Democracy Spraffa

Internal and External Audit Report Follow Up 2024-25

Argyll and Bute Council · 17 December 2024
Back to Audit and Scrutiny Committee — 17 December 2024 and its agenda

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ARGYLL AND BUTE COUNCIL  AUDIT AND SCRUTINY COMMITTEE                                                            
FINANCIAL SERVICES  17 DECEMBER 2024 
INTERNAL AND EXTERNAL AUDIT REPORT FOLLOW UP 2024-25 
1.0 INTRODUCTION 
1.1 Internal and external audit reports include an action plan with a
management response establishing the agreed action, timescale and
responsible officer. Internal Audit record these in a database and, on a
monthly basis, follow them up to ensure they are being progressed. 
1.2 This report updates the committee on all open actions as at 30 September
2024 including information on actions where the agreed implementation
date has been rescheduled.   
2.0 RECOMMENDATIONS 
2.1 To endorse the contents of the report. 
3.0 DETAIL 
3.1 The two tables below provide a numerical summary of open audit actions
with a split between actions due by and due after 30 September 2024. 
3.2 Appendix 1 provides further detail on actions that have either been delayed
and rescheduled, require further evidence or for which Internal Audit have
received no response from the service to inform this follow up.

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Table 1 - Actions Due by 30 September 2024 
SMT/Service
Complete
Delayed/
Rescheduled
Evidence
Required
Delayed &
NOT
Reschedule
d Total
Internal Audit
DH – Education Performance &
Improvement
1 0 0 0 1
DH – Legal & Regulatory Support 1 0 0 0 1
KF – Customer Support Services 2 2 0 0 4
KF – Development & Economic Growth 1 0 0 0 1
KF – Financial Services 3 7 0 0 10
KF – Roads & Infrastructure Services 1 7 0 0 8
H&SCP (IJB) – Adult Services (Older
Adults & Community Hospitals
0 1 0 0 1
H&SCP (SW) – Adult Services (Mental
Health Learning Disability, Addictions &
Lifelong Conditions)
0 3 0 0 3
H&SCP (SW) – Adult Services (Older
Adults & Community Hospitals)
0 2 0 1 3
H&SCP (SW) – Strategic Planning &
Performance
3 0 1 0 4
H&SCP (SW) – Children and Families and
Criminal Justice
0 1 0 0 1
External Audit
Nil 0 0 0 0 0
TOTAL 12 23 1 1 37 
Table 2 - Actions due after 30 September 2024 
SMT/Service
Complete
Delayed/
Rescheduled
On Course
Total
Internal Audit
DH – Commercial Services 0 0 2 2
DH – Education Performance &
Improvement
0 0 7 7
DH – Education Wellbeing, Inclusion &
Achievement
0 0 1 1
DH – Legal & Regulatory Support 0 0 2 2
KF – Customer Support Services 0 0 7 7
KF – Development & Economic Growth 0 0 6 6
KF – Financial Services 0 1 0 1
KF – Roads & Infrastructure Services 0 0 10 10

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SMT/Service
Complete
Delayed/
Rescheduled
On Course
Total
H&SCP (IJB) – Finance/Transformation 0 0 2 2
H&SCP (IJB) – Strategic Planning &
Performance
0 0 4 4
H&SCP (SW) – Adult Services (Mental
Health Learning Disability, Addictions &
Lifelong Conditions)
0 0 3 3
H&SCP (SW) – Children and Families and
Criminal Justice
0 0 1 1
H&SCP (SW) – Finance/Transformation 0 0 4 4
H&SCP (SW) – Strategic Planning &
Performance
0 0 1 1
External Audit
Nil 0 0 0 0
TOTAL 0 1 50 51 
4.0 CONCLUSION 
4.1 Satisfactory progress continues to be made implementing audit actions. 
5.0 IMPLICATIONS 
5.1 Policy – None 
5.2 Financial – None 
5.3 Legal – None 
5.4 HR – None 
5.5 Fairer Scotland Duty – None 
5.5.1 Equalities – protected characteristics – None
5.5.2 Socio-economic Duty – None
5.5.3 Islands – None 
5.6 Climate Change – None 
5.7 Risk – None
5.8 Customer Service – None
5.9 The Rights of the Child (UNCRC) – None 
Paul MacAskill
Chief Internal Auditor
17 December 2024                                                  
For further information contact: Paul MacAskill, 01546 604108
Paul.macaskill@argyll-bute.gov.uk 
APPENDICES
Appendix 1 – Action Plan Points - Delayed and Rescheduled/Evidence
Required/Delayed NOT Rescheduled

