2024_25_InternalAudit_Culture_FinalReport
Argyll and Bute Council · 17 December 2024
Back to Audit and Scrutiny Committee — 17 December 2024 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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Argyll & Bute Health & Social Care Partnership Internal Audit Report October 2024 FINAL High Medium Low VFM Number of Findings 0 5 0 0 Culture Audit Opinion: Reasonable
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2 Argyll & Bute Health & Social Care Partnership – Internal Audit Report – Culture, October 2024 Contents 1. Executive Summary ........................................................................................................................ 3 Introduction ............................................................................................................................................ 3 Background ............................................................................................................................................. 3 Scope ....................................................................................................................................................... 4 Key Dates ................................................................................................................................................ 4 Risks ........................................................................................................................................................ 4 Audit Opinion ......................................................................................................................................... 4 Recommendations ................................................................................................................................. 4 2. Objectives and Summary Assessment ........................................................................................... 5 3. Detailed Findings ............................................................................................................................ 6 Appendix 1 – Action Plan ..................................................................................................................... 10 Appendix 2 – Audit Opinion ................................................................................................................. 13 Contact Details Internal Auditor: Moira Weatherstone Telephone: 01546 604146 e-mail: moira.weatherstone@argyll-bute.gov.uk www.argyll-bute.gov.uk
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3 Argyll & Bute Health & Social Care Partnership – Internal Audit Report – Culture, October 2024 1. Executive Summary Introduction 1. As part of the 2024/25 internal audit plan, approved by the Audit & Risk Committee in April 2024, we have undertaken an audit of Argyll & Bute Health & Social Care Partnership (HSCP) system of internal control and governance in relation to Culture. 2. The audit was conducted in accordance with the Public Sector Internal Audit Standards (PSIAS) with our conclusions based on discussions with Health & Social Care Partnership officers and the information available at the time the fieldwork was performed. The findings outlined in this report are only those which have come to our attention during the course of our normal audit work and are not necessarily all the issues which may exist. Appendix 1 to this report includes agreed actions to strengthen internal control however it is the responsibility of management to determine the extent of the internal control system appropriate to the HSCP. 3. The contents of this report have been agreed with the appropriate Health & Social Care Partnership officers to confirm factual accuracy and appreciation is due for the cooperation and assistance received from all officers over the course of the audit. Background 4. The culture of an organisation drives how it conducts its business. Organisational culture is the set of shared values, beliefs, attitudes, systems and rules that outline and influence behaviour within the organisation. In addition, it reflects both the written and unwritten rules that people in the organisation should follow. 5. A positive organisational culture is often identified by open communication, mutual respect, shared commitment to the achievement of common goals and a commitment to growth and development. A positive, open culture supports the organisation’s attainment of its goals and objectives because it generally creates a more enjoyable place to work, enhances productivity, and leads to overall improved performance in addition to reducing risk exposure. Whilst poor organisational culture has been identified as the root cause of many serious issues across organisations. 6. The HSCP have formed a Culture and Wellbeing Group which continue to meet to progress local, board and council wide initiatives. They focus on; employee engagement, culture monitoring, learning and development, management development, wellbeing promotion, communication, systems and processes and improving data capture to inform decisions. The Council’s wellbeing team are a key contributor to this group and stronger links are being forged between the Council and NHS wellbeing teams and resources. 7. In addition, NHS have developed the Culture and Leadership framework which was approved by the Culture Oversight Group (COG) in October 2023. This outlines a four phase project plan focussing on Our Learning System, Leadership and Management Development and Colleague Development. The plan prioritises those interventions which are expected to have greatest impact on the behavioural and cultural changes the HCSP seek.
