Agenda Document Pack - Audit, Performance and Risk Committee - 25/08/2022
Moray Council · 25 August 2022
Back to Audit, Performance and Risk Committee — 25 August 2022 and its agenda
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Audit, Performance and Risk Committee Thursday, 25 August 2022 Council Chambers NOTICE IS HEREBY GIVEN that a Meeting of the Audit, Performance and Risk Committee, Council Chambers, Council Office, High Street, Elgin, IV30 1BX on Thursday, 25 August 2022 at 14:00 to consider the business noted below. AGENDA 1. Welcome and Apologies 2. Declaration of Member's Interests 3. Minutes of meeting of 30 June 2022 - am 3 - 4 4. Minute of Meeting of 30 June 2022 - pm 5 - 8 5. Action Log of Meeting of 30 June 2022 9 - 10 6. Quarter 1 Performance Report 11 - 40 7. Internal Audit Section - Update Report 41 - 44 8. Strategic Risk Register Report 45 - 74 9. Internal Audit Section - Completed Projects Report 75 - 84 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 Graham Hilditch (Member) Mr Steven Lindsay (Member) Ms Jane Mackie (Member) Simon Bokor-Ingram (Member) Sonya Duncan (Member) Deborah O'Shea (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, 30 June 2022 Remote Locations via Video Conference, PRESENT Simon Bokor-Ingram, Councillor John Divers, Councillor Scott Lawrence, Mr Steven Lindsay, Mr Derick Murray, Jeanette Netherwood, Mr Sandy Riddell APOLOGIES Mr Sean Coady, Ms Jane Mackie, Mr Neil Strachan IN ATTENDANCE Also in attendance were the Interim Chief Financial Officer, Internal Audit Manager and Tracey Sutherland, Committee Services Officer. 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. Unaudited Annual Accounts Report A report by the Interim Chief Financial Officer informed the Committee of the Unaudited Accounts of the Moray Integration Joint Board (MIJB) for the year ended 31 March 2022. Item 3. Page 3
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Mr Riddell explained to the Committee that due to timings, the special meeting had been called to allow the Committee to consider the unaudited accounts prior to the consideration by the main Integration Joint Board. Following consideration the Committee agreed: i) note the unaudited Annual Accounts prior to their submission to the external auditor, noting that all figures remain subject to audit; ii) note the Annual Governance Statement contained within the unaudited Annual Accounts; and iii) note the accounting policies applied in the production of the unaudited Annual Accounts, pages 41 to 42 of the accounts. Page 4
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MINUTE OF MEETING OF THE AUDIT, PERFORMANCE AND RISK COMMITTEE Thursday, 30 June 2022 remote locations via video conference, PRESENT Simon Bokor-Ingram, Mr Sean Coady, Councillor John Divers, Councillor Scott Lawrence, Mr Derick Murray, Jeanette Netherwood, Mr Sandy Riddell APOLOGIES Mr Steven Lindsay, Ms Jane Mackie, Mr Neil Strachan IN ATTENDANCE Also in attendance were Interim Chief Financial Officer, Internal Audit Manager and Tracey Sutherland, Committee Services Officer. 1. Welcome and Apologies Sandy Riddell as Chair of the meeting welcomed everyone to the meeting and apologies were noted. 2. Declaration of Member's Interests Mr Riddell declared that he is Chair of the Mental Welfare Commission, there were no further declarations. 3. Minute of Meeting of 31 March 2022 The minute of the meeting of 31 March 2022 was submitted and approved. 4. Action Log of Meeting of 31 March 2022 The Action Log of the meeting of 31 March 2022 was considered and updated accordingly. Item 4. Page 5
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5. Quarter 4 Performance Report A report by the Corporate Manager updated the Committee on performance as at Quarter 4 (January to March 2022) Mr Riddell expressed concern about the increase in staff absences, particularly within Moray Council. In response, the Corporate Manager assured him that managers are following the appropriate sickness procedures within each organisation. Following consideration, the Committee agreed to 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. 6. 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 the audit update. 7. Internal Audit Annual Report 2021-22 A report by the Chief Internal Auditer provided the 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. Following consideration the Committee agreed to note the contents of the annual report given as Appendix 1 to the report. 8. Strategic Risk Register Report A report by the Chief Officer, Health and Social Care, provided an overview of the current strategic risks, along with a summary of actions which are in place to mitigate those risks, updated June 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 6
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MEETING OF MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE THURSDAY 30 JUNE 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 Completed 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. Item 5. Page 9
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Item No. Title of Report Action Required Due Date Action By Update for 30/6/22 Completed 4. Civil Contingencies Resilience Standards Report Annual Assurance Report from HSCM Civil Contingencies Group March 2023 Jeanette Netherwood scheduled 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 10
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 25 AUGUST 2022 SUBJECT: QUARTER 1 (APRIL TO JUNE 2022) PERFORMANCE REPORT BY: CORPORATE MANAGER 1. REASON FOR REPORT 1.1 To update the Audit, Performance and Risk Committee on performance as at Quarter 1 (April to June 2022). 2. RECOMMENDATION 2.1 It is recommended that the Audit, Performance and Risk Committee consider and note: i) the performance of local indicators for Quarter 1 (April to June 2022) as presented in the Performance Report at APPENDIX 1; and 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; 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 6. Page 11
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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 1 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 1 of the financial year 2022/23 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 quarters 2 and 3 in 2021/22 and similar to quarter 4. This is a reflection of the pressure being placed on the service that has continued during quarter 1. 4.4 Figure 1 provides a summary and the historical trend by indicator since quarter 1 of year 2021/2022. A summary of performance for each of the 6 reporting categories is provided below. None of these areas are presenting as green, while two are amber and the other four are red. EMERGENCY DEPARTMENT - RED 4.5 There was in increase in the attendance rate per 1,000 this quarter from 20 to 24.3, exceeding the target and above the number presenting at the same period last year. The trend over the past 5 months has been a steady and consistent increase each month, in contrast to the gradual decrease each month in the previous 8 months. This increase in demand will not only put pressure on ED but will undoubtedly have an impact on other services. DELAYED DISCHARGES – RED 4.6 The number of delays at the June snapshot was 46, unchanged from the previous quarter, remaining well above the revised target of 10. Although the number of bed days lost due to delayed discharges reduced from 1294 last quarter to 1207 this is still 4 times the target. Both indicators are back to the levels last seen in the winter of 2019/20, just before the COVID-19 pandemic regulations were introduced. EMERGENCY ADMISSIONS – AMBER 4.7 The steady monthly increase in the rate of emergency occupied bed days for over 65s, noted in previous reports, continued this quarter. Since the end of quarter 4 last year the rate has increased from 1,773 to 2,320, exceeding the target of 2,037 per 1,000 population. The emergency admission rate per 1000 population for over 65s has reduced further this quarter from 183 to 177.5. Similarly, the long-term trend for the number of people over 65 admitted to hospital in an emergency in the previous 12 months also reduced from 125.2 to 122 over the same period. Both indicators are now GREEN but given the Page 12