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Appendix 1 - Action Plan Points with & Delayed and Rescheduled/Delayed NOT Rescheduled & Evidence Required 
Action Plan Points due by 30th September 2024 
Service, Report, Plan no. & Finding Agreed Action Dates Comment Responsible Officer
LOW
CUSTOMER SUPPORT SERVICES
Scottish Social Services Council (SSSC)
Registration 
1. SSSC Registration Policy 
Finding:  The SSSC Registration Policy and
guidance document are not dated and there is
no evidence of review date having been
considered.  
Finding:  Several of the corporate HR policy and
guidance documents reviewed contained no
evidence of update or review in a reasonable
timescale. 
Recommendation:  Management should apply
version control and review schedules to the
SSSC Registration and wider corporate HR Policy
and Guidance documents.  
SSSC Registration Policy and
Guidance are currently under
review to reflect revised SSSC
Codes of Practice 1 May 2024,
version control will be applied
during this review. An exercise will
be undertaken to apply review
dates to corporate HR policy and
guidance documents and these
reviews will be scheduled to take
place. 
30/09/2024
31 Oct 2024 
This has now been collated.
Document owners have
provided review dates and
these will be built into the
HROD work plan accordingly.
The team have a task to
complete the document tracker
by 25th October 2024. 
Delayed and Rescheduled 
HR Officer & HR
Manager Operations  
LOW
CUSTOMER SUPPORT SERVICES
Scottish Social Services Council (SSSC)
Registration 
2. Corporate HR Policy and Guidance
Documents  
Finding:  Embedded links within policy and
guidance documents were no longer active in
some instances.   
Recommendation:  Links provided within
documentation should be reviewed and
updated as necessary to ensure they are
returning expected information for employees. 
Links provided in policy and
guidance documents will be
reviewed and updated where
found to be no longer working. 
30/09/2024
31 Oct 2024 
All documents owned by HROD
have been transferred to an
accessible template and all links
removed or updated.  The team
have a task to complete the
document tracker by 25th
October 2024. 
Delayed and Rescheduled 
HR Manager -
Operations

