2023_2024_InternalAudit_SSSCRegistration_Report_Final2
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 May 2024 FINAL High Medium Low VFM Number of Findings 1 1 4 0 Scottish Social Services Council (SSSC) Registration Audit Opinion: Substantial
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2 Argyll and Bute Council – Internal Audit Report – SSSC Registration, May 2024 Contents 1. Executive Summary ........................................................................................................................ 3 Introduction ............................................................................................................................................ 3 Background ............................................................................................................................................. 3 Scope ....................................................................................................................................................... 4 Risks ........................................................................................................................................................ 4 Audit Opinion ......................................................................................................................................... 4 Recommendations ................................................................................................................................. 4 2. Objectives and Summary Assessment ........................................................................................... 5 3. Detailed Findings ............................................................................................................................ 6 Appendix 1 – Action Plan ..................................................................................................................... 12 Appendix 2 – Audit Opinion ................................................................................................................. 16 Contact Details Internal Auditor: Mhairi Weldon Telephone: 01546 604294 e-mail: mhairi.weldon@argyll-bute.gov.uk www.argyll-bute.gov.uk
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3 Argyll and Bute Council – Internal Audit Report – SSSC Registration, May 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 Scottish Social Services Council (SSSC) Registration. 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. The SSSC are the regulator for the social work and social care workforce in Scotland, they protect the public by registering social care workers, social workers, social work students and children and young people workers in a range of care services including residential and day centres, community facilities and in people’s homes. The SSSC Register was set up under the Regulation of Care (Scotland) Act 2001 to regulate social service workers and to promote their education and training. 5. The SSSC set standards for work practices, conduct, training and education and supports professional development, their regulatory function means that services are provided by a trusted, skilled, confident and valued workforce. Where workers fail to meet the standards of practice and conduct required, the SSSC can investigate and take action. 6. Registration with the SSSC depends on the employee’s role and responsibilities of their post and formal qualifications must be achieved within the timeframe outlined by the SSSC. Employers and employees are legally bound by these requirements and therefore unable to provide registered services with unregistered staff. 7. The Council must meet the following responsibilities as set out within the SSSC Codes of Practice (prior to the new codes published on 1 May 2024): Make sure people are suitable to be social service workers and that they understand their roles and responsibilities Have the culture and systems in place to support social service workers to meet their code of practice Provide learning and development opportunities to enable social service workers to strengthen and develop their skills and knowledge Have written policies and procedures in place to protect people who use services and carers, and to support social services workers
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4 Argyll and Bute Council – Internal Audit Report – SSSC Registration, May 2024 Publicise and promote the Code of Practice for Social Service Workers to people who use services and carers and cooperate with SSSC in their proceedings 8. As at 01 November 2023, within the Health and Community Care service area of the Health and Social Care Partnership (HSCP) there are 386 employees, 314 of whom require to be SSSC registered. There are a further 270 employees within other service areas of the HSCP and 335 within Education nurseries and schools who also require to be SSSC registered. 9. The policies, procedures and processes to support SSSC requirements are standardised across all Council areas, a sample of care homes was selected to evidence the application of these and any areas of best practice identified or recommendations raised as a result of this review will be communicated across all relevant service areas. Scope 10. The scope of the audit was to assess the arrangements for evidencing SSSC registration, monitoring and renewals within the Council as outlined in the Terms of Reference agreed with the Head of Adults – Health & Community Care on 21 November 2023. Risks 11. The risks considered throughout the audit were: Audit Risk 1: The Council does not meet it responsibilities as set out in section 53 of the Regulation of Care (Scotland) Act 2001 and the SSSC Codes of Practice Audit Risk 2: The Council is unable to provide a full range of services required or provides services with unregistered employees 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 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 14. We have highlighted one high priority recommendations, one medium priority recommendations and four low priority recommendations where we believe there is scope to strengthen the control and governance environment. These are summarised below: Version control should be applied to the SSSC Registration Policy and Guidance Documents Corporate HR Policies, procedures and guidance documents should be reviewed to ensure content is up-to-date.
