Appendix B

INTERNAL AUDIT REPORT

Case Management: Intensive Housing Management Service 2019/20

Date: 15th August 2019 Issued to: Keith Aubrey – Director for People and Communities

Author: Trevor Croote Aysha Rahman - People Manager

Dawn Garton - Director of Corporate Services (s151 Officer)

Adele Wylie – Director of Legal and Governance (Monitoring Officer) (final report)

Edd de Coverly – Chief Executive (final report)

2

Case Management: Intensive Housing Management 2019/20 Executive Summary

1. Introduction and overall opinion In 2015 Leicestershire County Council withdrew financial support for Housing Related Support Services in Melton. The Council decided that it wanted to continue providing support to local residents and embarked on a project to re-design the service and develop a new model of Intensive Housing Management (IHM), largely funded through charges to service users together with a contribution from the Housing Revenue Account (HRA) capped at £30k. It should be noted that there have been major staffing and organisational changes since 2015 and none of the senior managers involved in the initial development and design of the current IHM service are still working for the Council.

Based on interviews and review of documentation, there is no clear service plan or specification setting out the services provided or expected outcomes. Staff within the IHM team are committed and conscientious but the lack of a clear service plan, operational procedures or robust performance monitoring makes it difficult to demonstrate that the Council is delivering an efficient and effective service. The IHM team provides a broad range of support services to over 500 residents covering both tenancy and welfare related matters. However, supervision and management is relatively light-touch and there is no evidence of any formal assessment of workload or resources to ensure sufficient capacity and skills are available to deliver the service to an appropriate and consistent standard.

Case records are largely paper based although plans are in place to migrate all records to the ECINS case management system in future. All welfare visits, incidents and tenancy issue are recorded in note form but there is no standard or systematic approach to needs assessment, support planning or case review. IHM records are not included in the corporate information asset register and there is no evidence of a formal approach to document retention.

Gross costs have increased by over 27% since the IHM service was introduced in 2015, although overall expenditure has remained within budget and the HRA contribution cap has not been exceeded. For the 2019/20 budget, net costs have increased to £42k but the HRA cap has been achieved after £29k recharges to the General Fund. The rationale or basis of these recharges has not been explained.

A number of recommendations have been made to address the individual issues identified in this audit, although a more fundamental service review may be preferred to revisit the initial project in the light of current priorities and related service developments. The action plan in this report could then be used to inform the service review project.

The audit was carried out in accordance with the agreed Audit Planning Record (APR), which outlined the scope, terms and limitations to the audit. The auditor’s assurance opinion is summarised below:

Internal Audit Assurance Opinion

Control environment Limited Assurance

Compliance Satisfactory Assurance

Organisational impact Moderate

Risk Control environment

Compliance Recommendations

H M L

Risk 1 - Case management arrangements do not support the delivery of effective outcomes for service users.

Limited Assurance

Satisfactory Assurance

2 7 2

Risk 2 - Performance and financial management arrangements do not demonstrate value for money.

Limited Assurance

Satisfactory Assurance

1 5 0

Total Number of Recommendations 3 12 2

3

2. Summary of findings

Risk 1 - Case management arrangements do not support the delivery of effective outcomes for service users. Clearly defined services and expected outcomes Establishment of the current Intensive Housing Management Service was approved by the Policy, Finance and Administration (PFA) Committee on 27th January 2015. The report provides a summary of the key issues, proposed fees and overall financial implications of the new service. The overall objective is stated as being management of the needs of tenants who have vulnerability issues ensuring they remain independent for as long as possible and sustain their tenancies. It refers to provision of a lifeline service, daily access to a dedicated officer at sheltered housing schemes and fortnightly visits to all other properties. However, the report does not provide a detailed service specification or set any measurable targets or objectives (see recommendation 1). There is reference in the report to a number of housing management tasks that are eligible for housing benefit, but no detailed specification of the actual services to be provided by IHM officers. There is recognition, however, that existing staff will need to be “up skilled” to deliver the new services. The report also recommends continuation of the task group ensuring a six monthly review takes place to evaluate the effectiveness of the new service. There is no evidence, however, that a formal review has been undertaken. Gretton Court was not initially affected by the 2015 review as it is an extra care facility and was being reviewed separately by Leicestershire County Council. Gretton Court subsequently became part of the IHM service when the county council withdrew support for the housing related services there in 2017. A brochure and handbook in respect of Gretton Court are published on the Council’s website but have not been updated since 2014 and do not accurately reflect the current service provision (see recommendation 1). In practice, the IHM team provide a very broad range of services covering both personal welfare and tenancy related matters, including:

