2023_24_Learning+PhysicalDisabilityCarePackages_Report_FINAL
Argyll and Bute Council · 13 June 2024
Back to Audit and Scrutiny Committee — 13 June 2024 and its agenda
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Argyll and Bute Council Internal Audit Report April 2024 FINAL High Medium Low VFM Number of Findings 0 7 0 0 Learning and Physical Disability Care Packages Audit Opinion: (Reasonable)
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2 Argyll and Bute Council – Internal Audit Report – Learning and Physical Disability Care Packages April 2024 Contents 1. Executive Summary ........................................................................................................................ 3 Introduction ............................................................................................................................................ 3 Background ............................................................................................................................................. 3 Scope ....................................................................................................................................................... 4 Risks ........................................................................................................................................................ 4 Audit Opinion ......................................................................................................................................... 4 Recommendations ................................................................................................................................. 5 2. Objectives and Summary Assessment ........................................................................................... 5 3. Detailed Findings ............................................................................................................................ 7 Appendix 1 – Action Plan ..................................................................................................................... 12 Appendix 2 – Audit Opinion ................................................................................................................. 16 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 and Bute Council – Internal Audit Report – Learning and Physical Disability Care Packages April 2024 1. Executive Summary Introduction 1. As part of the 2023/24 internal audit plan, approved by the Audit & Scrutiny Committee in March 2023, we have undertaken an audit of Argyll and Bute Council’s (the Council) system of internal control and governance in relation to Learning and Physical Disability Care Packages. 2. The audit was conducted in accordance with the Public Sector Internal Audit Standards (PSIAS) with our conclusions based on discussions with council 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 Council. 3. The contents of this report have been agreed with the appropriate council 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. Learning Disability services provide essential person centred support for individuals by helping people with learning disabilities and complex conditions to access and continue education and development, paid employment opportunities, life skills development and meaningful activities, achieve their desired outcomes and become more involved in their communities. They also promote and support independent living skills. 5. Providing effective support for people with learning in ways that address their personal outcomes is a priority for the HSCP. However, with a shrinking population, recruitment and retention of health and social care staff and rurality of Argyll and Bute, this presents many challenges to the delivery of services. Whenever possible, the HSCP support people to live healthily and well within their local communities, with their families and friends. 6. Care Management is a term applied to an approach to intervention whereby a professionally qualified social work officer undertakes assessment, planning, monitoring and reviewing activity. The assessment process for services involves engaging and communicating with individuals to identify their strengths, needs, risks, capacity and aspirations with a view to determining how social work intervention could assist in meeting desired outcomes. Central to the process is the collation, analysis and interpretation of information. This approach has a strong focus on managing risk, the use of specific interventions and /or significant complexity will exist e.g. legal matters. It is only applicable to people who are most vulnerable, have complex or frequently changing needs or who present public protection concerns. 7. There are approximately 377 Adults living with a learning disability and/or autism spectrum diagnosis known to Argyll & Bute Health and Social Care Partnership (HSCP) within Argyll and Bute. Both nationally and locally the number of people with learning disabilities living into older age is increasing, with many presenting with a diverse range of complex and multiple interrelated health conditions. This growing population with complex health needs brings about
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4 Argyll and Bute Council – Internal Audit Report – Learning and Physical Disability Care Packages April 2024 new challenges for health professionals and social care services. The planning and provision of quality health and social care is crucial to improving the health and quality of life of people with learning and physical disabilities across Argyll and Bute. In addition the Council faces challenges, particularly in more rural locations due to the limited number of care providers who are able to provide the required services. 8. A defined amount of money is set aside in the budget for the provision of care services and resources are allocated according to a priority of needs. There are currently 63 Learning Disability/Physical Disability and Mental Health packages in excess of £100k per year and for the financial year ended 31 March 2023 this amounted to approximately £9.190m, just under half of the overall £20.206m spent on care packages in 2022/23. 9. There are currently 50 individuals placed out with Argyll and Bute with care packages totalling approximately £5 million per annum. Compared to a number of other local authorities there is likely to be a higher number of out of area placements due to the lack of service provision across the Council’s remote and rural geographic area. Scope 10. The scope of the audit was to review of the management and governance of learning disability high cost packages as outlined in the Terms of Reference agreed with the Head of Adult Services (Mental Health, Acute and Complex Care) on 30 August 2023. Risks 11. The risks considered throughout the audit were: SRR07: Failure of the HSCP to deliver on its Strategic Priorities results in deteriorating health and wellbeing outcomes for the population and / or reduced access to appropriate health and social care services. This could also result in financial and reputational risk to the Council Audit Risk 1: Failure to meet our statutory requirements Audit Risk 2: Failure to provide an effective assessment and review process Audit Opinion 12. 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. 13. 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.