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5 Argyll and Bute Council – Internal Audit Report – SSSC Registration, May 2024 Service user documentation should be updated to advise that instances of violence, threats or abuse directed towards employees is not acceptable. The Supervision Policy should be reviewed and updated to ensure it incorporates up-to- date needs and requirements of service delivery. The updated Supervision Policy should be circulated to managers with an instruction to comply with the content in a consistent manner. The content of care home handbooks should be updated to ensure complaints contact details are consistently provided. 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 Appropriate policies and procedures have been prepared and communicated to guide management and employees in meeting the requirements as set out in the SSSC Codes of Practice. Audit Risks 1 & 2 Substantial Policies, procedures and guidance have been prepared and made available to all employees, however, some of these are overdue for review or lack application of version control. A comprehensive induction process is in place to guide employees in their new role in terms of duties and conduct, however, there was no information to service users regarding conduct towards employees and only one care home advised visitors of expected conduct in their handbook. 2 Processes are in place and being followed to ensure compliance with SSSC Codes of Practice. Audit Risks 1 & 2 Substantial Records of SSSC registration status are maintained both locally and online with the SSSC. Recruitment follows a robust and consistent corporate process with appropriate checks in place. The Supervision policy is dated November 2011, it is applied inconsistently across the care homes reviewed and requirements documented are considered to be resource intensive. Feedback is gathered from service users and employees and used to inform improvements, both on an individual and service level. A Social Work Training Board has been established to oversee training across all Social Work services to identify needs, discuss progress through SVQ
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6 Argyll and Bute Council – Internal Audit Report – SSSC Registration, May 2024 achievements and CPL requirements and monitor the assigned budget. Support is provided to managers and employees via corporate processes. 3 Reporting arrangements are in place to inform management of risks/issues identified that may require action to be taken. Audit Risks 1 & 2 Substantial Employees SSSC registration status is recorded both locally and on the SSSC database, these are monitored and updated by managers, HR provide a six- monthly SSSC Registration status report for Senior Management oversight. Concerns may be reported both informally and formally to management or via the Council’s “Whistleblowing” policy. Reporting arrangements are in place to notify the Care Inspectorate with staffing reports and referrals to SSSC where an employee is considered unfit to practice. 17. Further details of our conclusions against each control objective can be found in Section 3 of this report. 3. Detailed Findings Appropriate policies and procedures have been prepared and communicated to guide management and employees in meeting the requirements as set out in the SSSC Codes of Practice. 18. The Council’s Scottish Social Services Council (SSSC) Registration Policy and associated guidance have been prepared to support compliance with SSSC requirements and made available to all Council employees on the Council’s intranet site (The Hub) for those with a corporate email address and on the employee website (My Council Works) available to all. Printed copies are also made available at Council offices and residential locations. 19. The content of both documents is comprehensive, easy to use and outlines the duties of the employer and employee in terms of maintaining registration. These documents, however, are not dated and there is no evidence of any review date having been considered. Action Plan 1 20. There are several additional policies, procedures and guidance that also support compliance with SSSC requirements, most of which apply corporately and are prepared and updated by Human Resources (HR): Dignity at Work Policy (Bullying & Harassment) Equality & Diversity Policy Equality and Socio-Economic Impact Assessment Grievance Procedure Disciplinary Procedures and Code of Practice Managers guide to recruitment & Selection
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7 Argyll and Bute Council – Internal Audit Report – SSSC Registration, May 2024 Phased Return to Work and Other Reasonable Adjustments: managers guide Employee Code of Conduct Social Work Complaints Procedure These documents are comprehensive and provide specific information regarding SSSC requirements where appropriate, several of these documents, however, do not exhibit evidence of updates or review within either the stated or a reasonable timescale and some embedded links to source further information are no longer active. Action Plan 1 & 2 21. The Council also provides Health, Safety and Wellbeing services and resources as well as an Employee Assistance Programme for any employee to access should a need for specific support be identified. 