUCE ANY NEGATIVE IMPACT OF THEIR CARING ROLE ON THEIR OWN HEALTH AND WELLBEING. 7 - PEOPLE USING HEALTH AND SOCIAL CARE SERVICES ARE SAFE FROM HARM. 8 - PEOPLE WHO WORK IN HEALTH AND SOCIAL CARE SERVICES FEEL ENGAGED WITH THE WORK THEY DO AND ARE SUPPORTED TO CONTINUOUSLY IMPROVE THE INFORMATION, SUPPORT, CARE, AND TREATMENT THEY PROVIDE. 9 - RESOURCES ARE USED EFFECTIVELY AND EFFICIENTLY IN THE PROVISION OF HEALTH AND SOCIAL CARE SERVICES. Page 41
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/ Ministerial Strategic Group for Health and Community Care The work of the Ministerial Strategic Group for Health and Community Care has now concluded, with its last meeting taking place in January 2020. Much progress has been made to implement the 25 proposals set out in the group’s review of integration final report and an update on progress made against these proposals was provided to the Health and Sport Committee by the then Cabinet Secretary for Health and Sport in February 2021. However, there is still outstanding work to do to ensure the success of integration across Scotland. While some of this work will be taken forward by the establishment of the new National Care Service, the Scottish Government will continue to identify and progress improvements within the current system during the establishment of the National Care Service (NCS). We will take forward this work with Integration Authorities, their Chief Officers, Boards and stakeholders to realise the full potential of integration and ensure that the people of Scotland get the right support, in the right place, at the right time, no matter their care needs. There are six MSG indicators: 1. Emergency admissions 2. Unscheduled hospital bed days 3. A&E performance 4. Delayed discharges 5. End of life care 6. The balance of care across institutional and community services. This data is currently produced by Public Health Scotland on a monthly basis and is circulated to partnership colleagues in the form of an excel spreadsheet. Contact: phs.source@nhs.net Charts for residents of all ages HSCM - MSG Integration Indicators Item 5. Page 43
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/ 1a - # Emergency Admissions 1b - # Admissions from A&E (ED) - All Ages 2b - # Unscheduled Bed-days; Acute Specialities 695695695 604604604 692692692 735735735664664664702702702 801801801 712712712 592592592546546546 662662662 636636636578578578 734734734694694694726726726 578578578 668668668 Number of Admissions April 2018 April 2019 April 2020 April 2021 August 2018 December 2018 August 2019 December 2019 August 2020 December 2020 August 2021 December 2021 0 200 400 600 800 1,000 Number of Admissions Percentage Conversion Rate 391391391 404404404 378378378 471471471 572572572 408408408486486486 507507507 408408408 588588588 580580580 447447447 19.8%19.8%19.8% 16.8%16.8%16.8% 20.7%20.7%20.7% 20.9%20.9%20.9% 22.8%22.8%22.8% 26.1%26.1%26.1% 24%24%24% 30.2%30.2%30.2% 27%27%27% 25.7%25.7%25.7% 28.3%28.3%28.3% 31.6%31.6%31.6% 32.7%32.7%32.7% 29.7%29.7%29.7% 23.3%23.3%23.3% 24.5%24.5%24.5% 27.1%27.1%27.1% 29.7%29.7%29.7% 25.5%25.5%25.5% Number of Admissions Conversion Rate (%) April 2018 July 2019 October 2020 January 2022 September 2018 February 2019 December 2019 May 2020 March 2021 August 2021 0 1,000 250 500 750 15% 20% 25% 30% 35% 5,3635,3635,363 5,1605,1605,160 4,3074,3074,307 4,8444,8444,844 5,1205,1205,120 5,6705,6705,670 3,6213,6213,621 4,1904,1904,190 4,6884,6884,688 4,0744,0744,074 5,0165,0165,016 3,0303,0303,030 4,0744,0744,074 4,6884,6884,688 Number of Bed-days April 2018 April 2019 April 2020 April 2021 August 2018 December 2018 August 2019 December 2019 August 2020 December 2020 August 2021 December 2021 0 2,000 4,000 6,000 Page 44
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/ 2b - # Unscheduled Bed-days; geriatric long stay 3a - # A&E (ED) Attendances 3b - % A&E (ED) seen within 4 hours Number of Unscheduled Bed-days Q1 2018/… Q2 2018/19 Q3 2018/19 Q4 2018/19 Q1 2019/20 Q2 2019/20 Q3 2019/20 Q4 2019/20 Q1 2020/21 Q2 2020/21 Q3 2020/21 Q4 2020/21 Q1 2021/22 Q2 2021/22 Q3 2021/22 0 2 4 6 8 10 1,9781,9781,978 2,2292,2292,229 1,8101,8101,810 2,0342,0342,034 2,2532,2532,253 2,3742,3742,374 2,0072,0072,007 1,6781,6781,678 1,3021,3021,302 1,8861,8861,886 1,6231,6231,623 1,3331,3331,333 1,8211,8211,821 2,0412,0412,041 2,2662,2662,266 1,9551,9551,955 1,3331,3331,333 1,7081,7081,708 Number of Attendances April 2018 April 2019 April 2020 April 2021 August 2018 December 2018 August 2019 December 2019 August 2020 December 2020 August 2021 December 2021 0 500 1,000 1,500 2,000 2,500 96.6%96.6%96.6% 97.7%97.7%97.7% 94.8%94.8%94.8% 90.8%90.8%90.8% 95.8%95.8%95.8% 94.2%94.2%94.2% 96.4%96.4%96.4% 94.9%94.9%94.9% 93.1%93.1%93.1% 90.4%90.4%90.4% 91.6%91.6%91.6% 93%93%93% 95.2%95.2%95.2% 88.3%88.3%88.3% 93.9%93.9%93.9% 89.4%89.4%89.4% 90.6%90.6%90.6% 91.7%91.7%91.7% 87.9%87.9%87.9% 79.4%79.4%79.4% 81.8%81.8%81.8% 80.6%80.6%80.6% Percentage on time April 2018 April 2019 April 2020 April 2021 August 2018 December 2018 August 2019 December 2019 August 2020 December 2020 August 2021 December 2021 75% 80% 85% 90% 95% 100% Page 45
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/ 4 - Delayed Discharge Bed-days 5a - % last 6 months of life by setting 5b - # days by setting (last 6 months of life) 1,1271,1271,127 893893893 1,3391,3391,339 1,1391,1391,139 968968968 810810810 751751751 1,0751,0751,075 1,2961,2961,296 332332332 566566566 876876876 735735735 595595595 770770770 623623623 784784784 948948948 1,2011,2011,201 # Bed-days April 2018 April 2019 April 2020 April 2021 August 2018 December 2018 August 2019 December 2019 August 2020 December 2020 August 2021 December 2021 0 250 500 750 1,000 1,250 1,500 88.8%88.8%88.8% 89.4%89.4%89.4% 90%90%90% 90.2%90.2%90.2% 89.4%89.4%89.4% 90%90%90% 90.6%90.6%90.6% 91.7%91.7%91.7% Large Hospital - % Community Hospital - % Hospice/Palliative Care - % Community - % 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19 2019/20 2020/21 0 25 50 75 100 5,0075,0075,007 5,5505,5505,550 5,2885,2885,288 5,3845,3845,384 5,9925,9925,992 4,9714,9714,971 6,1596,1596,159 3,8443,8443,8441,7491,7491,749 2,0912,0912,091 1,4581,4581,458 746746746 948948948 839839839 997997997 44,26944,26944,269 56,68256,68256,682 52,17652,17652,17653,48753,48753,487 51,22451,22451,224 50,45750,45750,457 56,04056,04056,040 55,94255,94255,942 Large Hospital - Days Community Hospital - Days Hospice/Palliative Care - Days Community - Days 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19 2019/20 2020/21 0 20,000 40,000 60,000 80,000 Page 46
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/ 6 - % Population in Community or Institutional Settings MSG PIs (data for All Ages) ... Code & Title Gauge Value Target HSCM - MSG1a Number of emergency admis… 668 HSCM - MSG1b Admissions from A&E (ED) 508 HSCM - MSG2a Number of unscheduled hosp… 4,688 HSCM - MSG2b Number of unscheduled hosp… 0 HSCM - MSG3a A&E Attendances 1,708 HSCM - MSG3b A&E seen within 4 hours 80.3% HSCM - MSG4 Delayed discharge bed days 1,201 HSCM - MSG5a Percentage of last six months… 99.91% HSCM - MSG5a01 Percentage of last six mont… 91.7% HSCM - MSG5a02 Percentage of last six mont… 0.01% HSCM - MSG5a03 Percentage of last six mont… 3.2% HSCM - MSG5a04 Percentage of last six mont… 5% HSCM - MSG5b Number of days by setting du… 61,685 HSCM - MSG5b01 Number of days by setting … 55,942 HSCM - MSG5b02 Number of days by setting … 774 HSCM - MSG5b03 Number of days by setting … 1,125 HSCM - MSG5b04 Number of days by setting … 3,844 HSCM - MSG6 Balance of care: Percentage of… 100% HSCM - MSG6-01 Balance of care: Percentag… 98.1% HSCM - MSG6-02 Balance of care: Percentag… 1.1% HSCM - MSG6-03 Balance of care: Percentag… 0.5% HSCM - MSG6-04 Balance of care: Percentag… 0% HSCM - MSG6-05 Balance of care: Percentag… 0.1% HSCM - MSG6-06 Balance of care: Percentag… 0.2% Charts for residents aged 65 years old and over 0.2%0.2%0.2% 0.2%0.2%0.2% 0.2%0.2%0.2% 0.2%0.2%0.2% 0.2%0.2%0.2%0.1%0.1%0.1% 0.1%0.1%0.1% 97.8%97.8%97.8% 97.9%97.9%97.9% 98%98%98% 98.2%98.2%98.2% 98%98%98% 98.1%98.1%98.1% 98.1%98.1%98.1% Large Hospital - % Community Hospital - % Hospice/Palliative Care Unit - % Care Home - % Home (Supported) - % Home (Unsupported) - % 2013/14 2014/15 2015/16 2016/17 2017/18 2018/19 2019/20 0% 25% 50% 75% 100% Page 47
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/ PIs - for population aged 65+ Code & Title Value Last Update History HSCM - MSG1a-65+ Number of emergency admissions (65 year olds and older) HSCM - MSG1b-65+ Admissions from A&E (ED) for patients aged 65 years and older HSCM - MSG2a-65+ Number of unscheduled hospital bed days; acute specialties (65… HSCM - MSG2b-65+ Number of unscheduled hospital bed days; geriatric long stay (… HSCM - MSG3a-65+ A&E attendances - 65 year olds and older HSCM - MSG6-65+ Balance of care: Percentage of population in community or institu… HSCM - MSG6a65+ Balance of care: Percentage of population at Home - Unsupporte… HSCM - MSG6b65+ Balance of care: Percentage of population at Home - Supported … HSCM - MSG6c65+ Balance of care: Percentage of population in Care Homes Resid… HSCM - MSG6d65+ Balance of care: Percentage of population in Hospice/Palliative … HSCM - MSG6e65+ Balance of care: Percentage of population in Community Hospita… HSCM - MSG6f65+ Balance of care: Percentage of population in Large Hospital Resi… Page 48
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 30 JUNE 2022 SUBJECT: INTERNAL AUDIT – COMPLETED PROJECTS 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 The Audit, Performance and Risk Committee is asked to consider and note the audit update. 3. BACKGROUND 3.1 Public Sector Internal Audit Standards (PSIAS) require the Chief Internal Auditor to prepare and present reports to the committee on internal audit’s activity relative to the audit plan and any other relevant matters. 3.2 Challenges associated with the pandemic remain, resulting in significant changes within current working practices that make the audit process more difficult, and uncertainty still remains regarding these arrangements in the period ahead. All audit staff are still working from home, which brings some limitations to the audit process. 3.3 In line with the approved internal audit plan, the following reviews were completed: 4. KEY MATTERS RELEVANT TO RECOMMENDATION Completed Projects- Client Monies 4.1 An audit has been undertaken of how Health and Social Care officers manage income held for individuals under Corporate Appointeeship Arrangements. Where no alternative exists, the Council can make an application to the Department for Work and Pensions (DWP) for a named officer to become the "Corporate Appointee" and have the legal authority to manage an individual's personal finances. Item 6. Page 53
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4.2 The audit involved a review of the procedures undertaken by the Community Care Finance Team into how they manage client funds held within the corporate bank account. In addition, a sample of individuals was also selected, and a check was made on how the Health and Social Care officer appointed as the named 'Corporate Appointee' manages and supports individuals to access and use their funds appropriately. The executive summary and recommendations for this project are given in Appendix 1. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Moray Partners in Care 2019 – 2029” Internal audit work supports good governance and assists in securing appropriate systems of internal control. (b) Policy and Legal The internal audit service is provided in terms of paragraph 7:1 of the Local Authority Accounts (Scotland) Regulations 2014, and there is a requirement to provide a service in accordance with published Public Sector Internal Audit Standards. (c) Financial Implications No implications directly arising from this report. (d) Risk Implications Audit reports highlight risk implications and contain recommendations for management to address as a means of mitigating. (e) Staffing Implications No implications directly arising from this report (f) Property No implications. (g) Equalities/ Socio Economic Impacts No implications. (h) Climate Change and Biodiversity Impacts None directly arising from this report. (i) Directions There are no directions arising as a direct result of 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 projects completed during the review period. Page 54
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Author of Report: Dafydd Lewis, Chief Internal Auditor Background Papers: Internal Audit Files Ref: mijb/ap&rc/30062022 Page 55