Personal needs assessments and support planning;

General welfare visits and calls;

Assistance with medical issues and appointments;

Responding to incidents and emergencies;

Referrals to other agencies and services;

Property viewings and tenancy sign-ups;

Lifeline equipment installations, programming and testing;

Liaison with lifeline call centre and provision of responder information;

Repairs logging and follow-up;

Assistance with housing benefit and universal credit claims;

Monitoring and follow-up of rent and council tax arrears, including agreeing payment arrangements;

Dealing with anti-social behaviour;

Fire safety checks, risk assessment and tests (sheltered schemes);

Assisting with property adaptation and assistive technology requests;

Property condition inspections; and

General health and safety checks (sheltered schemes) etc. There is an element of overlap between the IHM service and services provided by other teams, such as Customer Services, Me and My Learning, Housing and Communities and Housing Assets. How the teams work and link together is currently under review as part of departmental restructuring proposals.

4

Access to services is managed through the Choice Based Lettings Allocations Policy and process administered by the housing options team. Properties are advertised as being suitable for people with support needs and any relevant eligibility criteria applied during the short-listing. Property adverts and offer letters make clear that an additional support charge will be included in the rent but do not provide details of the specific services provided. Based on discussion with officers and review of case files, it is apparent that Gretton Court residents benefit from additional services such as organised social activities and events that are not provided at other sheltered schemes but are subject to the same charge. In addition, some residents have opted out of all support services but continue to be liable for the additional charge. This raises questions regarding consistency and fair charging (see recommendation 1). Operational procedures Documentation of operational procedures is good practice to support service quality, consistency and resilience in the event of unexpected staff absence. Based on discussion with officers, there are no documented procedures for the IHM service. A number of standard forms and checklists have been used in recent years but there is no current standard document set or templates in consistent use across the service (see recommendation 2). In particular, needs assessment and support planning is relatively informal and unstructured. Formal support agreements are prepared for all new IHM tenancies and include a needs assessment and referral section. However, this section is rarely completed or clearly linked to support or referral decisions (recommendation 3). Staff and structures As noted above, the People and Communities Directorate is currently undergoing a restructure and responsibility for the IHM service has been transferred from the Housing and Communities Manager to the People Manager. Original plans were for the IHM Service to report to the Case Management Lead but this has reverted to a separate team reporting to the IHM Team leader. In addition to the team leader, the team consists of seven Intensive Housing Officers (5.25 full time equivalents) plus a number of catering, cleaning and ancillary staff (6.33 full time equivalents). Interviews were held with a sample of IHM officers and job descriptions were obtained to determine experience and qualification requirements. Based on interviews it is clear that the IHM officers are committed and conscientious but all expressed concerns regarding the breadth of work and high caseload. Anecdotally, it was felt that insufficient time was available to deliver all aspects of the job to an appropriate standard and that the frequency of welfare visits and quality of documentation had reduced as a result. Officers confirmed that no formal workload or capacity analysis has been completed. A simple analysis was undertaken by Internal Audit and indicated a highly variable caseload ranging from 38 cases to 233 cases per full time equivalent (FTE) – see table 1. Table 1 – Caseload Analysis