22. Newly employed or transferring social workers/social care workers undertake an induction programme under the guidance of their new line manager. This is largely a corporate programme supplemented with service and location specific information. The specific roles and requirements of each post are articulated by managers and colleagues as well as being documented in the formal job descriptions and person specifications. 23. As part of the induction process, new employees are informed that bullying, harassment and discrimination is not tolerated and formal action under the Council’s Disciplinary Procedures and Code of Practice will be taken to deal with such behaviour. 24. In addition to the formal policies and procedures noted above, the Council also operates a Public Interest Disclosure (“Whistleblowing”) Policy whereby employees as well as the general public can bring their concerns regarding social workers/social care workers to the attention of management, including impairment of fitness to practice; exploitation, dangerous, discriminatory or abusive behaviour/practice or cause of physical, emotional financial or material harm/loss. 25. Social workers/social care workers are clearly informed that violence, threats or abuse are not acceptable via their terms and conditions of employment, employee codes of conduct and dignity at work policy. The Health and Social Care Standards advise service users and their family, friends and non-Council carers of the principles based quality of care they can expect to be provided. There is no content within these documents to acknowledge that violence directed towards employees from service users or their family, friends or non-Council Carers are not acceptable. The Resident and Family Handbook prepared for Ardfenaig does, however, advise visitors that their conduct should allow employees to undertake their duties free from threat or perceived threat of violence or intimidation. Action Plan 3 26. Policies, procedures and eLearning materials are in place and made available on both the Hub and My Council Works to support wellbeing and equality of social workers/social care workers and respect diversity.
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8 Argyll and Bute Council – Internal Audit Report – SSSC Registration, May 2024 Processes are in place and being followed to ensure compliance with SSSC Codes of Practice. 27. Line managers maintain a record of registration status relevant to their teams and have access to view the SSSC registration database for Council employees to help keep this up-to-date. The Council’s Human Resources (HR) team also have access to the SSSC registration database and conduct a six-monthly exercise to monitor status and identify any anomalies, this is then passed to Heads of Service for oversight and action as necessary. As at September 2023, there were 76 employees registered, 46 registered with conditions and one application submitted for registration within the Acute and Complex Care Service. 28. Recruitment of social workers/social care workers follows a robust process that is applied corporately using the TalentLink service. This ensures that a standardised approach is followed when filling a post following approval by management. Each post is advertised and short-listed by reviewing the application provided to assess suitability in terms of knowledge, skills, attitude and values, an interview panel of at least two persons is then appointed to select the successful candidate on a competitive basis. Information for managers regarding the recruitment process is available on the Hub to support this process. 29. Criminal conviction checks, membership of the Disclosure Scotland Protection of Vulnerable Groups (PVG) scheme and references are required as part of the recruitment process. A sample of ten employees was selected from the registration lists provided and checked to HR records where all ten were found to comply with the requirements. 30. The Council has a Supervision Policy in place to ensure high standards of professional care are maintained, areas for improvement are identified and employees are supported when undertaking their duties. The Policy provided is dated November 2011 with no evidence of review or update and evidence of compliance with the policy, where provided, was limited and inconsistent with the embedded templates. Discussions with two managers reveal that they are unable to fully comply with the requirements of the Policy and consider these to be unrealistic in terms of current available resources. Action Plan 4 & 5 31. Feedback is gathered from service users at residents or focus group meetings with representatives attending from the different staff groups to gather opinions and thoughts on the care and facilities provided and consider where service improvements can be made. Review meetings are also carried out for individual residents to gather feedback on more personal requirements to help inform revisions to care plans and specific individual needs. 32. Managers support employees to various extents depending on their specific training, continuous professional learning (CPL) needs and current operational demands. The various needs and opportunities for training are discussed collectively at staff meetings and individually at supervision meetings or during career conversations, observational monitoring also takes place to identify any additional areas for improvement or further training. SVQ assessors visit learners where possible or conduct interviews online using Teams. 33. Employees from other professions such as nursing or teaching are considered to be equally supported to meet the requirements as set out within their codes of practice. 34. There is a robust induction process in place for new employees with guidance provided both verbally and via access to formal documentation covering a range of both corporate and service