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Appendix 1 AUDIT REPORT 22'011 CLIENT MONIES Executive Summary The annual audit plan for 2021/22 provides for an audit review to be undertaken of how Health and Social Care Officers manage income held for individuals under Corporate Appointeeship arrangements. Where no alternative exists, the Council can make an application to the Department for Work and Pensions (DWP) for a named officer to become the 'Corporate Appointee' and have the legal authority to manage an individual's personal finances. The Adults with Incapacity (Scotland) Act 2000 enables a Health and Social Care Officer to be appointed by the DWP to have "Corporate Appointeeship" responsibility for managing the benefits received by an individual. It was noted that other formal agreements do exist, e.g. Access to Funds Scheme, Intervention or Guardianship orders, but a review of these arrangements were not included within this review. It was found that 59 individuals are being managed within the "Corporate Appointeeship" Scheme with a combined value of £483,000 held within the Council's corporate bank account. The audit has involved scrutiny of processes undertaken by the Community Care Finance Team in how they administer the corporate bank account. In addition, a sample of individuals was also selected, and a check made as to how the Health and Social Care Officer appointed as the named "Corporate Appointee" manages and supports individuals to access their funds appropriately. The audit was carried out in accordance with Public Sector Internal Audit Standards (PSIAS). The review has highlighted the following areas for improvement:- • Due to the requirements of remote working and pandemic restrictions, the withdrawal of cash for clients has moved to a 4-weekly cycle. This has resulted in changes in operating practices. A risk assessment review of current arrangements should be undertaken to ensure best practices are followed for the protection of both employees and the client's finances. Once this is carried out, procedures require to be updated to reflect the agreed operating arrangements. • A lack of segregation of duties exists with the bank reconciliation being prepared by the same officers who operate the account on a daily basis. An independent management check should be included within this process. • The audit notes that the corporate bank account included £80,482 of funds in relation to the combined balances of 10 deceased clients. Some of these funds have been held for a period of up to 4 years with no contact made by any executor of the deceased clients. Clarification should be obtained from Legal Services regarding the length of time funds must be retained on behalf of deceased clients and potential action that could be taken should the funds not be claimed within the timeframe. Item 6. Page 57
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Appendix 1 Recommendations 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) Comments Responsible Officer Timescale for Implementation Key Control: Clear and current policy documents and operational guidelines have been developed for the financial management of client monies. 5.01 The Procedures for Managing Service User's Money and Corporate Appointeeship should be reviewed and updated and a subsequent regular cycle of review maintained. Medium Yes Procedures will be reviewed to incorporate improvements and changes to practice. Commissioning Manager 31/10/2022 5.02 Procedures for the management of client monies should be promoted to ensure there is an awareness of their requirements by all officers involved in client finance administration. Medium Yes Procedures will be appropriately promoted to relevant officers after revision. Commissioning Manager 31/10/2022 Page 58
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Appendix 1 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) Comments Responsible Officer Timescale for Implementation Key Control: Correct formal powers to administer client monies have been obtained. 5.03 Clarification should be obtained from Legal Services regarding the length of time funds must be retained on behalf of deceased clients and potential action which can be taken should the funds not be claimed within the timeframe. Consideration should also be given to holding these funds separate to the corporate bank account for increased visibility. Medium Yes Clear guidance will be requested from Legal Services in order to be able to conclude deceased estates. This will be added to procedures to ensure deceased client monies are not being held in the corporate bank account beyond acceptable timescales. Community Care Finance Officer / Support Manager 31/10/2022 Page 59
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Appendix 1 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) Comments Responsible Officer Timescale for Implementation Key Control: All transactions should be for benefit of the client with justifiable supplier selection, verified to source documentation and in line with the client's Financial Management Plan. Any cash held is done so securely and with full accounting arrangements. 5.04 Due to changes in operating practices a full review of current cash handling procedures should be undertaken. The review should include a risk assessment to ensure best practices are followed regarding the safety and security of both officers and client funds. Documented procedures should thereafter be updated to reflect any agreed changes. High Yes Options to be prepared for discussion by the Practice Governance Group to agree cash handling procedures and practices which increase security whilst being practical within operational capacity. Community Care Finance Officer / Support Manager 31/07/2022 Key Control: Robust records of fund administration per client are maintained. 5.05 Confirmation of the monthly reconciliation of the Corporate bank account to manual records should be undertaken by Community Care Finance management. This should also include the verification of a sample of transactions to source documentation. High Yes A four-weekly management review will be implemented and added to the revised procedures. Community Care Finance Officer / Support Manager 31/05/2022 Page 60
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 30 JUNE 2022 SUBJECT: STRATEGIC RISK REGISTER – JUNE 2022 BY: CHIEF OFFICER 1. REASON FOR REPORT 1.1 To provide an overview of the current strategic risks, along with a summary of actions which are in place to mitigate those risks, updated June 2022. 2. RECOMMENDATION 2.1 It is recommended that the Audit, Performance and Risk Committee (APR) agree to: i) consider and note the updated Strategic Risk Register included in APPENDIX 1; and ii) note the Strategic Risk Register will be further refined to align with the transformation and redesign plans as they evolve 3. BACKGROUND 3.1 The strategic risk register is reviewed regularly by the Senior Management Team as part of a robust risk monitoring framework, to identify, assess and prioritise risks related to the delivery of services in relation to delegated functions, particularly any which are likely to affect the delivery of the Strategic Plan. 3.2 The Moray Integration Joint Board (MIJB) Strategic Risk Register is attached to this report at APPENDIX 1 and sets out the inherent risks being faced by the MIJB, together with a current assessment on the level of the risks and mitigating actions being taken to reduce the impact of the risks. This report is presented to Audit Performance and Risk committee for their oversight and comment. 3.3 Risk scores are weighted, based on assessment according to their likelihood and corresponding impact, as per Section 5 of the MIJB Risk Policy. Item 7. Page 61
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3.4 The Strategic Risks received an initial review to ensure they align to the Moray Partners in Care 2019-2029 strategic plan which was agreed at MIJB on 28 November 2019 (para 13 of the minute refers). 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 The Risk Management Framework review was completed and outcome was approved by the Board on 25 June 2020 (para 9 of the minute refers). The approved Risk Appetite Statements have been included in APPENDIX 1. 4.2 Work initially overseen by NE Partnership continues to progress locally, in line with our Strategic Plan objectives. Hospital without Walls and Hospital at Home themes are being developed and will be progressed through the Home First programme. These workstreams are required to progress a new approach to delivering person-focussed clinical services to people, for the benefit of individuals through a person centred approach and to maximise best use of available staff resources which continue to be stretched. 4.3 The impact of covid continues to be felt across some services from staff absences and is of particular concern in areas where there is a limitation on options for cover for staff, such as in specialist residential care e.g. Woodview as an example. Contingency plans are in place but there continues to be significant pressure on safe staffing levels in this area. Managers continue to reiterate the necessity for correct use of PPE, ventilation, hand hygiene and lateral flow testing for all staff. 4.4 Progression of development work had slowed during the increased pressure on services across our system during the first quarter of the year as a result of Covid. Whilst there are still significant pressures in some areas of the system, there are signs that other services are beginning to feel less in crisis. There continues to be a significant demand for social work assessments from the community and there are high levels of unmet need for care provision in the community which have been subject of separate reports to Clinical and Care Governance Committee which have been escalated to Moray Integration Joint Board ( 31 March 2022, para 9 of the minute refers). Managers are working with teams daily to try to meet the greatest needs through a variety of means but there are still those who are not receiving a service. These increases in demands for service are being faced by staffing resource that is reduced due to increasing sickness absence, staff vacancies, annual leave and the continued need for some staff redeployment. 4.5 The continued safe delivery of services is a priority and as such a considerable amount of management time is being directed to support oversight of operational risks to ensure they are managed and prioritised across the whole system. NHSG are reviewing the arrangements that were developed during Operation Iris to determine what meetings structure is required going forward , however the work that was undertaken to develop Grampian Operational Escalation System (GOPES) will be maintained to assist in the identification of pressure points across the whole system so that they can be addressed and prioritised appropriately. 4.6 There continues to be significant financial risk in the system which was highlighted at the MIJB development session on 6 June 2022. There have Page 62
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been significant additional supports provided during the last two years and whilst some of the additional funding is recurring, there is a recurring £3m deficit that is forecast for 2023/24 which will require to be addressed in order to be able to set a balanced budget. Additional funding has been made available by Scottish Government to support the increased pressures in the system, including those presented by the winter period and performance metrics are being identified to highlight progress in the key areas the funds have been provided for. These will be incorporated into future reports to this committee. The senior management team have, and continue to, assess where the funds should be applied for greatest benefit and approvals will be sought as appropriate. 4.7 Recruitment and selection to staff vacancies continues to prove challenging across several services. These challenges remain as previously reported regarding lack of appropriate applications for some posts and also the time taken to for the recruitment process in employing organisations to be followed. The recruitment cell in Care at Home services has been very successful when 31 new staff have been recruited in the period in comparison to 12 over same period in 2021, 16 in 2020 and 8 in 2019. They have implemented a rolling advert, weekly interviews and alignment of training schedules to make the process as efficient as possible and their efforts have also facilitated releasing management time to focus on service delivery. Staff wellbeing continues to be a key priority and a significant emphasis is being placed on ensuring that everyone is provided with the support that is readily available, where it is required. The issues that have been identified will be factored into the developing workforce plan and collaborative work will be progressed with partners across Grampian for recruitment. 4.8 Work is progressing with Allied our partner for care at home on the outcome based commissioning approach. Whilst it was recognised by all involved that it will be challenging to deliver these developments in the context of the continued impact of the pandemic it was also recognised that change is needed to create the capacity to meet the demand. Delivering on outcomes, rather than a time and task approach, underpins the MIJB strategic principles of Home First and supports people having choice of how and where they are cared for. However many current care packages are larger than those delivered prior to the pandemic and there is a lot more 2 to 1 care being provided at home, where previously the individual would have gone to residential or nursing care. This represents an increase in demand for services but unfortunately, despite best efforts, internal Care at home services and Allied have not been able to increase staffing levels to meet demand. Internal services have been recruiting successfully there have been many staff who have reduced their contracted hours to gain a better work life balance and more choice of hours they work. In addition there are less people choosing Option 1 for Self Directed Support (direct payment or organisation of their choice) and limited people choosing Option 2 which would be delivered by the four other care providers in the market locally. This places more demand for SDS Option 3 which is delivered by internal partnership. Due to the factors above currently capacity is not meeting demand which is demonstrated in the increase in unmet need. This situation is not likely to improve in the short term as there are still more people awaiting assessment which is likely to increase the demand for care in the community. Page 63