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continuing increase in the emergency occupied bed-days for over 65s the overall status for the three indicators combined is AMBER. HOSPITAL RE-ADMISSIONS - AMBER 4.8 The 28-day re-admissions remain on target at 8.3%, while the 7-day re- admissions have just gone over target at 4.3%. MENTAL HEALTH – RED 4.9 The service has been unable to meet the 18 week LDP1 target since September 2021. This has declined steadily and in the first quarter of 2022 the % of people who were referred into the service and treated within 18 weeks had fallen to 27%. STAFF MANAGEMENT – RED 4.10 NHS employed staff sickness levels (to the end of May 2022) have improved from 4.7% to 4.2%, closer to the target of 4%. Council employed staff sickness was 8.9% last quarter, more than double the 4% target Figure 1 - Performance Summary *SMO1 data to May 2022 5. AREAS NOT MEETING TARGETS Emergency Department 5.1 The rate per 1,000 population presenting at ED is 24.3, above the required performance level of 21.7 and displaying an increasing trend. In addition, the proportion of patients seen within the 4-hour target time continues to reduce (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 and at the end of quarter 1 was 71.4%. Performance is below target and continues to deteriorate. 1 Local Delivery Plan Standards; priorities set and agreed between the Scottish Government and NHS Boards. Previously known as HEAT Targets and Standards. Q1 2122 Q2 2122 Q3 2122 Q4 2122 Q1 2223 New Target Previous Target Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun (from Q1 2122) (from Q1 2021 or earlier) AE Accident and Emergency AE-01 A&E Attendance rate per 1000 population (All Ages) 23.5 21.7 20.0 20.0 24.3 no change 21.7 R DD Delayed Discharges DD-01* Number of delayed discharges (including code 9) at census point 20 30 39 46 46 no change 10 R DD-02 Number of bed days occupied by delayed discharges (including code 9) at census point 592 784 1142 1294 1207 no change 304 R EA Emergency Admissions EA-01 Rate of emergency occupied bed days for over 65s per 1000 population 1859 1934 2045 2140 2320 2037 2107 R EA-02 Emergency admission rate per 1000 population for over 65s 185.9 190.4 187.2 183 177.5 179.9 179.8 G‚ EA-03 Number of people over 65 years admitted as an emergency in the previous 12 months per 1000 population 124.1 126.7 126.3 125.2 122 123.4 124.6 G‚ HR Hospital Readmissions HR-01 % Emergency readmissions to hospital within 7 days of discharge 4.4% 4.1% 3.5% 3.4% 4.3% no change 4.2% A HR-02 % Emergency readmissions to hospital within 28 days of discharge 9.2% 8.4% 8.4% 8.0% 8.3% no change 8.4% G‚ MH Mental Health MH-01 % of patients commencing Psychological Therapy Treatment within 18 weeks of referral 100% 100% 67% 33% 27.0% no change 90% R SM Staff Management SM-01 NHS Sickness Absence (% of hours lost) 4.2% 6.0% 5.5% 4.7% 4.2% no change 4% A Health and Social Care Moray Performance Report Code Barometer (Indicator) RAG Page 13
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Figure 2 – Percentage of patients seen within 4 hours (all ages) – (PHS, A&E Datamart) 5.2 The Medicine and Unscheduled service are working closely with the hospital team and wider partnership to improve flow across the hospital. The hospital continues to experience a significant number of breaches within the ED, many attributed to long bed waits, secondary to delayed discharges and an extensive community hospital waiting list. This regularly equates to 30 percent of the bed base at Dr Gray’s Hospital (DGH). The team has re-established daily breach meetings to establish causes and help mitigate recurring trends. They are also working with the discharge coordinator/social work team and wider Moray partnership to review and manage this on a daily basis. 5.3 Regular, daily, safety briefs are being held to help address any urgent issues with crowding, Scottish Ambulance Service waits and reduced performance, working across the NHSG systems to establish solutions. Minor patients have been re-directed regularly over the last two months and a review of minor injury patients in Moray/DGH has been commenced under the leadership of the Head of Service HSCM and his team. This is ongoing. 5.4 The Medicine and Unscheduled service are also engaging with colleagues across NHSG as part of the redesign of unscheduled care, whilst working to complete the ED service plan which includes plans to reduce the numbers of attendances at ED and improve the performance figures. This includes the design of the rapid assessment and discharge unit based in DGH. This unit will help reduce the pressures faced by ED and improve the flow and performance within the department. 5.5 The ED also faced significant recruitment issues which have impacted on the service, requiring locum doctors and agency nurses to be engaged. Staffing is set to improve with some success in recruitment and rota gaps minimised. Regular staffing assurance meetings take place with the hospital manager and the team are active in rota management. Finally, a Business Impact Assessment has been completed to help mitigate the impact of gaps in the rota and to ensure the safety of the department, and the well-being of its staff. Delayed Discharge 5.6 The number of people waiting to be discharged from hospital remains high, and there are no indications that the target of 10 people is going to be met soon. The Delayed Discharge indicators (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. Page 14
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5.7 The reasons for the above target levels remain the same; there is an additional demand from the increase in patients presenting with COVID-19 cases linked to the latest variant during the start and end of the quarter (Figure 6 below shows the admissions for Scotland). Previous reports have noted the 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 1, although NHS staff absences were close to the target of 4%. 5.8 External providers of care within Moray were also experiencing similar high levels of staff absence as were care homes. This significantly limited the ability to meet the demand for care at home. At the end of quarter 1 three of the 14 care homes were at ‘Red’ status for COVID-19 and unable to receive residents, and the remaining 11 were ‘Green’ (Figure 3). Although not ideal, the situation is a significant improvement compared to the end of December 2021 and January 2022. Figure 3: Moray Care Home RAG Status (Number at Red, Amber or Green) 5.9 The measures outlined in previous reports did appear to be reducing the number of delayed discharges. However, by the end of quarter 1 the situation had reversed, and more people were facing delays when ready to be discharged from hospital. The highest number of Moray residents facing delays in being discharged from hospital in quarter 1 was 43 (note that in quarter 2 this figure reached 51 briefly). The magnitude of the problem facing Moray is illustrated at Figure 4, which shows the weekly average number of people experiencing delayed discharge, by hospital. Figure 4: Average Number of Delayed Discharge Patients in Moray per Week 5.10 Figure 4 indicates how many more patients each day are unable to leave hospital when medically fit than in the previous 2 years. This represents a Page 15