IHM Post Scheme FTE Caseload Caseload per FTE

Post 1 Bradgate Flats 1.00 136 136

Post 2 Granby House 1.00 112 112

Post 3 Wilton Court 1.00 118 118

Post 4 Not scheme based 0.60 135 225

Post 5 Not scheme based 0.49 114 233

Post 6 & 7 Gretton Court 1.18 45 38

5

Based on the above caseload and recorded visiting frequency, Internal Audit has estimated that staff undertaking welfare visits could be spending between 50% and 75% of their time on this activity alone. Given the broad range of services provided, there is evidence that staff concerns regarding capacity are likely to be justified. However, this takes no account of the caseload mix in terms of complexity and relative location. Nevertheless, a more formal and detailed caseload and capacity analysis should be undertaken to ensure equity and inform future decisions on service design and resource requirements (recommendation 4). IHM Officers are grade five posts and job descriptions confirm the broad range of tasks and activities required of the role, covering both tenancy and welfare/case management responsibilities. Current members of the team have a mix of skills and experience and some stated that they find it difficult to fulfil all aspects of the role effectively. The person specification for the role requires a minimum of two years’ experience in supported housing or housing management and a minimum of two GCSEs in English and Maths or an appropriate qualification in supported housing. No experience or qualifications in case management, needs assessment or support planning are required. However, officers stated that, in practice, a minority of cases are likely to require a full needs assessment and support plan with most service users requiring relatively low-level support. Nevertheless, if the role of IHM officers continues to include a significant element of case management responsibilities, this should be reflected in the job description and person specification in future and existing staff should be provided with relevant training and support where necessary (recommendation 5). Supervision and review Based on interviews with a sample of IHM officers, staff feel well supported and were generally positive about the way they are managed. In practice, supervision and management is relatively light-touch with staff managing their own workload and priorities. There are no routine one-to-one supervision meetings, sampling of case files, formal case reviews or case observations undertaken by the team leader. Supervision and management of the quality of service relies on informal but regular communications between the team leader and individual members of the IHM team. In addition, complex or difficult cases are escalated to the team leader when required. Development of a more formal supervision and review regime would provide a firmer basis for management of the service (recommendation 6). There are currently no team meetings within the service. Individual members of the team rely on their own informal networks and working relationships to share information, advice and ideas. No concerns were expressed amongst members of the team about the lack of team meetings, primarily due to work pressures and time constraints. However, periodic team meetings can provide a useful opportunity to share corporate messages, reflect on priorities and working practices, share good practice and deliver any service-wide training requirements (see recommendation 7). Case recording All service users have an individual case file, most of which are currently paper based and located either in Parkside or on site at the sheltered schemes. Plans are in place to transfer all records to the ECINS electronic case management system. However, only a minority of cases have been transferred so far and no firm target has been established to complete the migration process. All staff have been trained in use of the new system and support has been made available to assist with the set-up and transfer of files. However, based on interviews with a sample of staff, not all were aware of the availability of this support (see recommendation 8). All welfare visits, issues and incidents are recorded in narrative form within the paper file or ECINS system. Daily calls at sheltered schemes are not recorded unless there are any significant matters to note. Issues related to housing benefit, rent arrears, property repairs or council tax are recorded on the Northgate system. However, based on discussion with officers and review of a sample of case files, there is no standard or systematic approach to undertaking, recording or evidencing the needs assessment and support planning process. Those cases that did