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4.9 NHSG moved out of Operation Iris, the management strategy in response to Omicron, on 31 March 2022, services are no longer under emergency powers as determined by Scottish Government and there has been a de-escalation of Covid-19 infection prevention and control measures. Further work is being taken forward by the NHSG weekly connect meeting to identify, establish and embed any changes made over the last two years that are considered to have improved service delivery. Governance arrangements implemented during the Covid response are being reviewed and either adopted as business as usual or ceased. 4.10 With the confirmation of the NHSG Portfolio arrangements across Grampian and the likely delegation of Children and Families and Criminal Justice services to MIJB, there will be a need for alignment of the governance frameworks and a transition phase to accomplish this to ensure that staff are clear of the priorities and that information flow remains effective. 4.11 As plans evolve, the Strategic Risk Register will be updated to ensure that it reflects any barriers to realising the ambitions we are not enacting, to achieve the vision set out in our Strategic Plan. 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” 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. (e) Staffing Implications There are no additional staffing implications arising from this report. Senior Management Team have considered areas of high risk and are seeking to redeploy staff to address these as a matter of urgency. (f) Property There are no property implications arising from this report. Page 64
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(g) Equalities/Socio Economic Impact An Equalities Impact Assessment is not required because there are no service, policy or organisational changes being proposed. (h) Climate Change and Biodiversity Impacts There are no impacts arising from this report. (i) Directions None arising from this report. (j) Consultations Consultations have been undertaken with the Senior Management Team, Chief Internal Auditor and Tracey Sutherland, Committee Services Officer and comments have been incorporated in this report. 6. CONCLUSION 6.1 This report and appendices contains proposed risk appetite statements that, when approved, will underpin the MIJB approach to strategic decision making. 6.2 The report also outlines the current position in relation to the impact of COVID-19 on progress with transformation plans, and recommends the Board note the revised and updated version of the Strategic Risk Register. Author of Report: Jeanette Netherwood, Corporate Manager Background Papers: held by author Ref: Page 65
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Appendix 1 HEALTH AND SOCIAL CARE MORAY STRATEGIC RISK REGISTER AS AT 6 JUNE 2022 Item 7. Page 67
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Appendix 1 RISK SUMMARY 1. The Moray Integration Joint Board (MIJB) does not function as set out within the Integration Scheme, Strategic Plan and in-line with Standing Orders and fails to deliver its objectives or expected outcomes. 2. There is a risk of MIJB financial failure in that the demand for services outstripping available financial resources. Financial pressures being experienced by the funding Partners will directly impact on decision making and prioritisation of MIJB. 3. Inability to recruit and retain qualified and experienced staff to provide safe care whilst ensuring staff are fully able to manage changes resulting from integration. 4. Inability to demonstrate effective governance and effective communication and engagement with stakeholders. 5. Inability to cope with unforeseen external emergencies or incidents as a result of inadequate emergency and resilience planning. 6. Risk to MIJB decisions resulting in litigation/judicial review. Expectations from external inspections are not met. 7. Inability to achieve progress in relation to national Health and Wellbeing Outcomes. Performance falls below acceptable level. 8. Inability to progress with delivery of Strategic Objectives and Transformation projects as a result of inability to resolve data sharing and data security requirements. 9. Requirements for support services are not prioritised by NHS Grampian and Moray Council. RISK RATING LOW MEDIUM HIGH VERY HIGH RISK MOVEMENT DECREASE NO CHANGE INCREASE The process for managing risk is documented out with the MIJB Risk Policy. Page 68
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Appendix 1 Description of Risk: Regulatory The Integration Joint Board (IJB) does not function as set out within the Integration Scheme, Strategic Plan and Scheme of Administration and fails to deliver its objectives or expected outcomes. Lead: Chief Officer Risk Rating: Low/ medium/ high/ very high MEDIUM Risk Movement: Increase/ decrease/ no change INCREASING Rationale for Risk Rating: The strategic plan “Partners in Care” 2019 to 2029 was developed and launched in December 2019. Membership of IJB committees has recently changed due to the elections in May resulting in 4 new Council members, the resignation of the third sector representative and the GP Lead and Non-Primary Care advisor. An amendment to the Scheme to increase membership by one from each of the partner organisations was ratified in March 2022 by the Scottish Government following due process and approval by Moray Council and NHS Grampian Board. During the initial Covid 19 response, normal business was suspended and emergency arrangements were implemented. IJB, CCG and APR meetings restarted during August 2020. Weekly meetings were instigated with Chair/Vice Chair and Chief Officer and these continue. Progress is underway to review the Strategic Plan “Partners in Care” 2019 to 2029 Rationale for Risk Appetite: The Board, staff and providers across Moray are all committed to ensuring high standards of clinical care & governance through operational policies. Innovation and new ways of working may mean traditional regulations do not exist, or are contradictory. We will only take regulatory risks knowingly, following consultation with the relevant regulatory body and where we have clear risk mitigation in place. Controls: • Integration Scheme. • Strategic Plan “”Partners in Care” 2019 to 2029 • Governance arrangements formally documented and approved by MIJB January 2021. • Agreed risk appetite statement. • Performance reporting mechanisms. • Consultation with legal representative for all reports to committees and attendance at committee for key reports. • Standing orders have been reissued to all members Mitigating Actions: Induction sessions are held for new IJB members with the next scheduled for 22 June 2022. IJB member briefings are held regularly. 1 Page 69
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Appendix 1 Conduct and Standards training held for IJB Members in December 2020 with updates provided by Legal Services as appropriate and is scheduled for 22 June 2022. SMT regular meetings and directing managers and teams to focus on priorities. Regular development sessions held with IJB and System Leadership Group Strategic Plan and locality management structure is in place The work that has been progressed through the Covid19 response has escalated developments in some areas as a matter of priority. This has been achieved through collaborative working with partner organisations and the third sector. Assurances: • Audit, Performance and Risk Committee oversight and scrutiny. • Internal Audit function and Reporting • Reporting to Board. Gaps in assurance: The Covid 19 Response caused a delay in producing the Transformation Plans which in turn has impacted on communication and engagement with staff and partners in respect of the intended outcomes. Work is underway on the refresh of the Strategic plan and will incorporate the work being taken forward for Self-Directed support, Three conversations, Locality Planning, Hospital at home and Hospital without walls Current performance: Scheme of administration is reported when any changes are required. Legal advisors are currently working on the requirements to the integration scheme in relation to the proposed delegation of Children’s and Criminal Justice Services. Report presenting the Strategic Plan, Communication Strategy, Organisational Development and Workforce Plans, Performance Framework and the draft Transformational Plan were presented and approved at MIJB on 28 November 2019 Appointment of Standards Officer agreed by IJB 31 March 2022 Members Handbook has been updated and circulated to all members in June 2022. Governance Framework was approved by IJB 28 January 2021. Comments: Strategic Planning and Commissioning Group approved the generic Terms of Reference and Chairs of the transformation boards at the meeting on 19 December 2019. It was intended that these boards would be established by April 2020 however this work has been on hold due to Covid19 and is being restarted but will incorporate the changes Covid is causing on ways of working and will recommend a revised way forward. The interim Strategic Planning Lead is now taking this forward. Page 70
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Appendix 1 2 Description of Risk: Financial There is a risk of MIJB financial failure in that the demand for services outstrips available financial resources. Financial pressures being experienced both by the funding Partners and Community Planning Partners will directly impact on decision making and prioritisation of MIJB. Lead: Chief Officer/Chief Financial Officer Risk Rating: Low/ medium/ high/ very high VERY HIGH Risk Movement: Increase/ decrease/ no change NO CHANGE Rationale for Risk Rating: Whilst the 2020/21 and 2021/22 settlement saw additional investment for health and social care that was passed through to the MIJB, there remains a significant pressure due to the recurring core overspend, since most of the new investment related to new commitments. Financial settlements are set to continue on a one year only basis, which does not support sound financial planning. In addition, many uncertainties have arisen through the Covid response and continue as we continue to remobilise. The full impact is not yet quantifiable. Demand on services is greater than before and the IJB has £1.2m remaining general reserves. There is however significant earmarked reserves by the end of the 2021/22 financial year relating to the ongoing response to Covid and Primary Care Improvement Plan and the Scottish Government additional investment of £300m for winter funding. The Revenue Budget 2022/23 was approved by MIJB on 31 March 2022, displaying a balanced position. A small savings plan of £0.11 million was approved. Additional Scottish Government investment is provided again for 2022/23, this is to meet additional policy commitments in respect of adult social care pay uplift for externally provided services and seeks to ensure that capacity can be maximised and ensuring system flow. The final outturn position will be finalised and reported to the MIJB in June where it is anticipated there will be a small general reserve. The update medium Term Financial Framework was presented as part of the budget papers on the 31st March 2022 however, it is imperative that this is further reviewed during the 2022/23 year to ensure alignment with the upcoming revisions to the Strategic Plan. Rationale for Risk Appetite: The Board recognises the financial constraints all partners are working within. While we are cautious and open about accepting financial risks this will be done: • Where a clear business case or rationale exists for exposing ourselves to the financial risk • Where we can protect the long term sustainability of health & social care in Moray Covid-19 continues to place additional risk on the MIJB finances as we continue through the pandemic, recover and transform Page 71