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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 1 staff and managers were still having to make extraordinary arrangements for some people. 5.11 To put this in context, at the end of quarter 1 the average across Scotland had risen from 40 in July 2021 to 51, consistently higher than Moray but showing a similar trend (Figure 5). Figure 5: Hospital Delayed Discharges over time - Comparison of Scotland and Moray (Scottish Government data) Emergency Admissions 5.12 Emergency Admission rates for the over 65s (EA-02) have reduced further during quarter 1, continuing the trend observed in previous quarters. Note that the rate of 177.5 per 1,000 population is now back below the target based on the 2019 average of 179.9 per 1,000 population. Similarly, the number of people in this category admitted during the past 12 months (EA-03) has followed a similar trend. At the end of quarter 1 the rate had reduced to 122 per 1,000 population, below the target of 123.4 per 1,000 population (also based on the 2019 average). 5.13 However, the reduction in admissions may be due to the lack of available beds, in part caused by delays in discharging people and also generally high demand. Furthermore, the over 65s admitted for an emergency are staying in hospital longer as evidenced by the Emergency Occupied Bed Days for over 65s (EA-01) indicator. This has been increasing steadily since the start of 2021 and continued to increase each month during quarter 1 reaching a rate of 2,320 bed-days per 1,000 population, exceeding the target of 2,037 per 1,000 population. Page 16
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Mental Health 5.14 Referrals continue to be received by the team and they are working hard to reduce waiting times, offering short notice appointments when it is practical to do so. 5.15 A workshop was held on 29 June 2022 for all staff delivering psychological therapies in Moray to look at how the position can be improved. Two areas for action were identified, which those present felt would improve access to services and groups were set up to take these work-streams forward. The Moray psychological therapies steering group will reconvene once the work- streams are concluded and plan the next steps. Staff Management 5.16 With the easing of COVID-19 guidelines and the reduced requirement for LFD2 and PCR3 tests it is not possible to compare the data for positive cases with earlier data. However, there was a rise in cases during June that seem to have peaked at the end of quarter 1 suggesting there may be fewer cases, and hence fewer absences due to COVID-19 related causes in quarter 2. 5.17 At the end of quarter 1 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 89.3% and 85.4% respectively (compared to 95% and 89.1% for Scotland)4. In Moray 73.6% of the population have had a third vaccination, close to the national rate of 74.9%. 5.18 There was a significant rise in COVID-19 related hospital admissions across Scotland during quarter 4, 2021/22. While numbers started to reduce during April and May there was an upsurge during June 2022 reaching a figure of 197 admissions per day by the end of the quarter. Although lower than the daily admission rate recorded in the previous quarter, this figure is high when compared with other peaks recorded during 2021 (Figure 6). The 7-day average rate of admissions to ICU at the end of the quarter was 5.71 per day, lower than the end of quarter 4 figure of 6.43. However, the number of people being admitted to ICU across Scotland started to rise again during the final week of quarter 1, peaking at 12 per day (still a low figure compared to earlier in the pandemic).5 Figure 6 - Hospital admissions 1 April 2021 to 31 June 2022 (PHS Data) 2 Lateral Flow Device 3 Polymerase Chain Reaction 4 https://coronavirus.data.gov.uk/details/vaccinations?areaType=nation&areaName=Scotland Data to 30 June 2022. 5 Data for this measure is not available for individual local authorities. Page 17
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5.19 The average absence due to sickness for all Moray Council staff since May 2020 was 6.9% at the end of quarter 1. This is just above the Scottish average of 6.1% for the same period and above the pre-pandemic levels. Sickness absence for Moray Council employed HSCM staff remains high at just below 9%, but NHS staff absences due to sickness are continuing to reduce from 5.5% in quarter 3 down to 4.2% (up to the end of May). 5.20 The locally collected data for Provider Services provides an illustration of the magnitude of the difficulties facing managers in this front-line delivery service (Figure 7). 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 rose steadily each week to a peak of 11.6%, but by the end of quarter 1 it was close to the overall Council average at 9.1%. This fluctuating and high level of absence requires close management, with supervisors and managers often having to deliver care. Figure 7: Provider Services staff absence rate since 26 January 2022 (service collated data) 5.21 Managers are still being 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, the Community Nursing Team continues to feel the impact of the national shortage of trained District Nurses. Despite the team offering 3 trainee opportunities this year there were only 2 successful candidates, and they will commence their training in September. 5.22 The secondments for the 2 District Nurse Team leaders currently in post have been extended until end of March. There is a vacancy for one District Nurse Team Leader, and the service has 2 District Nurse posts to recruit to. In addition, four New Graduate nurses are due to start work in the Community hospitals from September (depending on when registration is processed by NMC). 5.23 Recent quarterly reports have highlighted the issues of staff burn-out and the staffing situation facing the HSCM services. There is not much more to add this quarter other than to say that managers and the HR team continue to Page 18
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spend much of their time on addressing the shortfall in staff and meeting the demand for care. Recruitment is improving and appears to be keeping up with the outflow of people from the service, albeit many remaining within the care sector, and there are indications that social care assistants are starting to request more hours. Analysis is currently being undertaken and a fuller report will be provided next quarter. 6. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Moray Partners in Care 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. Page 19
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(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. 7. CONCLUSION 7.1 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. Authors of Report: Sonya Duncan, Corporate Manager Carl Bennett, Senior Performance Officer Background Papers: Available on request Ref: Page 20
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Appendix 1 PERFORMANCE REPORT - SUPPORTING CHARTS QUARTER 1 2022/23 (1 APRIL 2022 – 30 JUNE 2022) Item 6. Page 21