6

have an assessment and support plan on file related to tenancies that commenced prior to the current IHM service being established and there was no evidence of periodic review or re-assessment of needs (see recommendations 9 and 10). In general, case records varied in quality and completeness with no indexation or logical order to the files. However, in most cases there was clear evidence of recording of visits, key issues and incidents, including any necessary follow-up action. In addition, there was evidence that visits had been conducted in accordance with the agreed frequency in most cases. Nevertheless, there is scope to improve the quality and consistency of records and documentation. In two cases the documentation appears to have been prepared after the cases had been selected for audit despite the tenancies having commenced in 2018. The migration of case records to the ECINS system, together with the development of operational procedures (recommendation 2) and periodic case reviews undertaken by the team leader (recommendation 6), should help to address this issue. Data security and protection The Council has a corporate Information Governance and Risk Policy that applies to all service areas, together with document retention and other guidance and information for officers. A detailed audit of compliance with General Data Protection Regulations (GDPR) was carried out and reported in December 2018 and has therefore not been revisited as part of this audit. However, a high level review of overall arrangements specifically related to IHM data has been undertaken. As noted above, case records are currently held both in paper and electronic form, although the majority are currently paper files held at the main council offices at Parkside or on site at the sheltered schemes. All files contain sensitive personal information and are therefore within the scope of GDPR requirements and paper files are inherently more vulnerable to data breaches. However, officers stated that all paper files are kept in locked cabinets within buildings with controlled access. Plans to transfer all records to the ECINS system should reduce the risk of future data breaches. Based on discussion with officers, there is currently no formal approach within the IHM team to compliance with data retention requirements. Some files contain information and documents going back several years and there are no periodic arrangements to ‘weed’ and dispose of appropriate documents. Furthermore, IHM records are not included in the corporate information asset register which increases the risk that appropriate controls and assurances may not be in place (see recommendation 11). Based on the above findings, the assurance rating for the design of controls to mitigate this risk is Limited Assurance, primarily due to the lack of service specification, operation procedure or formal supervision and review arrangements. The assurance rating for compliance with controls is Satisfactory Assurance. Risk 2 - Performance and financial management arrangements do not demonstrate value for money. Performance measurement and reporting The Council’s approach to strategic planning focusses on development and monitoring of the corporate delivery plan. As such, whilst the corporate delivery plan establishes a range of key priorities and objectives for each directorate, there are no detailed service plans or objectives for individual service areas. At directorate level, the Council has a number of projects and activities linked to each corporate priority. For the People Directorate, the key priorities and project that have a direct impact on the IHM service are shown in table 2 below.

7

Table 2 – Extract from corporate and directorate delivery plans

Corporate priority Directorate project / activity Target date

PP3 Independent Lives – Focussing on our priority neighbourhoods, support people to overcome disadvantage and live well independently.

28 – Ensure residents are appropriately supported within a robust and flexible approach to case management.

March 2019

In addition to the delivery plan, there are a range of corporate and service based performance indicators linked to each corporate priority. Progress against the delivery plan projects and corporate performance indicators is reported to Cabinet on a quarterly basis. The latest report to Cabinet in June 2019 provided a performance update for quarter four of 2018/19 and rated the case management project as green (on track and progressing well), albeit the target implementation date had passed and the narrative explained that the project was still in a transitional stage. There are currently no corporate performance indicators that relate directly to the IHM service. Excluding private lifeline customers (which is no longer part of the IHM service), there is currently only one IHM performance indicator that is regularly collected and reported:

Indicator Q1 2018/18 Q2 2018/19 Q3 2018/19 Q4 2018/19

PP3/19 Number of open IHMO cases (no target). 275 275 275 Not

reported

Two other measures are included but marked as either not applicable or under development:

PP3/20 End to end time of IHMO cases (not applicable)

PP3/21 Number of empty IHMO units at housing complexes (under development). It is unlikely that a single indicator related to caseload can provide an adequate measure of the success or otherwise of such a wide ranging service. Furthermore, it is not clear how this indictor links directly to the overall objective of enabling vulnerable tenants to remain independent and sustain a successful tenancy. The Service Director stated that an additional objective was to reduce the number of calls to the customer services team. Whilst overall analysis shows that the total number of calls has reduced, it is not clear how much impact the IHM service has had on this reduction. It is therefore necessary to establish a range of measures that reflect overall performance and can be influenced to some extent by the actions of IHM staff (recommendation 12). Whilst input and activity levels provide some useful information on service performance, measures and targets should, as far as possible, be focused on outcomes. Some potential additional indicators may include:

percentage of welfare visits due and completed (input);

needs assessments and support plans completed with x days of tenancy start date (input);

number of property condition inspections completed (input);

number of fire risk assessments completed (input);

number or percentage of cases where independence scores have improved (outcome);

percentage of tenancies sustained for x years or more (outcome);

reduction in cases with rent or council tax arrears (outcome);

number of properties requiring improvement (outcome); and

improvement in customer satisfaction scores (outcome).