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Appendix 1 Controls: Chief Finance Officer appointed - this role is crucial in ensuring sound financial management and supporting financial decision making, budget reporting and escalation. The previous CFO vacated their post on 31 March 2022. There is interim cover but It is essential that a successor is appointed on a permanent basis as soon as practicable. The CFO and Senior Management Team have worked together to address further savings which will be presented to the Board for approval as part of the budget setting procedures for 2022/23. This should be a focus of continuous review to ensure any investment is made taking cognisance of existing budget pressures. A revised Financial Framework was presented to the MIJB on 31 March 2022, and a further review will take place once the current strategic plan has been reviewed to assure alignment. Mitigating Actions: Risk remains of the challenge that the MIJB can deliver transformation and efficiencies at the pace required whilst dealing with the pressures that are emerging as a result of the pandemic. Financial information is reported regularly to both the MIJB, Senior Management Team and System Leadership Group. The Chief Officer and Chief Financial Officer (CFO) continue to engage in finance discussions with key personnel of both NHS Grampian and Moray Council. These conversations have continued throughout the pandemic phase. Chief Officer and CFO will continue to engage with the partner organisations in respect of the financial position throughout the year. Cross partnership performance meetings are in with partner CEOs, Finance Directors and the Chair/Vice Chair of the MIJB. Assurances: MIJB oversight and scrutiny of budget. Reporting through MIJB, NHS Grampian Board and Moray Council. Gaps in assurance: None known Current performance: For the 2021/22 financial year, overspend have been reported throughout the year, however, although the core services recurring overspend remains, there is slippage in additional investments received late in the financial year. The provisional outturn it is expected that MIJB will finish the year with a small general reserve that has been created through non- recurring slippage and a large earmarked reserve. A final position will be presented to the MIJB on 30 June 2022. Comments: Senior managers to work with Chief Officer and Chief Financial Officer to address the continuing financial challenge, continuing to seek efficiencies and opportunities for real transformation as we look to make efficient and effective investment in services that are truly transformational. Page 72
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Appendix 1 3 Description of Risk: Human Resources (People): Inability to recruit and retain qualified and experienced staff to provide and maintain sustainable, safe care, whilst ensuring staff are fully able to manage change resulting from response to external factors such as the impact of Covid and the actions that arose from the recommendations from the Independent Review of Adult Social Care 2021. Lead: Chief Officer Risk Rating: Low/ medium/ high/ very high HIGH Risk Movement: Increase/ decrease/ no change INCREASING Rationale for Risk Rating: There continues to be issues with recruitment to some front line services that require specific skills and experience. This has been the case for some time now and continues to place pressure on existing staff. Allied Health Professions, Social Work are two particular areas experiencing difficulties with obtaining people with the appropriate skills and training. Care at Home staffing levels are pressured for Internal services and externally with local providers all experiencing the same difficulties. There are also impacts on recruitment of Dentists and other graduates arising from Covid as the number graduating has reduced during the period. The various impacts of Covid-19 has placed a significant strain on the Partnerships resources across frontline and support functions and this has resulted in delays for the progress of projects relating to the achievement of strategic objectives. The Care Homes in Moray have continued to do well to maintain their staffing levels throughout the pandemic and whilst the difficulty with recruitment and retention of staff to caring roles is still being experienced. There is a particular issue with long term sickness, secondments and other absence in Care at Home management structure which is resulting in reduced support to frontline staff and increasing pressure on remaining management staff. Efforts are being made to provide support but the situation remains challenging. There have been some achievements in the appointment to the Geriatrician post, and recruitment to agreed models for orthopaedics, anaesthetics, general surgery and the emergency department in Dr Grays. There is further work being undertaken to develop the model for General medicine. There has also been an appointment of an Adult Psychology consultant. The benefit of these appointments are being felt across the whole system. The transition from EU membership has not presented any specific concerns for workforce and this will continue to be monitored. The impact of budgetary decisions by the Council in relation to reducing staffing levels has reduced levels of support provided in some key areas for Health and Social Care Moray (HSCM), such as ICT, HR, Legal and design. Page 73
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Appendix 1 Rationale for Risk Appetite: Safety risks that could result in harm to service users, staff or the public are inherent in Health & Social Care services. The safety of individuals is paramount therefore standards of safety management and clinical care have to be high, and the Board will continue to seek assurances this is the case. The Board’s ambition is for health & social care to be people centred. This means supporting people in decision making about their own health & care, which may expose individuals to higher risk where they make an informed decision. The Board will also seek to balance individual safety risks with collective safety risks to the community. Controls: Management structure in place with updates reported to the MIJB. Organisational Development plan in place and Workforce Plans are being updated to align to the new strategic plan. Continued activity to address specific recruitment and retention issues. The chief social worker reviewed the situation with managers and employed a Consultant Practitioner to develop options for addressing some of the particular issues affecting social work services in Moray and to provide support to managers and staff. There continues to be pressures around Social Work as more requests for assessment are being received from the community and an additional 3.68 FTE have been appointed for a temporary period to progress outstanding reviews. Management competencies continue to be developed through Kings Fund training although this is suspended due to Covid19. Communications & Engagement Strategy was approved in November 2019 and is being implemented. Council and NHS performance systems in operation with HSCM reporting being further developed and information relating to vacancies, turnover and staff absences is integral to this. Managers are highlighting any areas of concern and where appropriate this is identified in operational risk registers. HSCM services have commenced weekly reporting of workforce sit reps for Senior Management Team oversight highlighting vacancies, annual leave, sickness absence and Covid impacts so that issues can be identified and assessed quickly. Mitigating Actions: System re-design and transformation. Organisational Development Plan and Workforce plan were updated and approved by MIJB in November 2019. The Workforce plan is currently being updated again and will be completed by September 2022. These plans are core documents for the Workforce Forum which has recently re-commenced following a temporary suspension during the first quarter of this year due to Covid impact. Staff Wellbeing is a key focus and there are many initiatives being made available to all staff including training, support, information and access to activities. Locality Managers are developing the Multi-disciplinary teams in their areas and some project officer support has been provided to develop the locality planning model across Moray. Page 74
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Appendix 1 Lead Managers are involved in regional and national initiatives to ensure all learning is adopted to improve this position. Lead Managers and Professional Leads are linked to University Planning for intakes and programmes for future workforce development. Assurances: Operational oversight by Moray Workforce Forum has resumed and will report to MIJB in accordance with the agreed Governance framework. The HSCM Response Group was in place over the whole period of the Covid19 pandemic providing focussed leadership around emerging issues and resolving them. This group stood up again in April and is meeting daily whilst the system is pressured, this will be reviewed as the situation evolves. The Heads of Service are co-ordinating and escalate to SMT where necessary. Gaps in assurance: Further work required to develop workforce plans to reflect strategic plan implementation programmes once they are agreed. Current performance: The full IMatter surveys did not take place during 2020 however an IMatter pulse survey was undertaken in September 2020 to get a snap shot of what staff are feeling. Results were published 20 November 2020 and although there was a lower response rate of the 36% the “working within the organisation satisfaction” score was 6.91 compared with 6.94 in 2019. The IMatter survey results for 2021 were received by managers for review and action plans. Preparatory work is commencing on the survey for IMatter 2022 Discussions are underway with HR in both Council and NHS to develop access to appropriate HR information at a summarised level to facilitate the necessary workforce planning and subsequent monitoring of plans. There continues to be a need for more streamlining in recruitment processes as the delay in approval to recruit to having a member of staff available is in excess of 8 weeks. There is also a lack of suitable applicants for various posts which is impacting on ability to appoint for some roles. Comments: Staffing issues are owned by the Systems Leadership Group who will work collaboratively across the system to seek opportunities to make jobs more attractive where it has proved difficult to recruit in the past. For some professions there is a potential risk that staff move from one position to a new position within HSCM will just move the vacancy to elsewhere in the system, so Senior Management Team are aware of this risk and taking it into account in considerations for vacancies. Page 75
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Appendix 1 There is a concern that if there is a longer term continuing impact of Covid on system flow and beds continue to be blocked for new patients it will mean operations cannot be scheduled to reduce the backlog and key staff may not have the necessary time in surgery to maintain skills. 4 Description of Risk: Reputation: Inability to demonstrate effective governance and effective communication and engagement with stakeholders. Lead: Chief Officer Risk Rating: low/medium/high/very high MEDIUM Risk Movement: increase/decrease/no change NO CHANGE Rationale for Risk Rating: Locality planning assessed as medium in relation to ability to work at the pace required and current workforce capacity. Performance framework to be further developed from a planning perspective to show the links through operational service delivery to strategic objectives. The Third Sector rep stood down from MIJB and the substitute was only able to commit to attending until August 2021. Efforts are underway to recruit a replacement for this role and for other forums and it is anticipated that an appointment will be made for the 30 June 2022 meeting. Recent engagement with individuals representing their communities or third sector organisations in a variety of forums is highlighting that problems with their capacity to fulfil our needs so more co-ordination and clearer focus is required to ensure that the communication, engagement and outcomes are meeting identified needs. Rationale for Risk Appetite: The Board is cautious but open about risks that could damage relationships with different stakeholders. It recognises many of our aspirations depend on effective collaboration, coproduction and partnership working with a range of stakeholders. The appetite also recognises that while the aspiration is to be a co-operative partner, some partners will not be able to move at the same pace as us all the time. We will seek to protect relationships in the long term and will not set out to antagonise stakeholders deliberately. For example, we must not be seen to exclude or prevent participation in the design of services where there is an appetite to do this. Page 76