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Table of Contents Health and Social Care Moray - 1 - 2022-23 Quarter 1 Performance Report 1. TABLE OF CONTENTS 1. Table of Contents ............................................................................................................................. 1 1. Performance Summary .................................................................................................................... 2 Barometer Overview ........................................................................................................................... 2 2. Delayed Discharge - RED .................................................................................................................. 3 DD-01: Number of delayed discharges (including code 9, Census snapshot, at end of quarter) ....... 3 DD-02: Number of Bed Days Occupied by Delayed Discharges per quarter (inc code 9) per 1000 18+ population ........................................................................................................................................... 3 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 – RED ........................................................................................................ 8 AE-01: ED Attendance rates per 1,000 population (All Ages) ............................................................. 8 5. Hospital Re-admissions - AMBER ..................................................................................................... 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 22
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Performance Summary Health and Social Care Moray - 2 - 2022-23 Quarter 1 Performance Report 1. PERFORMANCE SUMMARY BAROMETER OVERVIEW Moray currently has 11 local indicators. Of these 3 are Green, 2 are Amber and 5 are Red. Figure 1 - Performance Summary Q1 2122 Q2 2122 Q3 2122 Q4 2122 Q1 2223 New Target Previous Target Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun (from Q1 2122) (from Q1 2021 or earlier) AE Accident and Emergency AE-01 A&E Attendance rate per 1000 population (All Ages) 23.5 21.7 20.0 20.0 24.3 no change 21.7 R DD Delayed Discharges DD-01* Number of delayed discharges (including code 9) at census point 20 30 39 46 46 no change 10 R DD-02 Number of bed days occupied by delayed discharges (including code 9) at census point 592 784 1142 1294 1207 no change 304 R EA Emergency Admissions EA-01 Rate of emergency occupied bed days for over 65s per 1000 population 1859 1934 2045 2140 2320 2037 2107 R EA-02 Emergency admission rate per 1000 population for over 65s 185.9 190.4 187.2 183 177.5 179.9 179.8 G‚ EA-03 Number of people over 65 years admitted as an emergency in the previous 12 months per 1000 population 124.1 126.7 126.3 125.2 122 123.4 124.6 G‚ HR Hospital Readmissions HR-01 % Emergency readmissions to hospital within 7 days of discharge 4.4% 4.1% 3.5% 3.4% 4.3% no change 4.2% A HR-02 % Emergency readmissions to hospital within 28 days of discharge 9.2% 8.4% 8.4% 8.0% 8.3% no change 8.4% G‚ MH Mental Health MH-01 % of patients commencing Psychological Therapy Treatment within 18 weeks of referral 100% 100% 67% 33% 27.0% no change 90% R SM Staff Management SM-01 NHS Sickness Absence (% of hours lost) 4.2% 6.0% 5.5% 4.7% 4.2% no change 4% A Health and Social Care Moray Performance Report Code Barometer (Indicator) RAG Page 23
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Delayed Discharge - RED Health and Social Care Moray - 3 - 2022-23 Quarter 1 Performance Report 2. DELAYED DISCHARGE - RED Trend Analysis The number of delays at snapshot (46) was the same as at the end of quarter 4 2021/22. The number of bed days lost due to delayed discharges reduced from 1294 to 1207. Both indicators remain over 4 times the target. 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 had been steadily increasing since the end of Quarter 4 2020/21. However, …. Source Public Health Scotland DD-02: NUMBER OF BED DAYS OCCUPIED BY DELAYED DISCHARGES PER QUARTER (INC CODE 9) PER 1000 18+ POPULATION Page 24
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Delayed Discharge - RED Health and Social Care Moray - 4 - 2022-23 Quarter 1 Performance Report 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 remained at around 1200 throughout Q1. Source Public Health Scotland Page 25
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Emergency Admissions - AMBER Health and Social Care Moray - 5 - 2022-23 Quarter 1 Performance Report 3. EMERGENCY ADMISSIONS - AMBER 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 1 from 2,140 to 2,320 in June 2022. However, the emergency admission rate per 1000 population for over 65s has reduced from 183 to 177.5 over the same period, while the number of people over 65 admitted to hospital in an emergency also reduced from 125.2 to 122. 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 exceeded the reduced target for the last 2 quarters. Source Health Intelligence Page 26
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Emergency Admissions - AMBER Health and Social Care Moray - 6 - 2022-23 Quarter 1 Performance Report EA-02: EMERGENCY ADMISSIONS RATE PER 1000 POPULATION FOR OVER 65S Purpose EA-01, EA-02, and EA-03 are all interconnected and provide a story when viewed together of whether emergency admissions and bed days are within tolerance and indicate where potential risks could arise. Strategic Priority 1: BUILDING RESILIENCE Linked Indicator(s) EA-01, EA-03 National Health & Wellbeing Outcomes 1, 2, 3, 5 Figure 5 – Emergency Admissions (Over 65s) Indicator Trend – Reducing At the start of 2021 the trend had been rapidly increasing, but since August there has been a steady and sustained reduction, which is now below the set target. Source Health Intelligence Page 27
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Emergency Admissions - AMBER Health and Social Care Moray - 7 - 2022-23 Quarter 1 Performance Report EA-03: NUMBER OF PEOPLE OVER 65 YEARS ADMITTED AS AN EMERGENCY IN THE PREVIOUS 12 MONTHS PER 1000 POPULATION Purpose EA-01, EA-02, and EA-03 are all interconnected and provide a story when viewed together of whether emergency admissions and bed days are within tolerance and indicate where potential risks could arise. Strategic Priority 1: BUILDING RESILIENCE Linked Indicator(s) EA-01, EA-02 National Health & Wellbeing Outcomes 1, 2, 3, 5 Figure 6 – Number of Over 65 People Emergency Admissions Indicator Trend – 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 is now below target. Source Health Intelligence Page 28
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Emergency Department – RED Health and Social Care Moray - 8 - 2022-23 Quarter 1 Performance Report 4. EMERGENCY DEPARTMENT – RED Trend Analysis There has been an increase in the rate per 1,000 this quarter from 20.2 to 24.3, exceeding the target and double the number presenting in April 2020. 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 29
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Hospital Re-admissions - AMBER Health and Social Care Moray - 9 - 2022-23 Quarter 1 Performance Report 5. HOSPITAL RE-ADMISSIONS - AMBER Trend Analysis 28-day re-admissions remain GREEN at 8.3%, while 7-day Re-admissions are now AMBER at 4.3%. 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% for this quarter. Source Health Intelligence Page 30
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Hospital Re-admissions - AMBER Health and Social Care Moray - 10 - 2022-23 Quarter 1 Performance Report HR-02: PERCENTAGE OF EMERGENCY RE-ADMISSIONS TO HOSPITAL WITHIN 7 DAYS - MORAY PATIENTS Purpose Re-admissions are often undesirable for patients and have also been shown to be associated with the quality of care provided to patients at several stages along the clinical pathway, including during initial hospital stays, transitional care services and post-discharge support. Strategic Priority 1: BUILDING RESILIENCE Linked Indicator(s) HR-01, AE-01 National Health & Wellbeing Outcome 1, 2, 3, 5 Figure 9 – 7-day Emergency Readmissions Indicator Trend – Increasing 7-day Hospital Re-admissions remained below the target of 4.2% for the first 2 months of this quarter, but reached 4.3% at the end of June. Source Health Intelligence Page 31