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Service, Report, Plan no. & Finding Agreed Action Dates Comment Responsible Officer
Medium
FINANCIAL SERVICES
MANAGEMENT OF DEBT/DEBT RECOVERY 
5. Debtors Procedure Manual and Processes
Finding:  There is insufficient evidence to
determine whether all Services receive details
of invoices being written off.  
Recommendation:  Services should be sent this
information. 
A thorough review of Sundry Debt
write-off procedure to be carried
out by the working group as part of
the overall update of the Sundry
Debt Procedures. Reporting and
communication with stakeholders
is being reviewed by the working
group. It is anticipated that reports
of debt written off will be sent to
departments as part of a standard
suite of reporting for discussions at
quarterly meetings this will be
confirmed within the reviewed
Sundry Debt Procedure Manual. 
31/12/2023
31/03/2024
30/09/2024
31 Mar 2025 
The Debt Recovery Guide was
developed in late August for
staff, this replaces the old
Sundry Debt Procedure Manual.
The Guide and the overarching
policy has a section on Write-
off. We have a new procedure
with a new single use
spreadsheet for all debt types. 
Documents being passed to ED-
DH for consideration/ approval   
Delayed and Rescheduled 
Revenues and Benefits
Manager 
Medium
FINANCIAL SERVICES
MANAGEMENT OF DEBT/DEBT RECOVERY 
6. Debtors Procedure Manual and Processes
Finding:  While there is a pdf version of the
authorisation and the spreadsheets containing
the individual invoices, there are concerns that
different sources of data are used during the
write off process as there is more than one
version of the write off spreadsheet.  
Recommendation:  Checks should be carried out
to ensure that Original Data is retained with
records kept of any alteration to the Source
Data. 
There must only be one version of
the write-off spreadsheet. This can
be shared between Finance and
Legal Services on MS Teams.
Changes can be made to the
document by Legal or Finance
before it is presented to senior
management for final
consideration. 
31/12/2023
31/03/2024
30/09/2024
31 Mar 2025 
Comments as per action point 5 
Documents being passed to ED-
DH for consideration/ approval.   
Delayed and Rescheduled 
Revenues and Benefits
Manager 
Medium
FINANCIAL SERVICES
MANAGEMENT OF DEBT/DEBT RECOVERY 
7. Debtors Procedure Manual and Processes
Finding:  The Debtors Procedure Manual does
not mention that the keying of the Sundry
Debtors Write Offs has two separate stages -
This can be added to the revision of
the procedure manual which will
be finalised in December 2023.
NDR and Income Manager will
ensure the write-offs in the
Debtors system are fully reconciled
31/12/2023
31/05/2024
30/09/2024
31 Mar 2025 
Comments as per action point 5 
Documents being passed to ED-
DH for consideration/ approval.   
Delayed and Rescheduled 
Revenues and Benefits
Manager

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Service, Report, Plan no. & Finding Agreed Action Dates Comment Responsible Officer
first is the creating and approving of invoices as
written off on the Debtors system and second is
the manual journals to be processed to account
for the VAT element of the invoices written off.
The journal processed in February did not
contain all of the invoices that had been written
off. This caused a difference in the debtors’
element of the VAT return. While this was a
small value it raises concerns as to whether
there is appropriate monitoring and oversight of
the balancing of the write off, back to the
authorised invoices and values. 
Recommendation:  Checks should be carried to
ensure that there is appropriate monitoring and
oversight of the balancing of the write off, back
to the authorised invoices and values. The
Debtors Procedure Manual should be updated
to reflect all stages of the write off. 
with the general ledger position
each quarter. 
Medium
FINANCIAL SERVICES
MANAGEMENT OF DEBT/DEBT RECOVERY 
8. Raising of invoices and Recovery Routes  
Finding:  Invoice inappropriately raised for the
drawdown of grant monies. Legal Services
confirm this is not a one off.  
Recommendation:  Services should be reminded
that Debtors invoices should not be raised for
the drawdown of grant monies nor to recover
income 
These examples should be collated
and used to support some internal
training that will be delivered to
launch the new Sundry Debt
Procedure Manual. Training will be
delivered by Finance and Legal
Services to all users of the Sundry
Debt System. Consideration will be
given to the format of the training,
mandatory e-training for all current
users and new users or something
delivered via MS Teams. Training to
be delivered to all users by June
2024. 
31/12/2023
31/05/2024
30/09/2024
31 Mar 2025 
Training has not yet been
delivered, however, e-mails are
being sent to users when
improvements are identified in
the interim. 
A gap analysis of current service
contacts is in progress, any
service without a current
contact in place will be asked to
assign this role. 
Once all contacts are agreed,
training will be scheduled in
quarter 4.   
Delayed and Rescheduled
Revenues and Benefits
Manager/Legal
Manager