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Appendix 1 We must be mindful that repairing relationships is easier when there is already a well of goodwill to draw on, and that further damage to an already damaged relationship will not be conducive to good long term outcomes. Traditional methods of engagement are not possible at present as social distancing rules apply however alternative mechanisms for engaging with stakeholders are being used along with social media Controls: Governance Framework approved by IJB January 2021 Communication and Engagement Strategy approved November 2019 Annual Governance statement produced as part of the Annual Accounts 2019/20 and submitted to External Audit. Annual Performance Report for 2019/20 was published in August 2020 Performance reporting mechanisms in place and being further developed through performance support team, home first group and system leadership team. Community engagement in place for key projects areas such as Forres, Keith and Lossiemouth with information being made available to stakeholders and the wider public via HSCM website. Participation of stakeholders in a variety of meetings such as Home First project, carer strategy, Strategic, Planning and Commissioning groups. Mitigating Actions: Schedule of Committee meetings and development days in place and implemented. Good working relationship established with Audit Scotland, the MIJB’s appointed external auditors since 16/17. Annual Performance Report for 2020/21 published in August 2021. Social media is actively used as a method of engaging with the public, with short videos focussing on particular services being trialled. SMT have considered the existing arrangements for engagement with stakeholders and work is being undertaken to align our framework with the Scottish Government “Planning with people guidance” and ensure that mechanisms are in place across services to evidence and evaluate their impact. Assurances: Oversight and scrutiny by Clinical and Care Governance Committee, Audit Performance and Risk Committee and MIJB. Summary reports of minutes of MIJB meetings are submitted to Council committee and NHS Board. Gaps in assurance: Progress on implementation of the Communication and Engagement Strategy has been impacted by the Covid 19. Due to the impact of COVID and requirement for social distancing the normal mechanism for engagement were not all available. More use is being made of social media and Microsoft teams and other options and methods for engagement with staff are being used via NHSG such as videos on YouTube and one question surveys. Going forward there may be more opportunity for face to face meetings to take place again. Page 77
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Appendix 1 Current performance: Communications Strategy was reviewed approved by IJB November 2019. Annual Performance Report 2020/21 published August 2021. Audited Accounts for 2020/21 were publicised by deadline 30 September 2021 Due to Covid19 there have been increased levels of briefings to staff, the public and Chair/Vice Chair of MIJB with a focus on the key elements of the response. The staff newsletter commenced during Covid but will continue to be produced. Comments: A communication cell was established as part of the Local Resilience Partnership Covid and storms response with representation from Councils, HSCP and NHSG. This was led by Aberdeen City Council and was an example of the collaborative working that took place. This forum provides assurance that messages to all stakeholders are consistent. It also ensures that there is support for our Communications Officer and resilience provided with the access to other communication officers. There has been representation from the Home first project at the Wellbeing forum to facilitate sharing of information and seeking views. 5 Description of Risk: Environmental: Inability to cope with unforeseen external emergencies or incidents as a result of inadequate emergency and resilience planning. Lead: Chief Officer Risk Rating: low/medium/high/very high HIGH Risk Movement: increase/decrease/no change NO CHANGE Rationale for Risk Rating: Due to the response requirements for Covid 19 progress has been made in a number of areas. SMOC information is updated, control room guidance updated and expanded, control centre protocols were implemented and remain in place and management teams have responded in an agile, responsive and collaborative way under very challenging conditions. HSCM did not have a collectively approved list of critical functions at the start of the response however this was quickly completed and used to prioritise allocation of resources to the response. This list was reviewed in 2021 and managers are working to a schedule to update for any further changes that have been implemented as a result of Omicron. Page 78
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Appendix 1 Covid infections continue in Moray however mitigations in place in accordance with Scottish Government guidance are intended to assist services maintain core staffing levels and service delivery. Teams continue to do their best but there are areas where they still feeling overwhelmed and service delivery is restricted to core elements. With effect from March 2021 MIJB is defined as a Category 1 responder under the Civil Contingencies (Scotland) Act and there are additional requirements for preparedness that is being taken forward in partnership with NHSG and Moray Council emergency planners. Rationale for Risk Appetite: The MIJB understand the requirement to meet the statutory obligations set out within the Civil Contingencies Act and the Category 1 status applied in March 2021, and work with partner organisations to meet these obligations Controls: Winter Preparedness Plan was updated (but not tested as in previous years) alongside NHSG plans as NHSG implemented their crisis management framework which required participation of partners at Daily connect meetings to discuss and prioritise resource to address issues with system flow. HSCM Civil Contingencies group established and meeting regularly to address priority subjects. NHS Grampian Resilience Standards Action Plan approved (3 year). Business Continuity Plans in place for most services although overdue a review in some areas. Knowledge of critical functions and ability to respond quickly and effectively has been in evidence during incidents such as Gas outages in Keith (January and February 2021) and Covid response, Storms (Arwen, Malik and Corrie) – debriefs carried out and learning identified. Debriefs being undertaken for HSCM, Moray (Council and HSCM) and Local Resilience Response with lessons learnt being collated and prioritised for an action plan. Mitigating Actions: Information from the updated BIA/BCP informed elements of the Winter Preparedness Plan A Friday huddle is in place which gathers the status of services across the whole system to provide information and contact details to the Senior Manager on Call (SMOC) over the weekend. NHSG have introduced system wide daily huddles to manage the flow and allocation of resources which require attendance from Dr Grays and HSCM. NHS Grampian have amended their approach to Pandemic preparation so HSCM Pandemic plan will require redrafting and testing. This will be taken forward by HSCM Civil Contingencies Group. Practitioner group established for Moray with representation from HSCM, Dr Grays, Moray Council and NHSG to discuss matters arising from the Local Resilience Forum and within our respective organisations. In addition it will provide a forum for discussion of the linkages between organisational response plans to ensure there are no gaps or over reliance on particular local resources. Page 79
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Appendix 1 HSCM continues to monitor the local situation regarding impacts on staffing and is engaged with NHSG emergency planning arrangements and Council Response and Recovery management team to be ready to escalate response if required. Work was undertaken within NHSG, Aberdeenshire HSCP and Aberdeen City HSCP to look at Surge flows and establish a mechanism that will provide easy identification of “hot spots” across the whole system in Grampian, to facilitate a collaborative approach to addressing the issues through the use of a common Operational Pressure Escalation approach. This work could underpin surge responses in winter and at other times of pressure and having a standard approach across Grampian could aid communication and understanding. Assurances: Audit, Performance and Risk Committee and NHS Grampian Civil Contingencies Group oversight and scrutiny. HSCM Civil Contingencies group review specific risks and action plans to mitigate, developing plans and testing arrangements in partnership with NHSG and Council Gaps in assurance: The recent experience of Storms and associated power outages proved challenging for all category 1 responders across Grampian however our staff responded extremely well. The debriefs have identified lessons learnt for Grampian Local Resilience Partnership and more locally for the response co-ordination within Moray. Action plans have been developed in collaboration with Moray Council’s emergency planning officer to address the issues identified. The main issues related to developing wider awareness of roles and responsibilities, and improving general awareness of response structures and meeting protocols. This will be incorporated into training schedules going forward. It has also highlighted the need for a more robust arrangement for out of hours contact and clarity of roles and responsibilities across the system which is being progressed through an organisational change steering group. Some table top exercises have been completed but the intended programme for 2020 is being rescheduled now we are out of response phase. Progress has been made however further work is required to address the targets in the implementation plan that have not been met and the Resilience standards as identified by the NHSG Civil Contingencies Group. Pandemic flu plans will require to be updated with the learning from Covid 19 The debrief reports following the gas outages from a Moray perspective and the Grampian Local Resilience Partnership (LRP), highlighted some issues for clarification in relation to the Care for People agenda. To address the local issues meetings have been taking place with Moray Council and HSCM representation to progress the Care for People plan and associated response structures. The Care for People group met in April and will meet again in June to review the draft Care for People plan for sign off. The intention is to hold a table top exercise with managers from HSCM and Moray Council to test the invocation arrangements to ensure common understanding of roles and responsibilities. Current performance: The Senior Management Team participated in Strategic Leadership in a Crisis training in 2020 and a programme of further training for the wider management team is scheduled. Page 80
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Appendix 1 Many services have business continuity arrangements and some are overdue for an update. Work has progressed in identification of a critical functions list for agreement by System Leadership Group that will inform planning arrangements going forward. There will need to be changes made to business continuity plans following the implementation of additional ICT resources in services which have provided a greater deal of resilience for some services and functions – albeit reliant on electricity supply. A schedule of review and exercising of business impact assessments and plans has been scheduled for this year across services. Annual report on progress against NHS resilience standards was reviewed by APR committee on 31 March 2022. Report on the implications of the designation as a Category 1 responder was presented to MIJB 25 November 2021. Information has been collated regarding dependencies of fuel for delivery of critical functions for submission to NHSG and Council for inclusion in the planned response to the invocation of the National Fuel Plan. Comments: Once the response phase is complete the HSCM Civil Contingencies group will schedule and review progress in achieving the NHSG resilience standards, reporting updates to System Leadership Group. Page 81