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Mental Health – RED Health and Social Care Moray - 11 - 2022-23 Quarter 1 Performance Report 6. MENTAL HEALTH – RED Trend Analysis After 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, since quarter 3 there has been a rapid reduction with 27% of patients being referred within 18 weeks during June 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 for the last 3 quarters, and was well below target throughout quarter 1. Source Health Intelligence Page 32
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Staff Management - RED Health and Social Care Moray - 12 - 2022-23 Quarter 1 Performance Report 7. STAFF MANAGEMENT - RED Trend Analysis Sickness absence for NHS employed staff rose to 6.4 during quarter 3, but has since reduced and for the first 2 months of quarter 1 is at 4.2%. This may indicate that staffing absence is back to pre- pandemic levels for NHS employed staff. However, Council employed staff sickness has remained high with a minimal reduction from 8.98% to 8.87%, which is above the figure for the same period in the previous 2 years. 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%) Q4 20/21 Q1 21/22 Q2 21/22 Q3 21/22 Q4 21/22 Q1 21/22 4% 3.1% 4.2% 6.0% 5.5% 4.7% 4.2%* Figure 11 – NHS Sickness Absence Indicator Trend – Fluctuating This indicator had been increasing over recent quarters but despite a blip in April is now close to the target of 4%. *Data to May 2022 Source Health Intelligence Page 33
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Staff Management - RED Health and Social Care Moray - 13 - 2022-23 Quarter 1 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 Q4 20/21 Q1 21/22 Q2 21/22 Q3 21/22 Q4 21/22 Q1 22/23 4% 6.2% 6.95% 7.8% 8.05% 8.98% 8.87% Figure 12 – Moray Council Sickness Absence Indicator Trend – Increasing This indicator continues to rise, remaining double the target and close to the figure of 9% recorded in quarter 4 2019/20 when it reached a peak. Source Council HR Page 34
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Staff Management - RED Health and Social Care Moray - 14 - 2022-23 Quarter 1 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 22 July 2022. Moray remains above the Scottish average. Figure 13 – Moray Council Sickness Absence Compared to National Average Page 35
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Staff Management - RED Health and Social Care Moray - 15 - 2022-23 Quarter 1 Performance Report APPENDIX 1: KEY AND DATA DEFINITIONS RAG SCORING CRITERIA GREEN If Moray is performing better than target. AMBER If Moray is performing worse than target but within specified tolerance. RED If Moray is performing worse than target but outside of specified tolerance. PEER GROUP DEFINITION Moray is defined as being in Peer Group 2 in the Local Government Benchmarking Framework Family Group 1 Family Group 2 Family Group 3 Family Group 4 East Renfrewshire East Dunbartonshire Aberdeenshire Edinburgh, City of Perth & Kinross Aberdeen City Shetland Islands Orkney Islands Moray Stirling East Lothian Angus Scottish Borders Highland Argyll & Bute Midlothian Falkirk Dumfries & Galloway Fife South Ayrshire West Lothian South Lanarkshire Renfrewshire Clackmannanshire Eilean Siar Dundee City East Ayrshire North Ayrshire North Lanarkshire Inverclyde West Dunbartonshire Glasgow City Page 36
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Staff Management - RED Health and Social Care Moray - 16 - 2022-23 Quarter 1 Performance Report APPENDIX 2: STRATEGIC PRIORITIES Page 37
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Staff Management - RED Health and Social Care Moray - 17 - 2022-23 Quarter 1 Performance Report •EA-01: RATE OF EMERGENCY OCCUPIED BED DAYS FOR OVER 65S PER 1000 POPULATION •EA-02: EMERGENCY ADMISSIONS RATE PER 1000 POPULATION FOR OVER 65S •EA-03: NUMBER OF PEOPLE OVER 65 YEARS ADMITTED AS AN EMERGENCY IN THE PREVIOUS 12 MONTHS PER 1000 POPULATION •HR-01: PERCENTAGE OF EMERGENCY RE-ADMISSIONS TO HOSPITAL WITHIN 28 DAYS -MORAY PATIENTS •HR-02: PERCENTAGE OF EMERGENCY RE-ADMISSIONS TO HOSPITAL WITHIN 7 DAYS -MORAY PATIENTS •SM-01: NHS SICKNESS ABSENCE % OF HOURS LOST •SM-02: COUNCIL SICKNESS ABSENCE (% OF CALENDAR DAYS LOST) BUILDING RESILIENCE •DD-01: NUMBER OF DELAYED DISCHARGES (INCLUDING CODE 9, CENSUS SNAPSHOT, AT END OF QUARTER) •DD-02: NUMBER OF BED DAYS OCCUPIED BY DELAYED DISCHARGES PER QUARTER (INC CODE 9) PER 1000 18+ POPULATION •UN-01: NUMBER OF LONG-TERM HOME CARE HOURS UNMET AT WEEKLY SNAPSHOT •UN-02: NUMBER OF PEOPLE WITH LONG-TERM CARE HOURS UNMET AT WEEKLY SNAPSHOT HOME FIRST •OA-01: NUMBER OF REVIEWS OUTSTANDING AT END OF QUARTER SNAPSHOT •MH-01: PERCENTAGE OF PATIENTS COMMENCING PSYCHOLOGICAL THERAPY TREATMENT WITHIN 18 WEEKS OF REFERRAL •AE-01: A&E ATTENDANCE RATES PER 1000 POPULATION (ALL AGES) PARTNERS IN CARE Page 38
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Staff Management - RED Health and Social Care Moray - 18 - 2022-23 Quarter 1 Performance Report APPENDIX 3: NATIONAL HEALTH AND WELLBEING OUTCOMES 1 - PEOPLE ARE ABLE TO LOOK AFTER AND IMPROVE THEIR OWN HEALTH AND WELLBEING AND LIVE IN GOOD HEALTH FOR LONGER. 2 - PEOPLE, INCLUDING THOSE WITH DISABILITIES OR LONG-TERM CONDITIONS, OR WHO ARE FRAIL; ARE ABLE TO LIVE, AS FAR AS REASONABLY PRACTICABLE, INDEPENDENTLY AT HOME, OR IN A HOMELY SETTING IN THEIR COMMUNITY. 3 - PEOPLE WHO USE HEALTH AND SOCIAL CARE SERVICES HAVE POSITIVE EXPERIENCES OF THOSE SERVICES, AND HAVE THEIR DIGNITY RESPECTED. 4 - HEALTH AND SOCIAL CARE SERVICES ARE CENTRED ON HELPING TO MAINTAIN OR IMPROVE THE QUALITY OF LIFE OF PEOPLE WHO USE THOSE SERVICES. 5 - HEALTH AND SOCIAL CARE SERVICES CONTRIBUTE TO REDUCING HEALTH INEQUALITIES. 6 - PEOPLE WHO PROVIDE UNPAID CARE ARE SUPPORTED TO LOOK AFTER THEIR OWN HEALTH AND WELLBEING, INCLUDING TO REDUCE ANY NEGATIVE IMPACT OF THEIR CARING ROLE ON THEIR OWN HEALTH AND WELLBEING. 7 - PEOPLE USING HEALTH AND SOCIAL CARE SERVICES ARE SAFE FROM HARM. 8 - PEOPLE WHO WORK IN HEALTH AND SOCIAL CARE SERVICES FEEL ENGAGED WITH THE WORK THEY DO AND ARE SUPPORTED TO CONTINUOUSLY IMPROVE THE INFORMATION, SUPPORT, CARE, AND TREATMENT THEY PROVIDE. 9 - RESOURCES ARE USED EFFECTIVELY AND EFFICIENTLY IN THE PROVISION OF HEALTH AND SOCIAL CARE SERVICES. Page 39
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 25 AUGUST 2022 SUBJECT: INTERNAL AUDIT SECTION - UPDATE REPORT BY: CHIEF INTERNAL AUDITOR 1. REASON FOR REPORT 1.1 To provide the Audit, Performance and Risk Committee with an update of progress against the 2022/23 Audit Plan. 2. RECOMMENDATION 2.1 The 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 committee on internal audit’s activity relative to the audit plan and on any other relevant matters. 3.2 This report provides an update on audit activity and projects progressed since the last meeting 4. KEY MATTERS RELEVANT TO RECOMMENDATION Social Care and CareFirst System Information Governance Review 4.1 An audit has been undertaken into how information relating to social care service users is recorded, accessed and kept up to date. The council uses a system known as CareFirst to record and manage social care cases for both adult and children’s services. CareFirst is a long standing widely used application within the public sector for recording social care data. Most of the service user data is available on CareFirst, with some data retained separately either on a council IT server or in paper files. 4.2 The scope of this review considered the findings from a review of the CareFirst System that was undertaken within the 2017/18 Audit Plan and a check undertaken to evidence the implementation of the recommendations. This audit also checked the management arrangements of case files to review who can view, add, amend or delete information, recognising that restricted Item 7. Page 41