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4 Argyll & Bute Health & Social Care Partnership – Internal Audit Report – Culture, October 2024 Scope 8. The scope of the audit was to assess organisational culture across NHS and LG via any recent staff survey results and review the progress being made by the A&B HSCP Culture Group as outlined in the Terms of Reference agreed with the Chief Officer on 11 June 2024. Key Dates 9. The Terms of Reference provided provisional timescales for the review to take place, the actual dates are noted below. Exhibit 1 – Key Dates Stage Actual Date Terms of Reference agreed 11 June 2024 Fieldwork Commencement 11 June 2024 Draft Report issued 13 August 2024 Management Comments received 19 August 2024 Final Report issued 2 October 2024 Audit and Risk Committee 17 December 2024 Risks 10. The risks considered throughout the audit were: SRR08: Equalities Audit Risk 1: failure to progress key objectives identified by the Culture Group Audit Risk 2: failure to identify and assess any areas for improvement identified through the staff survey Audit Risk 3: failure to report progress to relevant staff and committees Audit Opinion 11. We provide an overall audit opinion for all the audits we conduct. This is based on our judgement on the level of assurance which we can take over the established internal controls, governance and management of risk as evidenced by our audit work. Full details of the five possible categories of audit opinion is provided in Appendix 2 to this report. 12. Our overall audit opinion for this audit is that we can take a reasonable level of assurance. This means that internal control, governance and the management of risk are broadly reliable. However, whilst not displaying a general trend, there are areas of concern which have been identified where elements of residual risk or weakness may put some of the system objectives at risk. Recommendations 13. We have highlighted 5 medium priority recommendations where we believe there is scope to strengthen the control and governance environment. These are summarised below:
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5 Argyll & Bute Health & Social Care Partnership – Internal Audit Report – Culture, October 2024 Consideration should be given as to how staff surveys could focus on specific issues relating to the HSCP in order to assess the culture within the HSCP The work plan should be updated to reflect priorities within the HSCP that are focussed, measurable, have clear outcomes and target completion dates Progress against the work plan should be clearly recorded within the work plan Consideration should be given to how the HSCP can better communicate with staff across both organisations to encourage staff to participate and share their views in surveys Whilst it is acknowledged that proportionately the NHS have larger number of staff consideration should be given to how a balance of staff between NHS Highland and the Council could be represented on the Culture and Wellbeing Group 14. Full details of the audit findings, recommendations and management responses can be found in Section 3 of this report and in the action plan at Appendix 1. 2. Objectives and Summary Assessment 15. Exhibit 1 sets out the control objectives identified during the planning phase of the audit and our assessment against each objective. Exhibit 2 – Summary Assessment of Control Objectives Control Objective Link to Risk Assessment Summary Conclusion 1 The Culture Group has identified and prioritised key areas for development and improvement SRR08 Reasonable The HSCP Culture & Wellbeing Group have developed a work plan, dated 2023, which outlines priorities, outcomes, responsible person and timeframes. However, these are not specific, targeted or in some instances easily measurable with target dates for completion marked as ‘ongoing’. Regular staff surveys are undertaken by both employers and are used to provide information on the health of the organisations and inform the Group. Whilst participation in the NHS staff surveys tend to be higher and are improving, Council staff participation in surveys tends to be low. It is recognised that there are challenges in so far as the HSCP does not employ staff and that staff within the HSCP are part of two very separate organisations with their own cultures. The surveys issued focus on the culture within either the NHS Highland or the Council. 2 The Culture Group is monitoring progress against areas identified for Audit Risk 1 Audit Risk 2 Substantial The group is monitoring progress against the work plan which was approved in 2023. Progress reports are updated at Culture Group meetings and recorded in the notes of the