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Appendix 1 6 Description of Risk: Regulatory Risk to MIJB decisions resulting in litigation/judicial review. Expectations from external inspections are not met. Lead: Chief Officer Risk Rating: low/medium/high/very high MEDIUM Risk Movement: increase/decrease/no change INCREASING Rationale for Risk Rating: Considered medium risk due to the impact of Covid-19 and resultant efforts required to remobilise services and/or the increase in workloads stretching a workforce that has been under sustained pressure for a considerable time. The impact of the current level of Covid positive staff is stretching resources to deliver care in the community across all providers (internal and external) so there is a potential increased risk of expected standards not being achieved despite the best efforts of all concerned. Rationale for Risk Appetite: The Board, staff and providers across Moray are all committed to ensuring high standards of clinical care & governance through operational policies. Innovation and new ways of working may mean traditional regulations do not exist and require to be developed, no longer apply, or are contradictory. We will only take regulatory risks knowingly, following consultation with the relevant regulatory body and where we have clear risk mitigation in place. Controls: Clinical and Care Governance (CCG) Committee established and future reporting requirements identified Clinical Risk Management and Practice Governance group has oversight of their respective professional standards and feed into Clinical and Care Governance Group, which then escalates to CCG Committee as necessary. High and Very High operational risks are reviewed by System Leadership Group monthly and a review of all risks will be undertaken as part of the risk management framework. Complaints and compliments procedures in place and monitored. A complaints co-ordinator role is being developed and will be implemented to reduce duplication of effort, to provide co-ordination and improve information flow and support managers in responses with the intention of streamlining processes and improving achievement of target timescales. Clinical incidents and risks are being reviewed on a weekly basis to ensure processes are followed appropriately and consistently and responses are recorded in a timely manner. Adverse events and duty of candour procedures in place and being actioned where appropriate and summary reports submitted to CCG committee. Page 82
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Appendix 1 Reports from external inspections reported to appropriate operational groups and by exception to SMT for subsequent reporting to CCG or Audit Performance and Risk Committee as appropriate, albeit there has been a reduction in some areas of external inspection reporting during the Covid period due to social distancing restrictions Care Home Oversight Group was meeting daily but now three times a week to oversee and manage risks in care homes. Children and Adult Protection services are being delivered and reported to their respective committee on a regular basis. Mitigating Actions: This risk is discussed regularly by the three North East Chief Officers. Additional resource has been allocated to support the analysis of information for presentation to CCG committee Process for sign off and monitoring actions arising from Internal and External audits has been agreed Assurances: Audit, Performance and Risk and Clinical and Care Governance Sub-Committees oversight and scrutiny. Governance Framework in place and operational. 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 reviewed and actions arising are allocated to officers for taking forward. A summary of inspections was included in the Annual Performance report. The level is marked as an increasing risk on the basis that services are under pressure with the issues with staffing capacity and the need to focus on delivery of critical functions which may mean external inspection are not the priority at this moment in time. The Adult Support Protection inspection took place in April/May and the findings are awaited. Comments: No major concerns have been identified for HSCM services in any audits or inspections during 2021/22. The equipment store has received a follow up internal audit and the initial verbal feedback was positive. Page 83
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Appendix 1 7 Description of Risk: Operational Continuity and Performance: Inability to achieve progress in relation to national Health and Wellbeing Outcomes. Performance of services falls below acceptable level. Lead: Chief Officer Risk Rating: low/medium/high/very high HIGH Risk Movement: increase/decrease/no change NO CHANGE Rationale for Risk Rating: 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. Unplanned admissions or delayed discharges place additional cost and capacity burdens on the service. The level of delayed discharges has come down slightly too averaging 36 in the last month, reflecting the sustained pressure in the system as a result of Covid -19 impact 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. Rationale for Risk Appetite: The Board is cautious but open about risks that could affect outcomes that are priorities for people in Moray. There is a slightly higher appetite to risks that may mean nationally set outcomes – that by design are not given a high priority in Moray - are not met. This will only be accepted where there is a clear rationale, and preferably also a way of demonstrating what the IJB is doing to meet the aspiration the outcome was created for. Controls: Performance Management reporting framework. 2019 to 2029 “Partners in Care” Strategic Plan approved and refresh of Plan and development of implementation Plans underway. Performance regularly reported to MIJB. Revised Scorecard being developed to align to the new strategic priorities. Best practice elements from each body brought together to mitigate risks to MIJB’s objectives and outcomes. Chief Officer and SMT managing workload pressures as part of budget process. A daily dashboard of key indicators has been developed for HSCM and is circulated to service managers to ensure shared understanding of the pressures in the system. Work continues on refinement of G-OPES (Grampian Operating Page 84
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Appendix 1 Pressures and Escalation System) led by NHSG but being developed locally to identify the triggers and resultant actions required in services to respond to pressure points. Mitigating Actions: Service managers monitor performance regularly with their teams and escalate any issues to the System Leadership Group (SLG) for further discussion to provide wider support, developing shared ownership and a greater understanding across the whole system. Key operational performance data is collated and circulated daily to all managers. A Daily dashboard is held on illuminate for managers to access to ensure any potential issues are identified quickly so action can be taken. This dashboard is being reviewed and will be further developed with the intention of further dashboards to provide a whole system overview. This has been discussed at SLG and agreed. Performance information is presented to the Performance sub group of Practice Governance Group to inform Social Care managers of the trends in service demands so that resources can be allocated appropriately. Assurances: Audit, Performance and Risk Committee oversight. Operationally managed by service managers, summary reports to Practice Governance and clinical and care governance group and to System Leadership Group. Strategic direction provided by Senior Management Team. HSCM Response Group continues to meet and reviews the key performance information and actions that are required to deliver the priority services. Gaps in assurance: Development work in performance to establish clear links to describe the changes proposed by actions identified in the Strategic Plan has recommenced but is at an early stage. This will be progressed as the revised outcomes are determined and associated KPI are identified. Progress will be reported to future Board meetings. Current performance: Covid19 has impacted on all areas of the service and work is underway to take the learning and experience gained during the response to collate performance information in dashboards to support mangers interpret the impact of Covid19 on their services, now and going forward. There are likely to be changes to ways of working and this may also have impact on the performance information required. Comments: Locality profile information has been provided to Locality Steering Group/Locality Manager to inform potential priorities for consideration in Localities and work will be taken forward regarding development of performance monitoring and reporting of key performance indicators in relation to Localities once it has been determined what the intended outcomes are. The delayed discharge group has produced an action plan for implementation and progress is being made. Page 85
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Appendix 1 Practice Governance have reviewed their operational performance requirements and have a comprehensive data set used to inform operational priorities. The Home First priorities are being taken forward and updates are reported to this committee or MIJB on a regular basis. Progress in this area has been hampered due to the increased demand for urgent or critical services requiring staff resource to be prioritised to frontline service delivery. The Council has procured new modules for their performance reporting system Pentana and HSCM performance team has been developing its its use for reporting. 8 Description of Risk: Transformation Inability to progress with delivery of Strategic Objectives and Transformation projects. Lead: Chief Officer Risk Rating: low/medium/high/very high HIGH Risk Movement: increase/decrease/no change NO CHANGE Rationale for Risk Rating: There are many issues that will impact on the ability to progress to deliver Strategic Objectives. The Strategic Planning & Commissioning group has been refreshed and re-launched and key work is being progressed. There was an initial meeting held on 22 September 2021 to consider terms of reference and the proposed structure for oversight, prioritisation and assurance in relation to key developments, their fit with IJB strategy and enabling elements. The interim appointment of the Strategic Planning Lead provides capacity to take this forward and to align the priorities arising nationally, Grampian-wide and locally. The remobilisation plan for HSCM services that were suspended or reduced is progressing with Providers services and social work implementing the IJB decision to return to delivery of both substantial and critical eligibility criteria. Work has progressed risk assessments are completed and assessments have been or are in the process of being reviewed to ensure equality. There are still some restrictions of social distancing on some services mean that capacity for services is impacted. There are some tests of change underway with a focus on delivery of individual outcomes which may mean service users receiving a different type of service (after discussion and agreement) which will meet their defined outcomes. It is anticipated that a hybrid service will be offered which will facilitate tailoring of services to meet specific individual outcomes where this is appropriate. Page 86