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access has to be balanced with a need for prompt availability of information for those employees who require it for the effective delivery of services. The review has now been completed, and it is hoped the Executive Summary and audit action plan showing recommendations will be reported to the next Audit, Performance and Risk Committee. Cyber Security 4.3 Cyber Security concerns the protection of computers, servers, mobile devices, electronic systems, networks, and data from malicious attacks. Cyber security controls are designed to combat threats against networked systems and applications, whether those threats originate from inside or outside an organisation. The Scottish Government in 2020 issued a Cyber Resilience Framework to all Local Authorities. The Framework includes a self- assessment tool to assist Local Authorities in improving their cyber resilience and compliance with a range of legislative, regulatory, policy and audit requirements regarding cyber security. The audit programme has been developed from this Cyber Resilience Framework and other good practice guidelines. The impact of a successful cyber attack would immediately impact how services would be able to continue providing day to day services. The review has now been completed, and it is hoped the Executive Summary and audit action plan showing recommendations will be reported to the next Audit, Performance and Risk Committee. Information Management 4.4 In recent years, discussions have been held with the internal audit providers for NHS Grampian, Aberdeen City and Aberdeenshire Councils. The intention has been to develop closer working relationships to better coordinate the audit planning process. An audit of Information Management was agreed as the first step within this process. The audit will review that an appropriate system exists in the management, security and transfer of data. I am pleased to report the audit has been started. The Auditors undertaking the reviews are in contact to ensure consistency in our approach. This has included the sharing of an audit programme as part of this process. 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. Page 42
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(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 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 an update on internal audit work progressed in the latest review period. Author of Report: Dafydd Lewis, Chief Internal Auditor Background Papers: Internal Audit Files Ref: mijb/ap&rc/25082022 Page 43
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 25 AUGUST 2022 SUBJECT: STRATEGIC RISK REGISTER – AUGUST 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 August 2022. 2. RECOMMENDATION 2.1 It is recommended that the Committee 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 8. Page 45
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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 North East Partnership continues to progress locally, in line with our Strategic Plan objectives. Hospital without Walls and Hospital at Home themes continue to be progressed through the Home First Programme. 4.3 The return to ‘business as usual’ from the Covid-19 pandemic continues to progress. However, these increases in demands for service are being faced by staffing resource that is reduced due to increasing sickness absence, staff vacancies, and annual leave. 4.4 The continued safe delivery of services is a priority and as such dedicated management time is being directed to support oversight of operational risks. Grampian Operational Escalation System (GOPES) continues to be utilised to assist in the identification of pressure points across the whole system so that they can be addressed and prioritised appropriately. 4.5 The ability to cope with unforeseen incidents continues to provide challenges to the systems. Most recently the national cyber-attack on NSS Scotland systems and the drainage issue affecting clinical services at Dr Gray’s Hospital. Reassuringly, the contingency planning was effective and lessons learned will be considered. 4.6 There continues to be significant financial risk in the system which was highlighted at the MIJB development session on 6 June 2022. Future reports will incorporate updates to this committee. 4.7 Recruitment and selection to staff vacancies continues to prove challenging across several services. 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 continues with Allied, our partner for care at home on the outcome based commissioning approach. 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. Care at home services and Allied continue to face staffing difficulties to meet service demand. Due to a range of factors, capacity is unable to meet demand which is demonstrated in the increase in unmet need. This situation is unlikely to improve in the short term, due to the increasing demand for care in the community. Page 46
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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 effectively. 4.11 As plans evolve, the Strategic Risk Register will continue to be updated to ensure that it reflects any potential risks to realise 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. (f) Property There are no property implications arising from this report. (g) Equalities/Socio Economic Impact An Equalities Impact Assessment is not required because there are no service, policy or organisational changes being proposed. (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, Iain Macdonald, Locality Manager and Tracey Sutherland, Page 47
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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. Author of Report: Sonya Duncan, Corporate Manager Background Papers: held by HSCM Ref: Page 48
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Appendix 1 HEALTH AND SOCIAL CARE MORAY STRATEGIC RISK REGISTER AS AT 12 AUGUST 2022 Item 8. Page 49
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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 50
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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 which will be completed by December 2022. 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 held for new IJB members after May elections. . IJB member briefings are held regularly as development sessions. 1 Page 51
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Appendix 1 Conduct and Standards training held for IJB Members in June 2022 provided by Legal Services . 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. A delivery plan will be developed alongside the refreshed Strategic Plan. 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 Families and 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 Governance Framework was approved by IJB 28 January 2021.Re-appointment of Standards Officer agreed by IJB 31 March 2022 Members Handbook has been updated and circulated to all members in June 2022. 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 Strategy and Planning Lead is now taking this forward to prioritise and focus on strategic planning and priorities over the short and longer term. Page 52
