202324_InternalAudit_AdultService_FinalReport
Argyll and Bute Council · 5 September 2024
Back to Audit and Scrutiny Committee — 5 September 2024 and its agenda
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Argyll & Bute Health & Social Care Partnership Internal Audit Report March 2024 FINAL High Medium Low VFM Number of Findings 0 0 1 0 Adult Services-Adult Support and Protection Audit Opinion: Substantial
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2 Argyll & Bute Health & Social Care Partnership – Internal Audit Report – Adult Services-Adult Support and Protection, March 2024 Contents 1. Executive Summary ........................................................................................................................ 3 Introduction ............................................................................................................................................ 3 Background ............................................................................................................................................. 3 Scope ....................................................................................................................................................... 5 Risks ........................................................................................................................................................ 5 Audit Opinion ......................................................................................................................................... 5 Recommendations ................................................................................................................................. 5 2. Objectives and Summary Assessment ........................................................................................... 6 3. Detailed Findings ............................................................................................................................ 7 Appendix 1 – Action Plan ..................................................................................................................... 10 Appendix 2 – Audit Opinion ................................................................................................................. 12 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 – Adult Services-Adult Support and Protection, March 2024 1. Executive Summary Introduction 1. As part of the 2023/24 internal audit plan, approved by the Audit & Risk Committee in February 2023, we have undertaken an audit of Argyll & Bute Health & Social Care Partnership (HSCP) system of internal control and governance in relation to Adult Services-Adult Support and Protection. 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. Scottish Ministers requested that the Care Inspectorate lead joint inspections of adult support and protection in collaboration with Healthcare Improvement Scotland and Her Majesty’s Inspectorate of Constabulary in Scotland. The joint inspection of the Argyll and Bute partnership took place between June 2021 and September 2021, with the report being issued in September 2021. 5. To provide Scottish Ministers with timely high-level information, the joint inspection report included a statement about the Council’s progress in relation to our two key questions: • How good were the partnership’s key processes for adult support and protection? • How good was the partnership’s strategic leadership for adult support and protection? 6. The report concluded that the partnership’s key processes for adult support and protection were effective with areas for improvement. There were clear strengths supporting positive experiences and outcomes for adults at risk of harm, which collectively outweighed the areas for improvement. 7. The summary concluded: • “The Argyll and Bute partnership had an established and clear vision, supported by an effective multi-agency adult protection committee. The strategic response to the Covid- 19 pandemic was effective with strong community engagement. The partnership was particularly proactive in raising awareness of adult support and protection within the community and with the people responsible for planning, delivering and evaluating care and support;
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4 Argyll & Bute Health & Social Care Partnership – Internal Audit Report – Adult Services-Adult Support and Protection, March 2024 • Partner agencies worked collaboratively to improve outcomes for adults at risk of harm. The partnership should involve health and police staff more in key stages of the adult support and protection process. Senior leaders effectively managed significant challenges in maintaining adequate staffing levels during the Covid-19 pandemic. A combined approach from partner agencies and volunteers helped to keep people safe and protected; • The systems and processes for carrying out initial inquiries into adult support and protection concerns were effective which helped to ensure concerns raised by people were progressed timeously by appropriate staff. Investigations were carried out by the partnership effectively, which helped to keep adults at risk of harm safe and protected. However, the governance of risk assessments and chronologies needed to be significantly improved to minimise risks for adults at risk of harm. This had been identified by previous audits carried out by the partnership; however, the lack of improvement suggests leadership’s ability to affect change has been limited”. 8. The key strengths highlighted in the report were: • “Adults at risk of harm were safer due to effective multi-agency working; • The partnership conducted a comprehensive audit of adult support and protection practice to determine how effective systems were at protecting adults at risk of harm; • A range of adult support and protection learning and development sessions and online training were made available to all staff. Staff knew where to get advice if they had concerns about an adult at risk of harm. Staff raised concerns regarding adult support and protection timeously and most staff said referral processes were clear and well understood; • Adults at risk of harm benefitted from social contact, support and advice from staff and volunteers. This was particularly helpful during the periods of restriction due to Covid-19 when risks associated with isolation increased; • Investigations were collaborative, well documented and effective; • Strategic leadership recognised the impact of financial harm and implemented effective governance to minimise risks”. 9. There were 4 priority areas identified for improvement: • “All relevant partners should be invited to participate in case conferences and review case conferences; • The ‘three-point test’ is an essential factor in determining if the adult is at risk of harm. The application of the test should be clearly documented during initial inquiry to show decision making rationale; • All adults at risk of harm should have a risk assessment, which is comprehensive; • There should be a consistent approach to preparing and recording chronologies for all adults at risk of harm who require one”. 10. The report required that the Argyll and Bute partnership prepare an improvement plan to address the priority areas for improvement with the Care Inspectorate, through its link
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5 Argyll & Bute Health & Social Care Partnership – Internal Audit Report – Adult Services-Adult Support and Protection, March 2024 inspector, Healthcare Improvement Scotland and Her Majesty’s Inspectorate of Constabulary in Scotland will monitor progress implementing this plan. Scope 11. The scope of the audit was to assess response to 2021 Review of Adult Services to provide assurance that strategic decisions have been taken to deliver on outcomes as outlined in the Terms of Reference agreed with the Head of Adult Services (Mental Health, Acute and Complex Care) on 23 February 2024. Risks 12. The risks considered throughout the audit were: • SRR13 – Service Delivery • Audit Risk 1: Failure to prepare an improvement plan • Audit Risk 2: Failure to implement improvement plan • Audit Risk 3: Failure to monitor progress of plan Audit Opinion 13. 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. 14. Our overall audit opinion for this audit is that we can take a substantial level of assurance. This means that 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. Recommendations 15. We have highlighted one low priority recommendations where we believe there is scope to strengthen the control and governance environment. These are summarised below: • Work should continue to ensure that all the improvement plan action points are completed ahead of any follow up audit by the Care Inspectorate and that all partners engage with the processes and procedures put in place 16. 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.