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Service, Report, Plan no. & Finding Agreed Action Dates Comment Responsible Officer
Medium
FINANCIAL SERVICES
MANAGEMENT OF DEBT/DEBT RECOVERY 
11. Performance Monitoring and Reporting  
Findings:    
· There are no performance measures in place
to monitor recovery of Sundry debt 
· Quarterly meetings with Legal Services to
discuss recovery of Sundry Debtors were
postponed during the pandemic, these have not
been reinstated. 
· Management information relating to Sundry
Debtors is not made widely available; 
Aged debtors reports are only sent to Services
who ask; Reporting is only to the Financial
Services Management Team via Highlight
Reports.  
Recommendations:  Appropriate performance
measures should be put in place to monitor
recovery of Sundry Debt.  The meetings with
Legal Services should be re-instated and
consideration given to which committees and
meetings should receive reports regarding the
management and recovery of Sundry Debtors. 
Performance monitoring and
reporting will be a key part of the
Sundry Debt review undertaken by
the working group led by the Head
of Legal Services.  It is anticipated
that proposals for quarterly
meetings and the reporting suite
will be developed and
implemented by March 2024. 
31/10/2023
31/03/2024
30/09/2024
31 Mar 2025 
A single source data reporting
dashboard has been developed
which will enable information to
be reported at Council,
department and service levels. 
This will be circulated to Debt
Coordinators on a quarterly
basis and provide high level
recovery information with the
ability to drill down to invoice
level for discussions at quarterly
debt recovery account
meetings. 
Documents being passed to ED-
DH for review prior to
submission to SMT for approval. 
Delayed and Rescheduled 
Revenues and Benefits
Manager 
Medium
FINANCIAL SERVICES
MANAGEMENT OF DEBT/DEBT RECOVERY 
18. Procedure Manual and Processes
Finding:  Management information, detailing
outstanding invoices, should be provided on a
monthly basis to a Single Point of Contact in
each Service. This is not happening, currently
only those Services who request the
information are being sent the reports.  
Recommendation:  Reports should be provided
to all Services.
This working group review of
Sundry Debt will include the key
issue of reporting, this aspect of
the process will be vastly improved
in the future. A suite of reports will
be developed, the identification
departmental debt champions
reinstated and quarterly meetings
setup for all relevant stakeholders. 
31/12/2023
31/03/2024
30/09/2024
31 Mar 2025 
Comments as per action point 8
Delayed and Rescheduled 
Revenues and Benefits
Manager

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Service, Report, Plan no. & Finding Agreed Action Dates Comment Responsible Officer
Medium
FINANCIAL SERVICES
MANAGEMENT OF DEBT/DEBT RECOVERY 
20. Procedure Manual and Processes
Finding:  Insufficient evidence to conclude
whether supporting back up evidence of
invoices being written off is retained, leading to
concerns that full records may not be retained. 
Recommendations:  Checks should be carried
out to ensure that appropriate back up is
retained. 
Back up evidence re write-off
should be retained, the write-off
lists and any backup
documentation held together in
MS Teams group for example. This
could be further enhanced if we
can use EDMS for storage of the
information. If we can move this
onto Civica’s Electronic Document
Management System (EDMS)
Comino this will make collation of
information, document retention
and disposal so much easier and
more efficient. Discuss with Civica,
re the use of the Electronic
Document Management System
for these purposes and overall case
management. Improve the file
structure within the network with
the supporting documentation. 
Expected timescales for progress -
Civica EDMS System Admin
Discussion with Supplier by May
2023 - NDR and Income Manager
to review the file structure on the
network - Revenues and Benefits
Manager Evaluation of options by
July 2023 then NDR and Income
Manager to review the file
structure on the network. Revs and
Bens Manager Development and
Implementation of Solution March
2024 
30/09/2023
30/10/2023
30/03/2024
30/09/2024
31 Mar 2025 
As per previous comment -
Costs provided by Civica are
prohibitive - trying to find a
solution with no/minimum cost. 
Delayed and Rescheduled 
Revenues and Benefits
Manager 
High ROADS & INFRASTRUCTURE SERVICES
Burial Records
A unified approach to records
management will be implemented
and documented in a procedure
30/06/2023
31/12/2023
31/03/2024
A meeting with the Scottish
Government Inspector is
scheduled for the 15th October
Operations Manager,
Roads and
Infrastructure Services