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6 Argyll & Bute Health & Social Care Partnership – Internal Audit Report – Culture, October 2024 development and improvement meeting. However, there does not seem to be progress notes assigned to the work plan therefore difficult to assess, without reading every meeting note what progress has made. 3 The Culture Group meets on a regular basis and provides reports and updates to relevant staff and committees Audit risk 3 Substantial The Culture Group meets on a regular basis. The Terms of Reference for the Culture and Wellbeing group were created in June 2022 with the most recent update in May 2023. Initially to get momentum going the group met 4 weekly, however, it was felt to be too often and it was agreed to meet bimonthly. In 2023 the Group met most months, with the exception on a few months when meetings were cancelled. Updates from the Culture Group are reported to the Senior Management Team (SLT) and the IJB, with minutes of the IJB available to assess on the website. Reliance is placed on managers attending the Culture Group feeding back information to their teams. 16. Further details of our conclusions against each control objective can be found in Section 3 of this report. 3. Detailed Findings The Culture Group has identified and prioritised key areas for development and improvement 17. Culture and wellbeing became a high priority following the Sturrock report which identified areas of concern within the NHS relating to the culture within the organisation. In November 2019, as recommended in the Sturrock Review report, NHS Highland Board commissioned an independent company to carry out a survey for colleagues working in Argyll & Bute. As a result of the Sturrock Report the Culture Oversight group was formed reporting to the Integrated Joint Board (IJB). It was reported in 2020 that the NHS had made good progress with developing an updated Culture Plan. This has evolved and developed since 2020, with the introduction of a Culture & Wellbeing Group (the Group) for the HSCP. 18. Argyll & Bute Culture and Wellbeing Group was formed to support the wellbeing of staff and cultural change across the HSCP and ensure that wellbeing is at the heart of our HSCP culture. The Culture and Wellbeing Group, provides an integrated HSCP forum for staff to discuss, influence, develop and monitor culture and wellbeing across the partnership, specifically; to oversee the delivery of an action plan taking ownership for continuous improvement in the areas of culture and wellbeing;
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7 Argyll & Bute Health & Social Care Partnership – Internal Audit Report – Culture, October 2024 ensure that the HSCP continue to reflect on the learning from previous reviews while ensuring the HSCP are focussed on meeting the current and future needs of our integrated staff group; to support and highlight activities undertaken by both employing bodies (HSCP and the Council) to support a positive culture and working environment. 19. Regular staff surveys are undertaken by both employers and are used to provide information on the health of the organisations and inform the Group. The staff surveys undertaken are: The ‘I matter’ survey is issued to staff on an annual basis across both the NHS and the Council. This survey focusses on employee experience in relation to their job role, team, relationship with management, decision making and health and wellbeing. The response rate in 2024 was 50%. However, we were advised that ‘I matter’ response rates had improved year on year: 2022 - 31% 2023 - 48% and 2024 - 50%. Within the Council quality conversations are at the heart of how the Council do business. Having the skills and confidence to engage in quality conversations with colleagues, partners and communities is one of the Council’s key priorities. In order to measure the success and impact of the programme the Council agreed to conduct an annual survey and report on the findings each year. Line managers were also surveyed as it is important to hear about their experience of leading and engaging in quality conversations within their teams. The report, dated 5th June 2024 showed the completion rate across the HSCP services: 20. In addition the Council conducted an Employee Experience Survey in 2024 with 587 staff completing the survey. The survey results were issued to all Council staff and staff were invited to join a focus group with groups consisting of 12-15 people from the same job type the aim was to talk in more detail about what improvements could look like for their area of work. 21. It is recognised that there are challenges in so far as the HSCP does not employ staff and that staff within the HSCP are part of two very separate organisations with their own cultures. The surveys issued tend focus on the culture within either the NHS Highland or the Council. Previously there were listening and learning exercises (the last results report dated 2021) which employees of NHS Highland and Argyll and Bute Council working in the HSCP were encouraged Service No of employees in service No of employees who responded % Response rate Adult Services Health and Community Care 349 16 5% Adult Services Acute and Complex 122 13 11% Children, Families & Justice 290 26 9% Strategic, Planning & Performance 18 6 33% Total 779 61