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5 Argyll and Bute Council – Internal Audit Report – Learning and Physical Disability Care Packages April 2024 Recommendations 14. We have highlighted 7 medium priority recommendations where we believe there is scope to strengthen the control and governance environment. These are summarised below: Policies and procedures should be reviewed to ensure they are up to date, relevant and reflect the new practices within Eclipse; An induction pack is in the process of being developed and this will include an introduction to policies and procedures. The induction pack should be completed and circulated to all new staff; Staff should be reminded of the importance of keeping case notes and contact notes up to date; Client records should be maintained in a consistent way across the Council, minimising the number of locations where records are maintained. The Business Case for the roll out of the client record keeping project onto CIVICA, with links provided in Eclipse should be implemented; Robust measures should be put in place for the decision making processes for allocating resources for Learning Disability Care packages, including processes for recording those decisions; Systems, processes and commissioning contracts must be put in place to ensure the equity of access to personal care services for Learning Disability Services; A robust system of identifying and recording unmet needs with regards to Learning Disability clients should be put in place. 15. 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 16. 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 Care Assessment policies and procedures are in place SRR07 Audit Risk 1 Audit Risk 2 Reasonable Care Assessment policies and procedures are in place with a number of key documents provided for review, although these may not refer current practice and refer to Carefirst. Assessment and Care Planning Procedures’ (V1) details that the purpose of the policy, procedures and practice guidance is to improve outcomes for service users and carers by providing clear guidance for social work staff about assessment and planning with individuals. This guidance applies to community services service users and is applicable
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6 Argyll and Bute Council – Internal Audit Report – Learning and Physical Disability Care Packages April 2024 across all settings. An induction pack is in the process of being developed and this will include an introduction to policies and procedures. 2 All cases have been assigned a Case Manager and case reviews are being undertaken in accordance with policies and procedures Audit Risk 2 Reasonable High value care packages generally relate to those who require lifelong support either in a residential setting or supported within their communities, therefore there is very little change to their care packages. Both nationally and locally the number of people with learning disabilities living into older age is increasing, with many presenting with a diverse range of complex and multiple interrelated health conditions. Case reviews are undertaken when there is significant changes to the client’s care needs. Children with Learning Disabilities are provided with a full care assessment when they move to Adult Services. We reviewed a 9% sample size of Learning Disability high value care packages. Clients are assigned a case manager, although heavy reliance is placed on the care providers reporting and updating the case manager on a regularly basis. Where case managers were not assigned, this was due to the allocated Social Worker moving on to different positions and the case was assigned to the specific team for Learning Disability. Case notes are maintained on Eclipse, the replacement client database for Carefirst. It was noted that case notes were not always maintained and up to date. A previous audit report highlighted the fact that client records were stored in multiple locations, including on the Council’s network drive. Evidence obtained during the audit suggests that client records are still being maintained on the network drive with historical records stored in orange client files. A pilot project in the Mid Argyll area was undertaken to scan records onto CIVICA, which would have links from Carefirst (now Eclipse). 3 Resources are allocated in SRR07 Audit Risk 1 Reasonable A Resource Allocation framework is in place based on a prioritisation of needs
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7 Argyll and Bute Council – Internal Audit Report – Learning and Physical Disability Care Packages April 2024 accordance with policies and procedures and reviewed on a regular basis process. The prioritisation of all referrals is based primarily on the information received at the time of referral including any relevant background information held on CareFirst/Eclipse and is prioritised according to risk. We were provided with a Terms of Reference for the “Adult Care Allocation Group (ACAG)”. The main objective for the group is to review and approve total cost packages for both existing and new cases over 29 hours per week. However, we were advised that this group has been suspended as it was felt there was no added value to having a single ACAG as the majority of Learning Disability care packages were already over the threshold, and the wider ACAG members had no expertise or input in Learning Disability. In addition, how and where the decisions on resource allocations are taken and recorded has not yet been confirmed. Due to the pressures commissioning, Learning Disability have requested that a small number of packages be placed on the unmet need/waiting list for Care at Home services where they require personal care only. This has not yet been agreed by management and at present there is no overview of the total unmet need and available resources across each of the localities, we have been advised that services are working in silos. 4 Roles and responsibilities have been documented and assigned Audit Risk 2 Substantial Roles and Responsibilities are outlined in the various policies and procedures. The “Assessment and Care Planning procedures” outlines the roles and responsibilities for each of the staff categories. 17. Further details of our conclusions against each control objective can be found in Section 3 of this report. 3. Detailed Findings Care Assessment policies and procedures are in place