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Service, Report, Plan no. & Finding Agreed Action Dates Comment Responsible Officer 
1. No Procedure for Records Management
Finding:  There is no consistent approach to
updating and managing burial records across
the Service. 
Finding:  Private burials on home ground do not
appear to be authorised or registered.  
Finding:  Officers are printing documentation
provided by funeral directors and applicants via
email unnecessarily.    
Finding:  Documentation was missing or could
not be located at the time of the audit visit. 
Recommendation:  A unified approach to
records management should be adopted to
establish consistency and provide resilience
across the service.  Additionally, a sample of
burial records should be periodically checked for
accuracy.  This should be documented in a
procedure note and issued to the relevant
members of staff. 
note.  This will include a
requirement for periodic sample
checking to take place. 
30/06/2024
30/09/2024
31 Dec 2024 
2024, this is an annual
inspection which is carried out
at Cardross Crematorium. The
Inspector will be asked to carry
out random visits to the area
offices, any findings from these
visits would assist with the
completion of the procedure. 
Delayed and Rescheduled 
Medium
ROADS & INFRASTRUCTURE SERVICES
Burial Records 
2. Review of Policies and Procedures  
Finding:  Policies and procedures provided to
the auditor contained no evidence of recent
review or were not dated. 
Recommendation:  Policies and procedures
should be subject to periodic review and
updated as required.  Updated documents
should be promptly circulated to staff and
published on the Council’s website where
appropriate. 
Policies and procedures will be
reviewed and updated if required. 
These will be re-issued to staff and
published where appropriate. 
30/06/2023
31/12/2023
31/03/2024
30/06/2024
30/09/2024
31 Dec 2024 
Following the meeting with the
Scottish Government Inspector
on the 15th October 2024 any
necessary amendments will be
made to the updated procedure
and this will be circulated by
end of October. 
Delayed and Rescheduled 
Operations Manager,
Roads and
Infrastructure Services

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Service, Report, Plan no. & Finding Agreed Action Dates Comment Responsible Officer
Low
ROADS & INFRASTRUCTURE SERVICES
Burial Records 
5. Additional Functions within BACAS
Finding:  BACAS system has additional
functionality that is not currently utilised to
provide efficiencies. 
Recommendation:  Liaise with system provider
and other Local Authorities to establish which
additional features would provide benefits to
the service. 
The service will liaise with the
system provider and other local
authorities to identify useful
additional system functionality and
arrange training for
implementation. 
30/06/2023
31/12/2023
31/03/2024
30/06/2024
30/09/2024
31 Dec 2024 
Engagement has taken place
with Inverclyde Council who are
currently going through a
similar process with BACAS
details.  To date additional
information includes a
uniformed approach in
communicating each day's
services and details to cremator
room and chapel staff. 
Delayed and Rescheduled
Operations Manager,
Roads and
Infrastructure Services 
VFM
ROADS & INFRASTRUCTURE SERVICES
External Hire 
3. External hires exceeding their expected
return date 
Of the 124 current ongoing hires 101 of these
have exceeded their expected return. In
addition 29 items were over the return date by
more than 1000 days.  There is no document
available that explains the reasons why these
items have substantially exceeded their
expected return date. 
Roads and infrastructure services
are currently under a review of all
services and the recommendation
will be assessed as part of the
review. 
30/06/2023
31/12/2023
31/03/2024
31 Dec 2024 
Assistant Operations Managers
have advised that the hire desk
circulates a spreadsheet each
week showing the hires relating
to amenity, waste, roads and
street lighting, these are
reviewed monthly at area team
meetings.  From the original
document detailed in the audit
a number of vehicles and
equipment have been off hired. 
There are a number of lengthy
external hires across all
disciplines these relate to
vehicles not being replaced
during the service reviews of
2013/14 and the service choices
process of 2014/15 where
decisions were being made
regarding finance, subsequently
a fleet audit was carried out and
since all these processes have
been concluded insufficient
finances have been available to
Operations Manager,
Roads and
Infrastructure Services