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6 Argyll & Bute Health & Social Care Partnership – Internal Audit Report – Adult Services-Adult Support and Protection, March 2024 2. Objectives and Summary Assessment 17. Exhibit 1 sets out the control objectives identified during the planning phase of the audit and our assessment against each objective. Exhibit 1 – Summary Assessment of Control Objectives Control Objective Link to Risk Assessment Summary Conclusion 1 An improvement plan has been put in place SRR13 Audit Risk 1 High A comprehensive improvement plan was developed in 2021 with the aim of improving activity in health and social care to make services better for the people who use them. Argyll and Bute Adult Support and Protection Partnership (the Partnership) were required to submit the Improvement Plan by November 2021, to the Link Inspector, demonstrating that it addresses the priority areas for improvement identified within the report. In addition, the Partnership were required to respond to a post inspection questionnaire which was also required to be submitted in November 2021. Both were submitted within the deadline. 2 Recording and monitoring processes have been put in place to monitor progress against plan SRR13 Audit Risk 3 Substantial Recording and monitoring processes have been put in place to track progress against the Improvement Plan. The ASP Improvement Plan – Action Plan is populated to identify the action required, the Current Position/Update, the identified responsible officer, the timescales identifying when the action was last revised and the current status. A reflective retrospective Adult Support and Protection (ASP) audit was completed across the four Localities of Argyll. The purpose of the audit was to identify the quality of practice and recording in Adult Support and Protection cases after the Joint Inspection of Adult Support and Protection. The audit highlighted that there was room for improvement in a number of key areas, including greater participation of key partners in case conferences. In addition, chronologies, risk assessments and the ‘three point test’ must be completed.
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7 Argyll & Bute Health & Social Care Partnership – Internal Audit Report – Adult Services-Adult Support and Protection, March 2024 3 Progress against improvement plan has been reported to relevant officer and/or Committees Audit Risk 2 Substantial Progress against the Improvement Plan is published and reported. The Improvement Plan is a standing agenda item at the Argyll and Bute Adult Protection Committee (APC) where progress and updates are provided. The APC is a multi-agency committee. In addition, the Council Officer Forum discuss the improvement areas outlined in the report. This forum is attended by various Council Officers. 18. Further details of our conclusions against each control objective can be found in Section 3 of this report. 3. Detailed Findings An improvement plan has been put in place 19. A joint inspection of the Argyll and Bute partnership took place between June 2021 and September 2021, with a report being issued in September 2021. The report required that the Argyll and Bute Partnership prepare an improvement plan to address the priority areas for improvement. A comprehensive improvement plan was developed in 2021 with the aim of improving activity in health and social care to make services better for the people who use them, including considering making services safer, more effective, more person-centred, more equitable and timelier. 20. The improvement plan identifies the key areas for improvement within the report, identifies barriers to improvement, outlines an action plan for improvement and details the monitoring process including how success will be measured. In addition, it identifies target dates for completion. 21. Argyll and Bute Adult Support and Protection Partnership (the Partnership) were required to submit to the Link Inspector, the Improvement Plan by November 2021 demonstrating that it addresses the priority areas for improvement identified within the report. In addition the Partnership were required to respond to a post inspection questionnaire which was also required to be submitted in November 2021. Both were submitted within the deadline. Recording and monitoring processes have been put in place to monitor progress against plan 22. Recording and monitoring processes have been put in place to track progress against the Improvement Plan. The Adult Support and Protection (ASP) Improvement Plan – Action Plan is populated to identify the action required, the Current Position/Update, the identified responsible officer, the timescales identifying when the action was last revised and the current status. The current status is recorded as a traffic light system - red, amber and green.