8

Testing of reported performance for the caseload indicator was not possible as there are no working papers or audit trail showing the basis of the calculations. Based on discussion with the IHM Team Leader, there is uncertainty over the precise definition of the indicator but it has been interpreted to mean all cases in sheltered schemes and all designated properties with a visiting frequency of monthly or higher. The numbers were obtained by simply adding up the number of cases recorded on the IHM master caseload spreadsheet. Based on Internal Audit review and analysis of the spreadsheet at the time of audit, the number of cases meeting this definition was approximately 280 cases, which provides some assurance that the reported figure is unlikely to be materially misstated. However, a full audit trail of the calculations and supporting records should be maintained in future (recommendation 13). Staff performance As noted previously, staff management and supervision is relatively informal and performance monitoring is light-touch. Staff do not have individual or collective performance targets to measure or monitor efficiency or productivity. There is a corporate performance appraisal system in place across the council, but compliance is not actively enforced. Only two members of the IHM team have had a formal appraisal within the last year; others have commenced the appraisal but have not yet been completed. The IHM team leader stated that this is due to pressure of other work and limited capacity to complete the required documentation and processes (see recommendation 14). Customer accountability As noted above, there are various means in place to ensure that service users are aware of the additional cost of the service when they agree to the tenancy. For example, property advertisements and offer letters make clear that the property attracts an additional support charge. In addition, tenants are required to sign a formal support agreement which specifies the additional fee and includes the following statements: I am aware that I am moving/have moved into a property with support. I am aware that support services (listed overleaf) will be provided to me and I agree to accept them. I understand that this is the fee for my support services. The Support Service Charge is charged in line with the rent. This fee may be increased on an annual basis. The agreement includes a tick list of 27 potential support services, although the list is rarely completed in practice and reliance is placed on providing a verbal explanation of the services provided at the time of sign-up. Some officers stated that a significant proportion of services on the list are not provided or offered directly by the IHM team due to lack of capacity or expertise. Based on existing caseload and the skills, pay grade and experience of the staff involved, Internal Audit agrees that it is unrealistic to expect IHM officers to deliver all services on the list, for example:

developing domestic / life skills;

developing social skills / behaviour management;

emotional support, counselling and advice;

help establishing social contacts and activities;

supervising and monitoring medication;

help with shopping, errand running and good neighbour tasks;

Culture specific counselling and emotional support etc. If the support agreement is not completed properly there could be a lack of clarity over exactly what services are to be provided for the fee charged. This makes it difficult for service users to hold the Council to account in the event of a failure to deliver the agreed services. Conversely, there is also a risk that the agreement could establish unrealistic expectations on the part of the service user and expose the Council to risk of challenge (see recommendation 15).

9

Based on review of case files and discussion with officers, there is evidence that service user views are sought from residents at Gretton Court through completion of periodic surveys, use of a suggestions box and residents meetings. Surveys are also conducted periodically by the Tenants Forum Executive Committee (TFEC) focused on housing repairs. However, there is no customer satisfaction survey specifically for the IHM service as a whole. This, together with a lack of other performance information and measures, makes it difficult to clearly demonstrate value for money (recommendation 16). Financial management The financial impact of support charges on residents has been mitigated as the costs are treated as fully eligible for Housing Benefit. Officers confirmed that all service users are provided with assistance to complete housing benefit or universal credit claims and any changes of circumstances likely to affect their entitlement. Testing of a sample of case files confirmed that support of this nature had been provided in most cases. There was also good evidence that IHM officers were taking appropriate action where necessary in respect of service users with rent or council tax arrears. Review of overall budgetary control and overall financial management arrangements is outside the scope of this audit. However, there is clear alignment between budget and service responsibilities; which have been updated recently to reflect structural changes within the directorate. There is also evidence that budgets have been managed effectively as, whilst gross costs have increased by approximately 27% since the original 2015/16 budget, actual expenditure has remained within budget and the overall cap on the HRA contribution has been consistently achieved. Table 3 – Financial summary