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8 Argyll and Bute Council – Internal Audit Report – Learning and Physical Disability Care Packages April 2024 18. Care Assessment policies and procedures are in place with a number of key documents provided for review, however, these may not refer current practice and make reference to Carefirst (the Council’s client record management system), which has now been replaced by Eclipse. 19. Assessment and Care Planning Procedures’ (V1) details that the purpose of the policy, procedures and practice guidance is to improve outcomes for service users and carers by providing clear guidance for social work staff about assessment and planning with individuals. This guidance applies to community services service users and is applicable across all settings. It states that it should be adopted by all staff. 20. The Assessment and Care Planning Procedures (V1) covers a broad range of information from descriptions of terminology, explanations of care management and what it should achieve, approaches to monitoring and review, team review, service co-ordination. It documents the procedures to be followed from the referral stage in the process. It advises what information should be recorded and how it should be recorded on Carefirst, including how ongoing records are maintained. An additional policy: Recording & Reflective Practice Policy, Procedures & Standards was available to review. The aim of this document is to provide clear and concise information which outlines the approach to recording and reflective practice by the Social Work service. 21. A further policy entitled “Funding High Cost Care at Home Packages Procedural Guidance for Staff and Managers” was available for review. This is Version 2, dated December 2021. It details that the eligibility criteria for service is based on the identified needs of the assessment matched to the prioritisation framework. Action Plan 1 22. Staff have access to relevant policies and procedures, including access to relevant training. All staff have a session with the Carefirst/Eclipse support team to learn to navigate their way through the systems. There are guidance notes available on SharePoint and a generic email address for any requests for support staff may have. The Learning Disability Day Services/ Resource Centres redesign resulted in an action plan being drawn up, this included a training plan being identified. 23. We were advised that over the years, the finance team have provided advice and guidance on the management of budgets for packages, mainly for Team Managers. From a Social Work perspective, training on Self Directed Support has been delivered and this is as and when required. This focuses on outcomes for individuals and how those outcomes are being met. 24. An induction pack is in the process of being developed and this will include an introduction to policies and procedures. There is an expectation that trained staff will know the theories behind assessment, review and legislation, however, the induction process will assist new staff members to understand the systems and processes within the Council. Action Point 2 All cases have been assigned a Case Manager and case reviews are being undertaken in accordance with policies and procedures
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9 Argyll and Bute Council – Internal Audit Report – Learning and Physical Disability Care Packages April 2024 25. High value care packages generally relate to those who require lifelong support either in a residential setting or supported within their communities, therefore there is very little change to their care packages. Both nationally and locally the number of people with learning disabilities living into older age is increasing, with many presenting with a diverse range of complex and multiple interrelated health conditions. Case reviews are undertaken when there is significant changes to the client’s care needs. Children with Learning Disabilities are provided with a full care assessment when they move to Adult Services. 26. We reviewed a 9% sample size of Learning Disability high value care packages, this included cases within residential settings, placed out with the authority and cases looked after within the community in Argyll & Bute. Clients are assigned a case manager, although heavy reliance is placed on the care providers reporting and updating the case manager on a regularly basis. Where case managers were not assigned, this was due to the allocated Social Worker moving on to different positions and the case was assigned to the specific team for Learning Disability rather than a named case manager. Care providers are advised to allow regular contact and updates to be provided. During testing we were advised that some providers will update on a weekly basis, even if this is just to advise that all is well. 27. Regular contact is maintained with care providers and where the placement is out with the authority, 6 monthly reviews are undertaken with the Social Worker travelling to the residential unit to undertake the review. 