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8 Argyll & Bute Health & Social Care Partnership – Internal Audit Report – Adult Services-Adult Support and Protection, March 2024 23. A reflective retrospective ASP audit was completed across the four Localities of Argyll and Bute. The purpose of the audit was to identify the quality of practice and recording in ASP cases after the Joint Inspection of Adult Support and Protection. A sample of 40 case files which had ASP activity between March 2022 and April 2023 were randomly selected for audit review. 24. Significant progress has been made to address the key areas of improvement highlighted within the report specifically: • In terms of improvement, as per the requirements of the report, all relevant partners were invited to participate in case conferences and review case conferences. However, the final ASP Case File Audit 2023/24, dated 4 March 2023, noted that 100% of relevant parties were invited to attend the case conference, however, only 11% of files read considered that all relevant parties attended the case conference. The relevant parties invited but who did not attend include GP; Parkinson’s Nurse; Advocacy; Consultant Psychiatrist; Police; and Scottish Fire and Rescue. With more case conferences taking place online, this is considered to be the preferred option. It is now considered that increased ability for professionals to attend an online meeting might improve overall multi-agency attendance. • The report highlighted that the application of the ‘three-point test’ should be clearly documented during initial inquiry to show decision making rationale. Training courses, training materials and updated procedures which include information on the three point test have been made available. In addition, on Eclipse (the client record management database) there are three questions about each of the points of the three point test, these are all mandatory fields. There is also a supplementary text box for each to give details of the rationale for the answer to each of the three questions, these too are mandatory. Mandatory questions, if not answered, allow the user to fill in the form, however, the form cannot be submitted until all mandatory questions have been answered. From the 1st of April as a result of work currently being undertaken to update the forms and worklists on Eclipse, there will be a further mandatory question introduced “Does the person meet the criteria of the three point test”. The final ASP Case File Audit 2023/24, highlighted of 40 client records tested, the three-point test had been applied correctly in 87% cases. • In order to address the requirement that all adults at risk of harm should have a risk assessment, a newly devised comprehensive Risk Assessment (RA) document has been developed with the expectation that it is completed alongside the Eclipse IT documentation for all cases investigated. There is a requirement that the risk assessments must be completed for all ASP cases and submitted to a case conference 24 hours in advance. The final ASP Case File Audit 2023/24, noted that of the 40 client records tested, 57% of files had a risk assessment and of those, 96% of files were noted as having multi-agency involvement in the risk assessment, 9% of risk assessments were deemed to be weak, 31% were rated good and 30% very good. • Significant progress has been made to adopt a consistent approach to preparing and recording chronologies for all adults at risk of harm who require one, however it is noted that the implementation of a schedule of monthly peer review/ case file audit has been delayed due to workforce challenges. Quarterly scrutiny of inquiry and investigation
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9 Argyll & Bute Health & Social Care Partnership – Internal Audit Report – Adult Services-Adult Support and Protection, March 2024 documentation demonstrates that some workers continue to overlook this. The final ASP Case File Audit 2023/24 identified that of the 40 client records tested, there has been little improvement in chronologies within ASP recording with 53% of the audited cases not having a chronology when it was considered that there should have been one and of those with a chronology, 74% were to an acceptable standard. Training and guidance is in place and in addition all staff undertaking adult support and protection activity are aware that they are required to complete the Eclipse Chronology. ASP training has been further developed to ensure understanding and analysis of the 3 point test. A new second worker course aimed at Health workers as second workers has been created and trialled. The completion of useful Chronologies is a national issue, hence the creation of the National Implementation Group Chronologies of which the Lead Officer is a member. New learning and development materials are currently being identified nationally and training for all Argyll and Bute staff, involved in ASP recording, is currently being developed for use in 2024. • Scottish Fire and Rescue service and all other partners with a duty to cooperate are included in key stages of the adult protection processes when this is appropriate. The Multi-Agency Forum/Discussion (MAF/D) was established as part of Argyll and Bute Health and Social Care Partnership’s Adult Support and Protection Strategy. The overall aim of this group meeting is to have first line sight of individuals who come to the attention of services, including the police, ambulance, fire services, health or social care and housing and to provide a platform for multi-agency discussion to decide on the most appropriate response. Action Plan 1 Progress against improvement plan has been reported to relevant officer and/or Committees 25. Progress against the Improvement Plan is published and reported. The Improvement Plan is a standing agenda item at the Argyll and Bute Adult Protection Committee (APC) where progress and updates are provided. The APC is a multi-agency committee. We are advised that this is augmented by regular meetings with the link Inspector. 26. The Council Officer Forum discuss the improvement areas outlined in the report. This forum is attended by various Council Officers.
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Appendix 1 – Action Plan No Finding Risk Agreed Action Responsibility / Due Date Low 4 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. Adverse feedback from the follow up audit undertaken by the Care Inspectorate Adult services will facilitate an ASP audit on a six monthly basis to determine practice and compliance with ASP legislation and KPIs Head of Adult Services (Mental Health, Acute and Complex Care) 30 September 2024
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11 Argyll & Bute Health & Social Care Partnership – Internal Audit Report – Adult Services-Adult Support and Protection, March 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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12 Argyll & Bute Health & Social Care Partnership – Internal Audit Report – Adult Services-Adult Support and Protection, March 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.