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Service, Report, Plan no. & Finding Agreed Action Dates Comment Responsible Officer
replace all existing hires.  The
Operations Manager has asked
on a number of occasions if the
monies being paid for external
hires can be transferred to the
internal fleet budget to allow
the council to purchase its own
replacements and cease paying
private companies for lengthy
hires. 
Delayed and Rescheduled 
Low
ROADS & INFRASTRUCTURE SERVICES
PIERS & HARBOURS 
4. Remote Piers and Harbours  
Harbourmasters based at the main piers and
harbours are able to record the use of the
facilities where they are predominantly based,
however, a number of piers, slipways and
harbours are in remote locations and are
difficult to manage in terms of use. In addition,
there are no robust procedures in place to
identify commercial tour vessels using our
facilities potentially resulting in a loss of income
for the Council. 
Actionable evidence and
enforcement will continue to be an
issue where there are no Argyll &
Bute Council personnel on site.
Investigate issues and possible
solutions with Harbour Masters
and provide options for
consideration in report to DMT. 
31/12/2023
31/03/2024
30/06/2024
30/09/2024
30 Nov 2024 
CCTV not yet installed. 
Delayed and Rescheduled 
Marine Operations
Manager 
Low
ROADS & INFRASTRUCTURE SERVICES
PIERS & HARBOURS 
5. Fishing Fleet  
Fees and charges for the fishing fleet within the
Council area are managed by the fishing fleet
whereby they advise us of the value of their
landings once the catch has been sold. There is
no back up information provided to substantiate
Investigate issues and possible
solutions with Harbour Masters
and provide options for
consideration in report to DMT. 
31/12/2023
31/03/2024
30/06/2024
30/09/2024
30 Nov 2024 
CCTV not yet installed. 
Delayed and Rescheduled 
Marine Operations
Manager

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Service, Report, Plan no. & Finding Agreed Action Dates Comment Responsible Officer
the value and it is generally paid through cash
receipting or by cheque. 
Low
ROADS & INFRASTRUCTURE SERVICES
PIERS & HARBOURS 
6. Management of Debt  
The outstanding debt owed to the Council at the
end of June in respect of Piers and Harbours
amounted to £143k.  There are a number of
long-term outstanding debts, and it was noted
that in some instances there is continued use of
our facilities by vessels who have outstanding
debts dating back to 2019. 
Investigate with legal department
recovery or right off options. 
Provide a report to Head of Service
and Director with options. 
31/12/2023
31/03/2024
30/06/2024
30/09/2024
30 Nov 2024 
This process is continuing with
collection / write-off of
outstanding debts. 
Delayed and Rescheduled 
Marine Operations
Manager 
Low
ADULT SERVICES (OLDER ADULTS &
COMMUNITY HOSPITALS) 
Adult Services - Adult Support & Protection
1. Progress  
Whilst significant progress has been made to
address the key areas identified within the
report there remains challenges in terms of
ensuring attendance by all relevant partners at
case conferences, ensuring that chronologies
and risk assessments are completed and
ensuring that the ‘three-point test’ is
undertaken. 
Adult services will facilitate an ASP
audit on a six-monthly basis to
determine practice and compliance
with ASP legislation and KPIs. 
30/09/2024
31 Dec 2024 
This audit has taken place and
reported through the Adult
Protection Committee. A
planning group is also to be
established to consider the ASP
audit practicalities, timings,
model etc for the next ASP case
file audit. A report this has been
passed on for consideration,
however, currently delayed due
to operational issues. 
Delayed and Rescheduled 
Head of Adult Services
(Mental Health, Acute
and Complex Care) 
High
ADULT SERVICES (MENTAL HEALTH LEARNING
DISABILITY, ADDICTIONS & LIFELONG
CONDITIONS/CSWO)
CLIENT FUNDS 
6. Unaccounted Funds 
Detail Restricted.
Detail Restricted  30/06/2023
31/08/2023
31/12/2023
31/03/2024
30/09/2024
31 Mar 2025 
Delayed and Rescheduled  SW Admin Manager