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Appendix 1 The time period and extent of Covid 19 the impact on the population of Moray will not be fully understood until well after the response is over. It is therefore not possible to predict the extent of the impact on the ability to progress with delivery of Strategic Objectives. There are some aspects that have progressed very well such as introduction of Near Me consultations but there are others that are more difficult to progress. There is concern that due to the workloads and challenges over the last year that teams are weary and/or do not have capacity at this moment in time, to progress with delivery of development plans at this moment in time. In addition the pandemic is still present in the community so services are still responding to the impacts it has for the population of Moray. Managers are working with teams to establish “readiness” and their capacity and sense of wellbeing and the collated output will inform plans going forward. One key aspect to facilitate transformation is the need for progress in relation to ICT infrastructure, data sharing and data security across the whole system. Work was undertaken by NHS GRAMPIAN and partners to address the needs for ICT kit and information during the response to Covid and it is hoped that this progress can be built on Rationale for Risk Appetite: The Board has a high appetite for risks associated with delivery of transformational redesign. The following should be considered when accepting these risks: • We understand and can mitigate other risk types that may arise, e.g. safety or financial within appetite • Service users are consulted and informed of changes in an open & transparent way • We will monitor the outcome and change course if necessary Controls: Home First strategic theme is being progressed across the whole system and a local Home First Group is meeting monthly. A newsletter is being produced to keep staff and partners informed. It is recognised that there will be significant changes taking place in Social Work practice with the implementation of the Self Directed Support standards and the move to outcomes based services, so governance arrangements are being set up to facilitate the same type of oversight and communication that is in place for the Home First programme. Mitigating Actions: Integrated Infrastructure Group previously established, with ICT representation from NHSG and Moray Council, to consider and provide solutions to data sharing issues and ICT infrastructure matters which is an area that will be taken forward alongside the Moray Growth Deal projects. Linkages to Infrastructure board and Information sharing groups have been established albeit these meetings are not taking place regularly at the moment. Data sharing groups for Grampian and Health and Social Care Moray have been established and meetings were held regularly but have not taken place for several months due to Covid. These meetings have oversight of any issues arising from Data protection and GDPR matters from either Council or NHS systems. It is anticipated that these will restart during the next quarter. Page 87
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Appendix 1 Assurances: Strict ICT and data sharing policies and protocols in place with NHS Grampian and Moray Council. Gaps in assurance: Transformation/implementation planning is in development and will inform outcomes and performance reporting on the delivery of the strategic plan. Protocol for access to systems by employees of partner bodies are in place. Information Management arrangements to be developed and endorsed by MIJB. Process of identification of issue and submission to data sharing group requires to be reinforced to ensure matters are progressed. Hybrid working arrangements and preparation of offices for return require to be progressed in partnership with Council and NHSG. Current performance: Training programme to be developed on records management, data protection and related issues for staff working across and between partners. Comments: Where national systems are involved it may not be possible to identify a solution however the issues will be able to be raised at the appropriate level via the Grampian Data Sharing Group where all three partnerships are represented. Page 88
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Appendix 1 9 Description of Risk: Infrastructure Requirements for support services are not prioritised by NHS Grampian and Moray Council. Lead: Chief Officer Risk Rating: low/medium/high/very high HIGH Risk Movement: increase/decrease/no change NO CHANGE Rationale for Risk Rating: Changes to processes and necessary stakeholder buy-in still bedding in. Moray Council is undertaking a Property review of office and depot accommodation and the potential impact for HSCM services requires consideration. The output was anticipated in October 2019 however due to changes with roles and responsibilities within the Council however the paper has been out for consultation. The changes required to places of work as a result of Covid19 continue to restrict the number of people that can use an office. These decisions are being made by NHSG and Moray Council and we await their development of policy regarding workspace and availability of facilities going forward as highlighted in the Premises Strategy report to MIJB in May 2021. NHSG have advised that staff should continue to work from home at present whilst policies and protocols are developed. Moray Council are promoting a hybrid method of working and are limiting occupancy in offices at present to 50% of desk capacity. ICT infrastructure service plans in NHS Grampian and Moray Council are not yet visible to HSCM and development of communication and engagement process is required. The impact of Covid has resulted in a change in ICT strategy for Moray Council. Council employed staff requiring mobile technology have now been provided with it and many staff are working from home. This is a necessity where the number of desks available in offices has been reduced due to implementation of social distancing guidance. There is still an issue with availability of kit for NHS employed staff which has been escalated There are some significant risks in relation to accommodation for services on operational risk registers which are taking longer than would be ideal to resolve. Rationale for Risk Appetite: Low tolerance in relation to not meeting requirements. Controls: Chief Officer has regular meetings with partners Computer Use Policies and HR policies in place for NHS and Moray Council and staff are required (through and automated process) to confirm they have read these every 6 months Page 89
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Appendix 1 PSN accreditation secured by Moray Council Infrastructure Programme Board was established with Chief Officer as Senior Responsible Officer/Chief Officer member of CMT. Process for submission of projects to the infrastructure board approved and implemented to ensure appropriate oversight of all projects underway in HSCM. The Board is not meeting at present, so in the interim, project requests are being processed via Senior Management Team. Mitigating Actions: Membership of the Board was reviewed and revised to ensure representation of all existing infrastructure processes and funding opportunities. Process for ensuring infrastructure change/investment requests developed Interim Infrastructure Manager in post and linking into other Infrastructure groups within NHSG & Moray Council to ensure level of ‘gatekeeping’. Dr Gray’s site development plan is being produced collaboratively with input from NHSG and HSCM management Work is progressing on identification of needs for some services with regard to accommodation which will be communicated with partners to find the most effective solution. Assurances: Infrastructure Programme Board functions to provide robust governance and assurance that proposed projects have a robust business case and meets requirements of the respective partner organisations. This board reports to Strategic Planning and Commissioning Group. Both of these groups are being refreshed and remobilised. Workforce Forum meeting regularly with representation of HR and unions from both partner organisations Gaps in assurance: Further work is required on developing the process for approval for projects so that they are progressed timeously. Need to review all existing processes in relation to infrastructure changes/projects/investments and streamline to avoid duplication of effort. Infrastructure Board is in development and priority issues are being addressed in relation to infrastructure and premises risk. Legal services have reduced capacity to provide support due to budget cuts so any requests may take longer. Recruitment for vacancies takes considerable time due to various factors and is presenting a strain on services to maintain normal service whilst covering vacancies. There have been several posts that have had to go out to advert more than once extending the time other staff are covering gaps. Page 90
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Appendix 1 Current performance: The Infrastructure Board is currently suspended. Its purpose is for highlights/exceptions to be taken to SLG for communication and information purposes. Access to support for development of HSCM priorities is difficult at time because projects/requests are prioritised against all other services in the partner organisations. The challenges and impact on the ability to adopt efficient working processes for HSCM staff and managers whilst have to use networks/systems from two organisations, which cannot be accessed by all members of teams due to data sharing, matters is very significant. Comments: Existing projects will be reviewed as part of the development of the transformation plans for the Strategic Plan to ensure resources are being dedicated appropriately and aligned to the emerging Strategic priorities. Our requirements for support will be communicated via appropriate channels There remains issues with access to ICT equipment for staff with orders over 6 months old outstanding with both NHSG and Moray Council. This impacts on services effectiveness. The matter has been escalated by senior managers with colleagues in the partner organisations. Page 91
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 30 JUNE 2022 SUBJECT: INTERNAL AUDIT ANNUAL REPORT – 2021/22 BY: CHIEF INTERNAL AUDITOR 1. REASON FOR REPORT 1.1 This report provides the Audit, Performance and Risk Committee with details of internal audit work undertaken relative to the Moray Integration Joint Board (MIJB) for the financial year ended 31 March 2022, and the assurances available on which to base the internal audit opinion on the adequacy of the MIJB’s systems of internal control. 2. RECOMMENDATION 2.1 The Audit, Performance and Risk Committee is asked to consider and note the contents of the annual report given as Appendix 1 to this report. 3. BACKGROUND 3.1 The purpose of this report is to present the Audit, Performance and Risk Committee with the Internal Audit Annual Report for the year to 31 March 2022 which includes the Chief Internal Auditor’s independent assurance opinion on the adequacy of the MIJB’s systems of internal control. 3.2 The Public Sector Internal Audit Standards (PSIAS) require that the Chief Audit Executive (CAE), the MIJB’s Chief Internal Auditor, to provide an annual internal audit opinion and report on the adequacy and effectiveness of the MIJB’s systems of governance, risk management and internal controls to support the preparation of the Annual Governance Statement. This is in support of the overall governance arrangements of the MIJB. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 The report covers the year to 31st March 2022 and is provided as Appendix 1. Item 8. Page 93
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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” Internal audit work supports good governance and assists in securing appropriate systems of internal control. (b) Policy and Legal The internal audit service is provided in terms of paragraph 7:1 of the Local Authority Accounts (Scotland) Regulations 2014, and there is a requirement to provide a service in accordance with published Public Sector Internal Audit Standards. (c) Financial Implications No implications directly arising from this report. (d) Risk Implications No direct implications. (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 No implications. (i) Directions There are no directions arising as a result of this report (j) Consultations There have been no direct consultations during the preparation of this report. 6. CONCLUSION 6.1 This report provides a summary overview of the nature and extent of audit work carried out during the year, and informs the annual internal audit opinion on the internal control environment operating within the MIJB. Author of Report: Dafydd Lewis, Chief Internal Auditor Background Papers: Internal Audit Files Ref: mijb/ap&rc/30062022 Page 94
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APPENDIX 1 INTERNAL AUDIT ANNUAL REPORT and OPINION 1 APRIL 2021 to 31 MARCH 2022 Item 8. Page 95
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2 | P a g e CONTENTS PAGE SECTION 1 INTRODUCTION 3 SECTION 2 BASIS OF OPINION 4 SECTION 3 SUMMARY AND LIMITATIONS OF WORK THAT SUPPORTS OPINION 4 - 6 SECTION 4 OPINION 7 Page 96