Original Budget 2015/16

Actual 2015/16

Actual 2016/17

Actual 2017/18

Forecast 2018/19

Budget 2019/20

Total gross cost of service £204,750 £183,374 £201,917 £227,937 £237,500 £260,850

Income from charges -£180,720 -£173,826 -£178,476 -£202,603 -£207,980 -£218,780

LCC income 0 -£15,000 0 0 0 0

Net cost of service £24,030 -£26,738 £23,441 £25,334 £29,520 £42,070

Recharges to General Fund 0 0 0 0 0 -£28,560

Recharges to other HRA services 0 0 0 0 0 -£22,850

Total net service costs £24,030 -£26,738 £23,441 £25,334 £29,520 -£9,340

For 2019/20 the net cost of the service has increased to £42k but the HRA contribution cap has been achieved after recharging approximately £29k to the General Fund. However, officers were unable to provide any explanation of the basis or justification for the recharge (see recommendation 17). Based on the above findings, the assurance rating for the design of controls to mitigate this risk is Limited Assurance, primarily due to inadequate performance measurement and reporting leading to insufficient evidence of value for money. The assurance rating for compliance with controls is Satisfactory Assurance.

3. Action Plan The action plan at appendix one includes a number of recommendations to address the findings identified by this review. If accepted and implemented, these should positively improve the control environment and aid the Council in effectively managing its risks.

10

4. Limitations to the scope of the audit

This is an assurance audit and an opinion is provided on the effectiveness of arrangements for managing only the risks specified in the Audit Planning Record. The Auditor’s work does not provide any guarantee against material errors, loss or fraud. It does not provide absolute assurance that material error, loss or fraud does not exist.

11

Appendix 1 ACTION PLAN

Rec No.

ISSUE RECOMMENDATION Management Comments Priority Officer Responsible

Due date

1 Lack of an overall service plan, specification or other document setting out the services provided and expected outcomes means it is not possible to easily demonstrate achievement of the Council’s objectives or delivery of value for money. The lack of a clear strategic and operating framework also makes resource planning, review of service structures and fee design more difficult.

Prepare a formal service specification or plan setting out the overall aims and objectives of the IHM service, expected outcomes and detailed description of the services provided. This should clearly distinguish between welfare and tenancy based services and how they are delivered to maximise effectiveness and value for money. The service specification should be used as a basis to inform the current departmental restructure, links to other services and future workforce/staff development plans. The IHM service specification and associated service standards should be published on the Council’s website so that current and potential service users have a clear understanding of the services provided. This should include updating the brochure and information booklet for the Gretton Court extra care service. Development of the specification should include a review of charges to ensure fairness and consistency. The policy of charging tenants that have opted-out of services should also be reviewed.

SLT have approved a request to undertake a full service review / redesign of the IHMS service. This will go hand in hand with review of the allocations policy which our Housing team is undertaking. All of the recommendations within the action plan will be incorporated and considered within the service redesign. It is difficult to put a specific timescale on such a large piece of work and therefore proposed to work on some initial milestones being achieved, specifically:

31 October 2019 Financial impact on the service assessed as a result of allocations policy implementation

30 November 2019 Framework for a revised structure and service completed

After this, timescales for implementation of the structure will depend on HR guidelines for staff consultations etc.

High People Manager

30 November 2019

12

Rec No.

ISSUE RECOMMENDATION Management Comments Priority Officer Responsible

Due date

2 The absence of documented operating procedures increases the risk of inconsistencies in service delivery and a lack of resilience in the event of unexpected absence of key staff.

Operational policies and procedures should be documented in a procedure manual or equivalent. All operational procedure notes should include version control information and be periodically reviewed and updated. The procedures should include copies of all standard forms, templates and checklists expected to be used together with guidance on their completion and general documentation standards.

See R1 above Medium People Manager

30 November 2019

3 Needs assessment and support planning is largely informal and unstructured. This increases the risk of inconsistencies and that support provided does not match the needs of individual service users.