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8 Argyll & Bute Health & Social Care Partnership – Internal Audit Report – Culture, October 2024 to participate in. This survey fed into action plans and more recently resulted in a report being issued - ‘You Said, We Did’. Recent surveys undertaken by each organisation do not focus specifically on the HSCP in terms of culture (how are the service working together, communicating with each other, sharing information), instead focussing on staff experiences in each organisation. Action Plan 1 22. The HSCP Culture & Wellbeing Group have developed a work plan, dated 2023, which outlines priorities, outcomes, responsible person and timeframes. However, these are not specific, targeted or in some instances easily measurable with target dates for completion marked as ‘ongoing’. Action Plan 2 23. Approved by the Culture Oversight Group (COG), in October 2023, “Our Culture and Leadership Framework” proposal paper was developed collaboratively by colleagues within Education, Learning & Development, and Organisational Development teams. This outlines a 4 phase project plan focussing on: Our Learning System, Leadership and Management Development and Colleague Development. Phase 1 was concluded in March 2024, with phase 2 now well underway. The document was brought together by NHS and focusses on their priorities, however, the framework sets out how the HSCP seek to achieve the behavioural changes that lead to the cultural changes they seek. Feedback from module participants, data from OD casework and facilitator feedback have all been considered to establish next steps for each of the following tasks: Leadership and Culture Framework: Development and approval of a framework that sets out how we seek to achieve the behavioural changes that lead to the cultural changes we seek Leadership and Management Development Programme : Development and delivery of an updated programme to include new modules that the COG prioritise as having the most impact on behavioural and cultural change Staff (Colleague) Development Programme: Development and delivery of an updated programme to include new modules that the COG prioritise as having the most impact on behavioural and cultural change. 24. Time frames have been established for each of the 4 phases, with completion in March 2027: Phase I: September 2023 – March 2024 Phase 2: April 2024-March 2025 Phase 3: April 2025 – March 2026 Phase 4: April 2026 – March 2027 The Culture Group is monitoring progress against areas identified for development and improvement 25. The group is monitoring progress against the work plan which was approved in 2023. Progress reports are updated at Culture Group meetings and recorded in the notes of the meeting. However, there does not seem to be progress notes assigned to the work plan therefore difficult
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9 Argyll & Bute Health & Social Care Partnership – Internal Audit Report – Culture, October 2024 to assess, without reading every meeting note what progress has made. In addition as noted above a number of targets dates are simply noted as ‘ongoing’. Action Plan 3 The Culture Group meets on a regular basis and provides reports and updates to relevant staff and committees 26. The Culture Group meets on a regular basis. The Terms of Reference for the Culture and Wellbeing group were created in June 2022 with the most recent update in May 2023. Initially to get momentum going the group met 4 weekly, however, it was felt to be too often and it was agreed to meet bimonthly. In 2023 the Group met most months, with the exception on a few months when meetings were cancelled. 27. Updates from the Culture Group are reported to the Senior Management Team (SLT) and the IJB, with minutes of the IJB available on the website. Reliance is placed on managers attending the Culture Group feeding back information to their teams. 28. Within the Work Plan 2023 there are identified outcomes with regards to improving communication channels and how to ensure that all staff views within the HSCP are heard. The results of surveys have demonstrated engagement and participation by HSCP staff could be improved. 29. It is acknowledged that there are still a large amount of staff that are non-networked and therefore there are challenges to sharing information and to allow staff easy access to online surveys. There have been a number of imaginative initiatives to engage with non-networked staff for example posters and QR codes containing links. In addition ‘My Council Works’ has been developed. This is the new, open to all hub – which mean NHS staff and non-networked employees can easily access it on their smart phones or personal laptops. This is facilitating a greater ability to communicate with staff across the HSCP. The HUB contains, staff news/Health and Wellbeing information/HR information /learning material/policies and procedures. Action Plan 4 30. Whilst the Culture Group is open to all staff across the HSCP, there is a greater proportion of representation of NHS staff. Whilst it is acknowledged that proportionately the NHS have larger number of staff than the Council, consideration should be given to how a balance of staff between NHS Highland and the Council could be represented on the Culture and Wellbeing Group. Action Plan 5