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9 Argyll and Bute Council – Internal Audit Report – SSSC Registration, May 2024 specific information. There are four stages to the induction process, each with specific goals to be met within the first few days, first week, six weeks and six months. 35. Training opportunities are available to permanent employees wishing to progress through formal SVQs and are tailored to their individual needs identified at recruitment or via supervision meetings and career conversations. 36. The Social Work Training Board has been established to oversee training across all Social Work and Social Care services. This Board identifies needs, discusses SVQ attainment progress and monitors the assigned budget to ensure service delivery is aligned with strategic priorities and staff are appropriately developed to meet their registration conditions and CPL requirements. Training opportunities focus on permanent employees, casual employees cannot be retained after five years without receipt of training to meet registration conditions resulting in loss of experienced employees. Discussions have taken place regarding provision of support to casual employees to obtain qualifications, however, with limited budget, permanent employees must be prioritised. 37. Managers and colleagues support employees who feel unable or unprepared to carry out their work wherever possible to ensure an acceptable standard of service is provided, this will vary from person to person. A corporate Performance Improvement Procedure has been prepared and made available to all on the Hub should a more formal approach be required. Protected conversations and allocation of a mentor to provide closer support may also be provided and where support of a more personal nature is required the employee and eligible family members have access to the Employee Assistance Programme (EAP) for independent and confidential support and information. 38. Reflective practice identifies development and improvement opportunities and takes place daily at hand-over between teams and at scheduled team meetings, supervision sessions and career conversations. 39. Employees who have experienced violence or trauma in the work place are provided with peer support and opportunities to talk about issues identified. Stress risk assessments are also used and an accompanying action plan prepared to manage future work. Where the experience has led to a period of employee absence, the corporate Phased Return to Work Procedure may be used and occupational health referrals made. The EAP may also be accessed to provide support in these circumstances. 40. Where an employee’s fitness to practice is considered to be impaired, they are provided with clear communications and documentation to ensure processes are followed through and wellbeing support is provided. In some instances the employee may be redeployed or suspended pending investigation and subsequent findings. 41. The care and safety of service users is prioritised while employees are receiving additional support and adhere to the Adult Support and Protection (Scotland) Act 2007 and the new Health and Care (Staffing) (Scotland) Act 2019 to ensure that “suitable qualified and competent individuals are working in such numbers as are appropriate for the health, wellbeing and safety of people using the service”. A staffing level calculation tool is used to ensure there are sufficient suitably qualified and competent employees present to provide services. 42. Copies of the SSSC Code of Practice are provided to employees as part of their induction process, made available within their service location and freely available on the SSSC website. All Social
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10 Argyll and Bute Council – Internal Audit Report – SSSC Registration, May 2024 Workers/Social Care Workers are required to read and comply with the content in addition to the content of the Registration Policy and guidance. 43. The SSSC Codes of Practice are available online and at care homes for service users and visitors to view. They are also advised that employees are appropriately qualified (or working towards a qualification), skilled and competent to carry out their duties and made aware that there is a complaints procedure in place to report any concerns. Two of the three handbooks provided contained details of how to communicate any concerns. Action Point 6 44. The Council’s Employee relations team provide support to lead managers via the corporate disciplinary process when concerns are raised about an employee’s fitness to practice. As part of this support, lead managers are provided with a suite of documents including templates and a worked example to ensure the process is conducted in a fair and consistent manner, they are also provided with guidance on when to refer the employee to the SSSC or other relevant professional body. Documentation reviewed indicated that the process had been followed accordingly. Managers are also able to contact the relevant professional body directly for specific advice prior to any referrals being made. 45. The Chief Social Worker is the first point of contact within the HSCP where the SSSC, other relevant professional body or authority require assistance when investigating an employee’s fitness to work, this could be in the form of documentation, attendance at hearings or responses to enquiries. Employees are enabled and supported to assist in these instances e.g. attend hearings or provide witness statements. Reporting arrangements are in place to inform management of risks/issues identified that may require action to be taken. 