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Service, Report, Plan no. & Finding Agreed Action Dates Comment Responsible Officer
Medium
ADULT SERVICES (MENTAL HEALTH LEARNING
DISABILITY, ADDICTIONS & LIFELONG
CONDITIONS/CSWO)
CLIENT FUNDS PROGRESS REVIEW 
1. Procedures   
Detail Restricted. 
Detail Restricted  30/09/2024
31 Mar 2025 
Delayed and Rescheduled  SW Admin Manager 
Medium
ADULT SERVICES (MENTAL HEALTH LEARNING
DISABILITY, ADDICTIONS & LIFELONG
CONDITIONS/CSWO)
CLIENT FUNDS PROGRESS REVIEW 
3. Implementation of New Working Practices
Detail Restricted. 
Detail Restricted  31/08/2024
31 Dec 2024 
Delayed and Rescheduled  SW Admin Manager 
Medium
ADULT SERVICES (OLDER ADULTS &
COMMUNITY HOSPITALS)
Learning & Physical Disability Care Packages 
6. Allocation of Resources  
The large majority of Learning Disability services
are commissioned under the Supported Living
contract and Older People services are
commissioned under Care at Home contract.
There are a few anomalies where some
providers of Care at Home services are
commissioned to provide support outside of
their normal client group, however it was found
that priority was given to older peoples services
with Learning Disability clients remaining on a
waiting list for personal care services. 
Review the Care at Home contract
as a matter of priority to ensure
that there is personal care
provision across the authority for
those under the age of 65 with
complex needs, who do not require
more intensive care such as that
provided via Supported Living. 
30/06/2024
31/08/2024 
Comments have been provided
as this action is now due. Due to
responsible person being off
work this is to be delayed and
NOT rescheduled. This will be
rescheduled when a revised
date is received from HSCP
Leadership. 
Delayed and NOT Rescheduled 
Head of Adult Services -
Acute & Complex Care 
Medium ADULT SERVICES (OLDER ADULTS &
COMMUNITY HOSPITALS)
Learning & Physical Disability Care Packages 
Include the data re unmet need for
those under 65 in the weekly
reporting format already in place
for Older People.
30/06/2024
30/09/2024
The reporting of Unmet need
across the HSCP is a national
weekly data return. LD specific
client data is accessible via the
Head of Strategic
Planning, Performance
and Technology & Head

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Service, Report, Plan no. & Finding Agreed Action Dates Comment Responsible Officer
Unmet Need Unmet need for Older People Care
at Home is collated by the resources team on a
weekly basis, this is then submitted to
Performance and Improvement Team and is
reported to Scottish Government. The data for
Learning Disability is not currently recorded
formally and not included in the above.
Eclipse reporting database using
SAP BOBI. There is also an
Unmet Need – Self Service
Performance Dashboard for all
managers to track their
performance within SharePoint
The SG criteria for unmet need
includes: 
· All clients 18+ in receipt of care
at home this could include LD
clients 
· This includes the 4 SDS options
which could include LD clients 
· Unmet need also includes
those who are in receipt of an
assessment this will include
social work, third sector etc. 
The care package part of the
return includes those in
supported living, adapted
housing etc. 
Evidence Required 
of Adult Services (Health
& Community Care)
Low
ADULT SERVICES (OLDER ADULTS &
COMMUNITY HOSPITALS)
Scottish Social Services Council (SSSC)
Registration 
6. Care Home Handbook  
Finding:  Details of how to communicate
concerns/complaints were provided in two out
of three handbooks provided.
Recommendation:  Review and update content
of care home handbooks to ensure complaints
contact details are consistently provided. 
Review all care home
complaints/concerns processes. 
31/07/2024
31 Dec 2024 
All care homes have posters up
indicating how to make a
complaint, confirmed by our
Lead Nurse. Managers are not
yet in full agreement about a
handbook for every home. 
Delayed and Rescheduled 
Lead Nurse (Care
Homes)