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Appendix 1 – Action Plan No Finding Risk Agreed Action Responsibility / Due Date Medium 1 Surveys Recent surveys undertaken by each organisation do not focus specifically on the HSCP in terms of culture (how are the services working together, communicating with each other, sharing information), instead focussing on staff experiences in each organisation. Priorities are set based on cultures within NHS Highland and the Council rather than within the HSCP HR leads within ABC and NHSH to review survey landscape and explore joint survey option over and above existing employer only surveys. To report to SLT and JPF Depute Director of People, NHS Highland March 2025 Medium 2 Work Plan The work plan outlines priorities, outcomes, responsible person and timeframes. However, these are not specific, targeted or in some instances easily measurable with target dates for completion marked as ‘ongoing’. Lack of clear identifiable outcomes and completion dates Refresh and review of the remit and purpose of the Culture Group. The work plan will be included as part of the review to focus on meaningful action and timescales Depute Director of People, NHS Highland March 2025 Medium 3 Monitoring Progress There does not seem to be progress notes assigned to the work plan therefore difficult to assess, without reading every meeting note what progress has made. In addition as noted above a number of targets dates are simply noted as ‘ongoing’. Target dates for completion are missed Refresh and review of the remit and purpose of the Culture Group to include timescales and progress reporting as appropriate Depute Director of People, NHS Highland March 2025
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11 Argyll & Bute Health & Social Care Partnership – Internal Audit Report – Culture, October 2024 Medium 4 Survey Participation The results of surveys have demonstrated engagement and participation by HSCP staff could be improved. Unrepresentative views of the organisation Chief Officer to communicate commencement of surveys to all staff via CO comms Chief Officer March 2025 Medium 5 Culture and Wellbeing Group Whilst the Culture Group is open to all staff across the HSCP, there is a greater proportion of representation of NHS staff. Bias of views and opinions based on one organisation As per refresh and review of Culture Group, review membership as a result of revised remit and purpose Depute Director of People, NHS Highland March 2025
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12 Argyll & Bute Health & Social Care Partnership – Internal Audit Report – Culture, October 2024 In order to assist management in using our reports a system of grading audit findings has been adopted to allow the significance of findings to be ascertained. The definitions of each classification are as follows: Grading Definition High A major observation on high level controls and other important internal controls or a significant matter relating to the critical success of the objectives of the system. The weakness may therefore give rise to loss or error. Medium Observations on less significant internal controls and/or improvements to the efficiency and effectiveness of controls which will assist in meeting the objectives of the system. The weakness is not necessarily substantial however the risk of error would be significantly reduced if corrective action was taken. Low Minor recommendations to improve the efficiency and effectiveness of controls or an isolated issue subsequently corrected. The weakness does not appear to significantly affect the ability of the system to meet its objectives. VFM An observation which does not highlight an issue relating to internal controls but represents a possible opportunity for the HSCP to achieve better value for money (VFM).
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13 Argyll & Bute Health & Social Care Partnership – Internal Audit Report – Culture, October 2024 Appendix 2 – Audit Opinion Level of Assurance Definition High Internal control, governance and the management of risk are at a high standard. Only marginal elements of residual risk have been identified with these either being accepted or dealt with. A sound system of control designed to achieve the system objectives is in place and being applied consistently. Substantial Internal control, governance and the management of risk is sound. However, there are minor areas of weakness which put some system objectives at risk and specific elements of residual risk that are slightly above an acceptable level and need to be addressed within a reasonable timescale. Reasonable Internal control, governance and the management of risk are broadly reliable. However, whilst not displaying a general trend, there are areas of concern which have been identified where elements of residual risk or weakness may put some of the system objectives at risk. Limited Internal control, governance and the management of risk are displaying a general trend of unacceptable residual risk above an acceptable level and placing system objectives are at risk. Weakness must be addressed with a reasonable timescale with management allocating appropriate resources to the issues raised. No Assurance Internal control, governance and the management of risk is poor. Significant residual risk and/or significant non-compliance with basic controls exists leaving the system open to error, loss or abuse. Residual risk must be addressed immediately with management allocating appropriate resources to the issues.