46. Management information regarding employee’s registration status is maintained locally via spreadsheets and online access to the SSSC registers. This information enables managers to ensure records reflect current employee status, monitor progress in meeting any conditions set and take action where registrations have or are about to expire. The Council’s HR service also undertake a six-monthly exercise to assess registration status and renewal position and flag individuals appearing on the list who no longer work for the Council. 47. Where allegations of harm or abuse are received, the Council’s formal disciplinary process is followed by management with support from the HR service and this includes appropriate investigation and reporting. 48. Employees may approach managers at any time to report and discuss concerns they may have regarding inadequate resources, difficulties in delivering care or inappropriate/unsafe working practices, they are also aware of the overarching management structure should they feel issues need to be escalated. The Council’s “Whistleblowing” policy provides an additional avenue for concerns to be reported. 49. Weekly notifications are submitted to the Care Inspectorate on staffing issues including absences and vacancies that may have an impact on service delivery. Any concerns are raised with senior management as they arise and are carefully monitored and managed via resident’s dependency analysis.
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11 Argyll and Bute Council – Internal Audit Report – SSSC Registration, May 2024 50. Managers are aware of their responsibility to make referrals regarding employees who are unfit to practice to the appropriate authorities and are fully supported by the Council’s HR Service to do so when the need arises.
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Appendix 1 – Action Plan No Finding Risk Agreed Action Responsibility / Due Date Low 1 SSSC Registration Policy and Corporate HR Policies and Guidance Documents 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 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. Management and employees may use superseded versions containing outdated information, legislation, regulations or standards. 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. HR Officer HR Manager - Operations 30 September 2024 Low 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 fail to provide further information to assist employees. Links provided in policy and guidance documents will be reviewed and updated where found to be no longer working. HR Manager - Operations 30 September 2024 Low 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. Lack of awareness that violence, harm or abuse directed at Council employees from service-users or their family, friends or non-Council carers is not acceptable. Review all social work and social care service user documentation in adult services. Senior Manager – Resources/ Professional Lead – Social Work 31 August 2024
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13 Argyll and Bute Council – Internal Audit Report – SSSC Registration, May 2024 No Finding Risk Agreed Action Responsibility / Due Date Recommendation: Service-user documentation should be revised to advise that instances of violence, threats or abuse directed towards employees is not acceptable. Medium 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. Supervision Policy does not reflect current SSSC or Council requirements. Develop a social work and social care supervision policy. Professional Lead – Social Work 31 August 2024 High 5 Compliance with Supervision Policy Finding: evidence of compliance with the supervision policy was limited and embedded templates were not being consistently used. Recommendation: Following review of the Supervision Policy, Managers should be reminded of the need to schedule supervision meetings with employees in advance and retain records in an appropriate and consistent format. Failure to comply with the Council’s Supervision Policy. Appropriate documentation will be provided following development of social work and social care supervision policy. Professional Lead – Social Work 31 August 2024 Low 6 Care Home Handbook Finding: Details of how to communicate concerns/complaints were provided in two out of three handbooks provided. Service users and visitors are unable to escalate unresolved concerns to the appropriate bodies. Review all care home complaints/concerns processes. Lead Nurse (Care Homes) 31 July 2024
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14 Argyll and Bute Council – Internal Audit Report – SSSC Registration, May 2024 No Finding Risk Agreed Action Responsibility / Due Date Recommendation: Review and update content of care home handbooks to ensure complaints contact details are consistently provided.
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15 Argyll and Bute Council – Internal Audit Report – SSSC Registration, May 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 – SSSC Registration, May 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.