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3 | P a g e SECTION 1 – INTRODUCTION Purpose of this report Public Sector Internal Audit Standards (PSIAS) requires that the Chief Internal Auditor provide a written statement to inform the Annual Governance Statement. This report constitutes the required statement. As required by PSIAS, this report presents the opinion on the overall adequacy and effectiveness of the Moray Integration Joint Board (MIJB) risk management, control and governance processes based on the work Internal Audit has performed. In addition, my evaluation will also include an assessment of reports issued by other review agencies. The scope of Internal Audit work, the responsibilities of Internal Audit and the assurance given on the adequacy and effectiveness of the Internal Control System of the MIJB are explained further in Section 4 of this report. Responsibilities of Management and Internal Audit It is management’s responsibility to maintain systems of risk management, internal control and governance. Internal Audit is an element of the internal control framework established by management to examine, evaluate and report on accounting and other controls over operations. Internal Audit assists management in the effective discharge of its responsibilities and functions by examining and evaluating controls. Internal Audit cannot be held responsible for internal control failures. Internal Audit’s role includes assessing the adequacy of the risk management, internal controls and governance arrangements put in place by management and performing testing on a sample of transactions to ensure those controls were operating for the period under review. The responsibility for providing the Internal Audit Service to the MIJB is by the Moray Council’s Internal Audi Section. However reliance is also obtained from the Internal Audit Service Provider for NHS Grampian to support the annual internal opinion on the MIJB’s internal control environment Public Sector Internal Audit Standards (PSIAS) require officers of the Internal Audit Section to communicate on a timely basis all facts and matters that may have a bearing on their independence. I can confirm that all staff members involved in 2021/22 internal audit reviews were independent of operational processes and their objectivity was not compromised in any way. Page 97
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4 | P a g e SECTION 2 –BASIS OF OPINION My evaluation on the adequacy and effectiveness of the MIJB framework of governance, risk management and internal control is based on the following; • The audit work undertaken by Internal Audit during the year to 31 March 2022. • The governance statement signed by the Chief Officer of the MIJB for the year ended 31 March 2022. • Reports issued by the MIJB’s External Auditor, Audit Scotland, and other external review agencies. • My knowledge of the MIJB’s governance, risk management and performance monitoring arrangements. Assurance is also based on the wider audit work conducted by the Chief Internal Auditor in his capacity as the Audit and Risk Manager of the Moray Council and from an annual internal audit report prepared for Grampian Health Board providing an opinion on the adequacy and effectiveness of its system of internal control. SECTION 3- SUMMARY AND LIMITATIONS OF WORK THAT SUPPORTS THE OPINION Progress on the 2021/22 internal Audit Plan Internal Audit operates independently within the organisation. While there may have been limitations in the scope of the audit due to the pandemic, there have been no limitations imposed by management on the scope of audit work performed. The Annual Audit Plan presented to the Audit, Performance and Risk Committee describes in some detail the framework around which audit work is developed. In addition, the selection of audit topics was selected having regard to corporate planning documents, budget data and information drawn from the corporate risk register, and takes into account input from senior management regarding possible areas for audit. The internal audit work has been conducted in accordance with an established methodology that promotes quality and conformance with the Public Sector Internal Audit Standards and the agreed Internal Audit Annual Audit Plan. A summary of the audit projects from MIJB Audit Plan is summarised as follows: Page 98
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5 | P a g e • An audit was undertaken into the financial monitoring arrangements within the Self Directed Support Team for direct payments made to service users. The audit has checked for effective procedures in the monitoring of funds issued to service users. This involved the random selection of a sample of care packages and a check made to ensure compliance with operating procedures, expenditure incurred by the service users are in accordance with the agreed budget and support plans and surplus funds are recovered from service users where appropriate. • The audit found several areas where further improvements are required to current operating arrangements with a need to review all service user care packages to recover any excess funds. It is appreciated that staff resources have been diverted to support Covid related activities and the focus has been on supporting direct payment recipients, employers and personal assistants to ensure essential care has continued to be delivered. • An audit was undertaken into how Health and Social Care Officers manage income held for individuals under Corporate Appointeeship Arrangements. Where an individual is assessed as requiring assistance in the financial management of benefits received, an application can be made to the Department for Work and Pensions (DWP) in order for Social Work Officers to become the 'Corporate Appointee' and have legal authority for administering this income. • The audit involved a review of the procedures undertaken by the Community Care Finance Team into how they manage client funds held within the corporate bank account. In addition, a sample of individuals was also selected, and a check was made on how officers appointed as the named 'Corporate Appointee' manages and support individuals to access and use their funds appropriately. The audit found that overall, the service was being administered well, but findings were noted, including a need to review cash handling procedures, further management overview of the corporate bank account reconciliation process. • A review has also been undertaken of creditor payments made within 2021/22. The use of an audit software interrogation system called IDEA was used to randomly select a sample of payments to check. The purpose of the audit was to confirm ongoing compliance with procurement and payment processing regulations. A check was also made for duplicate payments by extracting listings where more than one invoice from a single supplier has been paid for the same amount. From the sample checked, no issues were noted for reporting. • The impact of the pandemic has affected the Internal Audit Service in that officers have been working from home with a need to change established working practices and make greater use of audio, video and screen sharing software applications. These changes in working practices have brought challenges, however the implementation of an Internal Audit Software Application has assisted to ensure consistent working practices with the ability to review working papers online. The Service has also had several staff vacancies during the year. However, moving forward all positions have now been filled. Unfortunately, due to the limitations detailed and an unplanned audit project it has not been possible to complete a review of the Moray Council’s arrangements to safeguard systems and services from a Cyber Security attack. Due to the importance of this topic, it has also been included within the Moray Council’s Audit Plan for 2022/23. Page 99
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6 | P a g e Governance - from a review of the annual governance statement prepared for inclusion with the MIJB accounts, it was noted that the statement had been prepared in line with good practice guidance issued by CIPFA / SOLACE. The statement included an assessment of the effectiveness of governance arrangements within the MIJB in terms of the seven principles of good governance identified within the guidance. It also referenced the governance processes of the principal partner bodies (NHS Grampian and Moray Council) as sources of additional assurance. Delivery of services has continued in addition to meeting the significant challenges from the current pandemic. A review of the annual report from the Moray Council’s Chief Social Work Officer noted a number of governance arrangements in place to ensure effective service delivery. The quality of social work services is assured by Practice Governance meetings. Any issues are reported to the Clinical & Care Governance Committee of the MIJB for adults. Posts of Consultant Social Work Practitioner are well established in adult services and also now in children’s services. Consultants work with line managers to support social work in complex cases, model best practices and set practice standards in their respective areas. Consultants also undertake practice audits in Adult Social Work. A report to the Audit, Performance and Risk Committee on the 31st of March detailed the outcome of a review of the Health and Social Care Moray Commissioning Service into how social care contracts are currently managed. This was a “peer” review led by the Strategic Procurement Manager (Social Care) of Aberdeen City and Aberdeenshire Councils. The report has highlighted a number of significant concerns about how social care contracts are managed. The Audit, Performance and Risk Committee have agreed for an external organisation to undertake a review of the Commissioning Service. As the Chief Internal Auditor, I am concerned and will closely monitor progress regarding this issue. Risk Management - procedures are well developed with a risk management policy and strategy in place, a risk appetite statement has been developed and a risk register reviewed and updated at regular intervals. The recently updated Risk Register summarises the principal risks facing the organisation under nine themes; these themes focus on critical risk areas including finance, environment and operational continuity, together with transformation risks associated with change, and infrastructure risks given the reliance of the IJB on support from both the Council and the NHS. Statement on Conformance with the Public Sector Internal Audit Standards The Local Authority Accounts (Scotland) Regulations 2014 require public bodies to operate a professional and objective internal auditing service in accordance with recognised standards and practices in relation to internal auditing, the Public Sector Internal Audit Standards The Scottish Local Authorities Chief Internal Auditors’ Group, comprising the audit managers or equivalent of all Scottish Councils, has developed a checklist for assessing conformance with the Standards. This supports the requirement for self- assessments and external assessments as part of Internal Audit’s Quality Assurance and Improvement Programme. Internal monitoring of performance against the Standards will continue on an ongoing basis until the next External Quality Assessment, scheduled for 2023 is completed. However, a more structured quality self-assessment is planned to highlight any issues arising from changing working practices and service delivery due to the pandemic. Page 100
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7 | P a g e SECTION 4 – OPINION Any system of control can only ever provide reasonable and not absolute assurances that control weaknesses or irregularities do not exist or that there is no risk of error, fraud, or breaches of laws or regulations. Furthermore, it is the responsibility of management to establish an appropriate and sound system of internal control and monitor the effectiveness of that system. It is the responsibility of the Chief Internal Auditor to provide an annual assessment of the robustness of the internal control system. The provision of this annual assessment and opinion has had regard to the consequences of the pandemic relative to service disruption and disruption to the Internal Audit Section from staff vacancies and officers working from home. The effect of these impacts was to reduce the outputs of the Internal Audit Section, although setting this in context, any restrictions applying were not considered material in terms of affecting the audit opinion when assessed alongside governance practices referenced throughout this report and the controls assurances provided separately by NHS Grampian and Moray Council. (Assurance was obtained in the interim form at the time of drafting this report from the Internal Audit Provider of Grampian NHS). After consideration to the results of the work carried out by Internal Audit, taken together with other sources of assurance, with specific reference to the peer review into how the Commissioning Service manages social care contracts; it is my opinion that I can only provide limited assurance that the Moray Integration Joint Board has adequate systems of governance and internal control. Dafydd Lewis Chief Internal Auditor 26 May 2022 Page 101
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