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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 national investment of £300m for winter funding. The Revenue Budget 2022/23 was approved by MIJB on 31 March 2022 as a balanced budget. 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 53
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Appendix 1 Controls: There is an interim arrangement for CFO cover from Moray Council. Permanent recruitment efforts have not been successful. The Chief Officer is working with both the Council and NHS Finance Leads to secure a longer term interim arrangement. 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 54
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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 however there are examples where there is a reliance on agency staffing. The difficulty with recruitment and retention of staff to care at home roles in particular 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 posts, 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. Page 55
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Appendix 1 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. 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. Page 56
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Appendix 1 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. 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 IMatter survey results for 2021 were received by managers for review and action plans. Preparatory work is commencing on the action plans 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. 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. Page 57
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Appendix 1 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. 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. Page 58
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Appendix 1 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. 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 Page 59
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Appendix 1 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. 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. Page 60
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Appendix 1 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. 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 Page 61
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Appendix 1 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. 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 Page 62
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Appendix 1 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 63
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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 64
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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 our action plan has been developed. 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 65
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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 remained high, 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 Huddle and write up circulates the picture on performance across community and acute services for the Portfolio and service managers have a shared understanding of the pressures in the system and mitigations taking Page 66
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Appendix 1 place. Work continues on refinement of G-OPES (Grampian Operating 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 67
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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 and 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 68
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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 69
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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 70
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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. A dedicated MC officer is leading on hybrid working plan with input from HSCM inputing their requirements. 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 Page 71
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Appendix 1 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 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. The interim Strategy and Planning Lead will support the the Infrastructure Programme Board for Moray portfoilio to be re established. 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 strategy (vision for the future) 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. Page 72
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Appendix 1 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. Current performance: The Infrastructure Board is currently suspended, with the intent to re-establish the Board by Nov 22. 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 73
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REPORT TO: MORAY INTEGRATION JOINT BOARD AUDIT, PERFORMANCE AND RISK COMMITTEE ON 25 AUGUST 2022 SUBJECT: INTERNAL AUDIT SECTION– COMPLETED PROJECTS REPORT BY: CHIEF INTERNAL AUDITOR 1. REASON FOR REPORT 1.1 To provide an update on audit work completed since the last meeting of the Committee. 2. RECOMMENDATION 2.1 The 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 In line with the approved internal audit plan, the reviews detailed in Section 4 of the report are completed. 4. KEY MATTERS RELEVANT TO RECOMMENDATION Procurement and Creditor Payments 4.1 The annual audit plan for 2022/23 provides for a review of payments made by the Authority to suppliers of goods and services. This audit review related to testing a sample of transactions generated under the direction of the Moray Integration Joint Board. 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. The purpose of the audit was to confirm that effective controls are operating to ensure all payments are appropriately authorised, accurate and paid in accordance with financial regulations and agreed terms and conditions. The executive summary and recommendations for this project are given on Appendix 1. Item 9. Page 75
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Follow Up Reviews 4.2 Internal Audit reports are regularly presented to members detailing not only findings but also the responses by management to the recommendations with agreed dates of implementation. Internal Audit undertake follow-up reviews to evidence the effective implementation of these recommendations. I am now intending to report these follow-up reports to the Audit Performance and Risk Committee. The Status / Explanation column within the report records the Auditor’s review in verifying the implementation of the recommendations. Please see detailed the following completed follow-up review: Petty Cash 4.3 An audit was undertaken of the systems and procedures for administering petty cash funds. Petty cash is an amount of money held by establishments or services in cash to usually meet minor items of expenditure. Examples include postage, stationery, sundry items, etc. The Follow Up Report to review the implementation of the agreed recommendations is attached on Appendix 2. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Moray Partners in Care 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 result of this report Page 76