28. Case notes are maintained on Eclipse, the replacement client database for Carefirst. It was noted that case notes were not always maintained and up to date. However, reassurance was provided that this was due to capacity and that although not updated regarding contact notes, regular contact was maintained with providers. Action Plan 3 29. A previous audit report highlighted the fact that client records were stored in multiple locations, including on the Council’s network drive. Evidence obtained during the audit suggests that client records are still being maintained in multiple locations, including on the network drive with historical records stored in orange client files. A pilot project in the Mid Argyll area was undertaken to scan records onto CIVICA (the Council’s document management system), which in turn would link to CareFirst – now Eclipse. This project was considered to be a success and there is a strong opinion that it should be rolled out to the rest of the Council areas. A proposal has been submitted requesting funding in order to roll this project out, firstly across Social Work Services, then when completed across Health. Action Plan 4 Resources are allocated in accordance with policies and procedures and reviewed on a regular basis 30. A Resource Allocation framework is in place based on a prioritisation of needs process. The prioritisation of all referrals is based primarily on the information received at the time of referral including any relevant background information held on CareFirst/Eclipse and is prioritised according to risk.
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10 Argyll and Bute Council – Internal Audit Report – Learning and Physical Disability Care Packages April 2024 31. We were provided with a Terms of Reference for the “Adult Care Allocation Group (ACAG)”. The main objective for the group is to review and approve total cost packages for both existing and new cases over 29 hours per week and above for any cases falling into one of the following categories: Adult Social Care (includes all Self Directed Support options and residential care for under 65’s) NHS Complex Clinical Care – following approval at the Argyll and Bute NHS Complex Clinical Care Group Complex care We were advised that this group has been suspended as it was felt there was no added value to having a single ACAG as the majority of Learning Disability care packages were already over the threshold, and the wider ACAG members had no expertise or input in Learning Disability. It was felt that all the required expertise to make decisions on high cost care packages for Learning Disability sat with the new CRG, along with the appropriate budget holders. Learning Disability also have an additional Complex Care Group meeting where care packages are requesting an element of funding from Health. In addition, how and where the decisions on resource allocations are taken and recorded has not yet been confirmed. Action Plan 5 32. 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 (majority in rural areas where it’s difficult to commission). We were advised that the question regarding prioritisation of personal care in each locality has been raised several times over the last few months. Due to the pressures on both sides for commissioning, Learning Disability have requested that a small number of packages be placed on the unmet need/waiting list for Care at Home services where they require personal care only. This has not yet been agreed by management. A paper was submitted to management for comment and response in November but there has been no feedback as of yet. Action Plan 6 33. 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. This data is available on the HSCP SharePoint site. The data for Learning Disability is not currently recorded formally and not included in the above, increasing the risk that individuals remain in the community without the required support in place to meet their needs, particularly around personal care needs. At present there is no overview of the total unmet need and available resources across each of the localities, we have been advised that services are working in silos. Action Plan 7 34. The Coming Home Implementation Report, published by the Scottish Government, focusses on improving care for people with complex needs and learning disabilities. As part of the Coming Home Implementation work, the Scottish Government is working to improve monitoring of the
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11 Argyll and Bute Council – Internal Audit Report – Learning and Physical Disability Care Packages April 2024 experiences of people with learning disabilities and complex care needs who are in hospital, who are in out-of-area placements and/or whose current support arrangements are at risk of breaking down. This is to avoid people living in hospitals or in inappropriate out-of-area placements that they and their family have not chosen. Through the Coming Home Implementation Memorandum of Understanding between the Scottish Government and COSLA, it has been agreed that Integration Authorities will use and operate a local Dynamic Support Register. The Dynamic Support Register is designed to improve outcomes. The Register records information about people with learning disabilities and complex care needs who are in hospital, in out-of-area placements or whose current support arrangements are at risk of breaking down. The HSCP reports data quarterly from their Register using a new national reporting process delivered by Public Health Scotland (PHS). Roles and responsibilities have been documented and assigned 35. Roles and Responsibilities are outlined in the various policies and procedures. The “Assessment and Care Planning procedures” outlines the roles and responsibilities for each of the staff categories, including Service Managers/ Area Service Managers/Team Leaders, First Line Managers, Practitioners and Administration staff. Financial processes and budget information is provided in the document with guidance on responsibilities for budgets outlined.