Page 15

Service, Report, Plan no. & Finding Agreed Action Dates Comment Responsible Officer
Low
ADULT SERVICES (OLDER ADULTS &
COMMUNITY HOSPITALS)
Scottish Social Services Council (SSSC)
Registration 
3. Service-user information  
Finding:  Service-users and their family, friends
and non-Council carers are advised that
violence, threats or abuse towards them from
Council employees will not be tolerated,
however, only one handbook provided advised
visitors on expected conduct regarding violence,
threats or abuse towards employees. There was
no documentation containing information
regarding conduct of service users towards
employees.  
Recommendation:  Service-user documentation
should be revised to advise that instances of
violence, threats or abuse directed towards
employees is not acceptable.
Review all social work and social
care service user documentation in
adult services. 
31/08/2024
31 Dec 2024 
Audit Action-Violent Behaviour-
not complete, Lead Nurse will
pick up by the end of the year. 
Delayed and Rescheduled 
Senior Manager -
Resources/Professional
Lead - Social Work
Medium
CHILDREN AND FAMILIES AND CRIMINAL
JUSTICE
Scottish Social Services Council (SSSC)
Registration 
4. Supervision Policy  
Finding:  The Supervision Policy is dated
November 2011 with no evidence of review or
update, additionally, the requirements in terms
of frequency and duration of supervision
meetings are considered by mangers to be
unrealistic in terms of current available
resources. 
Recommendation:  The Supervision Policy be
reviewed and updated to ensure it incorporates
up-to-date needs and requirements of service
delivery.
Develop a social work and social
care supervision policy. 
31/08/2024
30/09/2024
31 Dec 2024 
This is a larger piece of work
than first anticipated.  Updates
are required to reflect changes
in the HSCP structure, SSSC
registration and CPL that took
place earlier this year as well as
the implementation of the
NQSW mandatory supported
year which came into place
October 2024.  The updated
policy will be assurance checked
for compliance and circulated to
SW managers and practitioners
for comment before taken to
the SW Leadership group and
CC&G for sign off/noting.
Delayed and Rescheduled
Professional Lead -
Social Work

Page 16

Action Plan Points due after 30th September 2024 
Service, Report, Plan no. & Finding Agreed Action Dates Comment Responsible Officer
Medium
FINANCIAL SERVICES – Capital Monitoring 
Capital Programme Planning & Management
Guide The Council’s Capital Guide has not been
revised since 2018 and requires a review to
ensure it reflects current working practices and
provides appropriate support to officers involved
in the capital monitoring process. The Council is
currently developing a new Capital Strategy
which is to be presented to the Policy and
Resources Committee in August 2021 and we
recognise that a review of the Guide should be
conducted after the Strategy has been finalised
to ensure the two documents complement each
other and. The Guide could also benefit from
being linked to, or referencing, other relevant
Council processes, in particular the Project
Management section on the Hub. 
Capital Planning and Management
Guide to be updated once the
Capital Strategy has been approved
to ensure the two are aligned and
provide clarity.
31/03/2022
30/09/2022
31/12/2022
31/03/2023
30/09/2023
31/12/2023
31/03/2024
31/03/2025
30 Sep 2025
Further information to be
gathered on current governance
processes around capital,
including PIP/POP, capital
planning, monitoring, reporting,
Capital board, Asset
Management Plans and links to
budget processes. 
Delayed and Rescheduled 
Head of Commercial
Services/Finance
Manager