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(j) Consultations There have been no direct consultations during the preparation of this report. 6. CONCLUSION 6.1 This report provides Committee with a summary of findings arising from audit project completed during the review period. Author of Report: Dafydd Lewis, Chief Internal Auditor Background Papers: Internal Audit Files Ref: mijb/ap&rc/30062022 Page 77
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Appendix 1 AUDIT REPORT 23'010 PROCUREMENT AND CREDITOR PAYMENTS Executive Summary The annual audit plan for 2022/23 provides for a review to be undertaken of payments made by the Authority to suppliers of goods and services. The purpose of the audit was to confirm that effective controls are operating to ensure all payments are appropriately authorised, accurate and paid in accordance with financial regulations and agreed terms and conditions. This audit review related to testing a sample of transactions generated under the direction of the Moray Integration Joint Board. Approximately £21 million was paid through the Council’s creditors system by Health and Social Care Moray in the six months from October 2021 to March 2022 to suppliers of goods and services. Through the use of computer audit software, a sample of payments was randomly selected from this period with a value of £1.05 million. The testing undertaken was developed from the Chartered Institute of Public Finance and Accountancy’s Audit Programme, in addition to consultation with the External Auditor. The audit work also involved a separate exercise of extracting multiple invoices from the same supplier with the same value as a check for duplicate payments. The audit was carried out in accordance with Public Sector Internal Audit Standards (PSIAS) Findings from the audit undertaken noted the following areas for consideration:- • Testing found that payments had been made to Care Providers before the services were delivered. The advance payment period ranged from a couple of days to approximately 6 months. Payments made by Health and Social Care Moray and processed by the Moray Council must comply with the Council’s Financial Regulations. These Regulations state that unless written authority is obtained from the Head of Financial Services, payments should not be made in advance for the delivery of goods or services. • A computer audit software application was used to check for potential duplicate payments by undertaking a data matching analysis of invoices paid to the same company with an identical value. An example was found from a sample of fifteen matches investigated where a company had been paid twice for the same service. The value of this duplicate payment amounted to £9,796.93. Action is currently being undertaken to recover this duplicate payment. In addition, a recommendation has also been made within this report to further strengthen controls within the Community Care Finance Team in the processing of invoices. • The audit noted issues concerning the management of social care contracts. This is related to the contractual relationships with care providers and the administration of individual contracts. With consideration to the scope of the planned external review of adult social care commissioning, no further action is planned by Internal Audit. However, progress regarding this review will be closely monitored. Item 9. Page 79
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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: Effective controls in the processing of creditor payments to ensure compliance with Financial Regulations and Procurement Guidelines 5.01 A review should be undertaken across all social care external providers to ensure that payments are not made in advance of the service delivery. High Yes All invoices received will be more rigorously checked to ensure providers are not paid in advance unless a prior agreement has been received. Any issues will be escalated to the Commissioning Manager for resolution. Community Care Finance Officer 15 August 2022 Page 80
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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 5.02 Monitoring arrangements within the Community Care Finance Team should be amended to include a requirement to record all invoices processed for payment. Medium Yes Procedures are being drafted to include clear instructions and a checklist for recording all invoices received for payment. Community Care Finance Officer 31 August 2022 5.03 The Community Care Finance Team should check invoices received from Care Providers to ensure the care delivered to each service user corresponds to their individual authorised support package detailed within CareFirst. Medium Yes This is currently in place, albeit not for all services. This check will be expanded to include all service areas. Community Care Finance Officer 31 August 2022 5.04 Payments should be made to the agreed Care Provider and not a sub contracted company. High Yes Agreed. Advice will be required from the Commissioning Team for any invoices Commissioning Manager 31 August 2022 Page 81
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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 received from a sub contractor for the delivery of care. Page 82
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Moray Council Appendix 2 Internal Audit Section SUBJECT: Petty Cash REPORT REF: 22'010 Follow Up Audit Review Click here to enter text. Risk Ratings for Recommendations High Key controls absent, not being operated as designed or could be improved. Urgent attention required. Medium Less critically important controls absent, not being operated as designed or could be improved. Low Lower level controls absent, not being operated as designed or could be improved. No. Audit Recommendation Priority Accepted (Yes/ No) Date of Completion Status / Explanation Key Control: Effective controls exist in the administration and monitoring of petty cash funds 5.01 All officers administering petty cash funds should be reminded to follow recommended operating guidelines for the administration of the funds. Medium Yes 10/05/2022 A reminder has been issued to all fund holders to follow established guidelines in petty cash administration. In addition, a comprehensive review of petty cash usage has been commenced by Financial Services. Item 9. Page 83
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Moray Council Appendix 2 Internal Audit Section Risk Ratings for Recommendations High Key controls absent, not being operated as designed or could be improved. Urgent attention required. Medium Less critically important controls absent, not being operated as designed or could be improved. Low Lower level controls absent, not being operated as designed or could be improved. No. Audit Recommendation Priority Accepted (Yes/ No) Date of Completion Status / Explanation 5.02 Vouchers and receipts should be retained to evidence all payments made from the Throughcare and Aftercare petty cash fund, irrespective of any claim for replenishment of funds. Medium Implemented 28/07/2021 Sample transactions have been selected over a 3 month period and vouchers obtained, evidencing that the service is now retaining vouchers and receipts as standard operational practice. 5.03 A review should be undertaken of the central control database and updated with current operating details. Medium Yes 31/03/2022 Review was undertaken and completed by end of financial year with queries on fund amounts addressed and some imprest accounts closed where no further need was established. Control database is being kept up to date and will be subject to ongoing review. Page 84