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Appendix 1 – Action Plan No Finding Risk Agreed Action Responsibility / Due Date Medium 1 Policies and Procedures Care Assessment policies and procedures are in place with a number of key documents provided for review. The documents provided refer Carefirst. With the implementation of the new client database recording system – Eclipse these require to reviewed and updated. Policies and procedures may not reflect current practice Policies and procedures to be updated as part of the Eclipse Implementation Program Head of Strategic Planning, Performance and Technology 30 June 2024 Medium 2 Induction Pack Staff have access to relevant policies and procedures, including access to relevant training. All staff should have a session with the Carefirst/eclipse support team to learn to navigate their way through the systems. An induction pack is in the process of being developed and this will include an introduction to policies and procedures. New staff may not be aware of how to access policies and procedures leading to inconsistencies in practice Incorporate Eclipse Training into the HSCPs induction program Facilitate training sessions as part of the Eclipse Implementation Program Head of Strategic Planning, Performance and Technology 30 June 2024 Medium 3 Case Notes Case notes are maintained on Eclipse, the replacement client database for Carefirst. It was noted that case notes were not always maintained and up to date. Records not maintained and up to date Record keeping session(s) to be delivered by professional lead Senior Managers to implement case note audit within their respective services – this should be linked to individual practitioner supervision Senior Managers (Adult Services) 30 June 2024
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13 Argyll and Bute Council – Internal Audit Report – Learning and Physical Disability Care Packages April 2024 No Finding Risk Agreed Action Responsibility / Due Date Medium 4 Client Records A previous audit report highlighted the fact that client records were stored in multiple locations, including on the Council’s network drive. Evidence obtained during the audit suggests that client records are still being maintained in several locations. A successful pilot project was run in Mid Argyll transferring all records onto CIVICA. A proposal has been submitted to roll this out across all other areas in Argyll. Lack of consistency in the recording of client records which may lead to inaccurate record management or loss of information Ensure that a standardised and compliant electronic recording system is implemented across HSCP services – this should be achieved via the Eclipse Implementation Program Head of Strategic Planning, Performance and Technology 30 June 2024 Medium 5 Resource Allocation Group We were provided with a Terms of Reference for the “Adult Care Allocation Group (ACAG)”. We were advised that this group has been suspended as it was felt there was no added value to having a single ACAG as the majority of Learning Disability care packages were already over the threshold, and the wider ACAG members had no expertise or input in Learning Disability. In addition, how and where the decisions on resource allocations are taken and recorded has not yet been confirmed. Inconsistencies in allocation or resources and a lack of transparency of resource allocation decisions Develop a Terms of Reference for the Acute and Complex Care directorate’s Care Allocation Group that meets fortnightly and is chaired by the Head of Service Head of Adult Services (Complex and Critical Care) 30 June 2024 Medium 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. Inequity of service provision 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. Head of Adult Services (Health & Community Care) Chief Finance Officer 30 June 2024
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14 Argyll and Bute Council – Internal Audit Report – Learning and Physical Disability Care Packages April 2024 No Finding Risk Agreed Action Responsibility / Due Date Medium 7 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. Clients’ needs may not be met Include the data re unmet need for those under 65 in the weekly reporting format already in place for Older People Head of Strategic Planning, Performance and Technology Head of Adult Services (Health & Community Care) 30 June 2024
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15 Argyll and Bute Council – Internal Audit Report – Learning and Physical Disability Care Packages April 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 council to achieve better value for money (VFM).
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16 Argyll and Bute Council – Internal Audit Report – Learning and Physical Disability Care Packages April 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.