As part of the documentation of operational procedures (R2), guidance and instructions should be provided on undertaking initial assessments and determining support requirements, including frequency of visits, referrals to other agencies and any other support services to be provided. This should include documentation and evidence requirements and should be supplemented with staff training on needs assessment and support planning where necessary. Guidance should distinguish between cases requiring relatively low-level support and those with multiple or complex needs.

See R1 above Medium People Manager

30 November 2019

4 There has been no formal workload or capacity analysis and caseload varies considerably amongst staff. This increases the risk that expected outcomes may not be achieved if insufficient resources are allocated to the service.

Undertake a formal resource and workload analysis to determine whether existing resources are sufficient and caseload is distributed equitably amongst staff. This may require a temporary period of time recording to support an accurate assessment of time spent on different activities and functions. This could also be used to inform future decisions on service design and resource requirements.

See R1 above High People Manager

30 November 2019

13

Rec No.

ISSUE RECOMMENDATION Management Comments Priority Officer Responsible

Due date

5 Job descriptions cover a broad range of services including tenancy and welfare (case management) functions. Case management is a relatively specialist function but the person specification does not require any specific case management experience or qualifications. This increases the risk that staff may not have sufficient skills or experience to undertake all aspects of the role effectively.

If the role and responsibilities of IHM officers continues to include a significant element of case management (e.g. undertaking assessments, providing support and making referrals), the person specification should be updated to require appropriate experience and/or qualifications. Where necessary, existing staff should be provided with relevant training and support to enable them to deliver this aspect of the role effectively and minimise any safeguarding risks.

See R1 above. Medium People Manager

30 November 2019

6 Supervision and management is relatively informal with no proactive case reviews, observations or other formal quality management arrangements. This increases the risk of inconsistencies and failure to identify training and development needs.

The IHM Team Leader should undertake periodic sampling of case files and undertake case reviews in collaboration with individual IHM Officers. This could be supplemented with ‘shadowing’ during welfare visits to observe officers at work. Case reviews could focus on those cases with particularly complex or high level needs. The supervision and case review process should be recorded and used to inform overall service development as well as individual staff appraisals and identification of training and development needs.

See R1 above. Medium People Manager

30 November 2019

7 Lack of periodic team meetings means that reliance in placed on informal communications to discuss working practices and share good practice.

Team meetings should be reinstated and held at regular intervals (e.g. quarterly) in future to provide an opportunity to disseminate corporate messages, discuss service developments and performance, share experiences and good practice. Team meetings could also provide an opportunity to efficiently deliver any service-wide training.

See R1 above Low People Manager

30 November 2019

14

Rec No.

ISSUE RECOMMENDATION Management Comments Priority Officer Responsible

Due date

8 Plans to migrate case records to the ECINS system have been slow to progress and no deadline or target date has been established. Creation of a formal target should help to focus attention and enable management to effectively monitor and hold officer to account for delivery.

A target date should be established for moving all cases to the ECINS system. All members of the IHM team should be advised of the target date and the availability of support to assist with setting up case profiles and migration of historical records.

See R1 above Medium People Manager

30 November 2019

9 There is no standard or systematic approach to undertaking, recording or evidencing the needs assessment and support planning process. Based on testing of a sample of case files, in most cases there was no record of the basis for determine the frequency of welfare visits or other support.

Case records should include a clear record of the basis for determining the frequency of welfare visits and evidence of agreement by the service user.

See R1 above Low People Manager

30 November 2019

10 There is no periodic review of needs to ensure that the support provided continues to meet users’ needs. Tenants that have opted out of support are not revisited or reviewed to determine whether they wish to opt in at a later stage.

All cases should be subject to at least an annual review of needs to determine whether the frequency of visits and other support provided continues to match the user’s needs. This should include cases that have opted out of support to determine whether they wish to opt back in at a later stage.

See R1 above Medium People Manager

30 November 2019

11 IHM records contain sensitive personal information but do not appear in the Information Asset Register and there is no evidence that GDPR compliance assurances have been obtained.

IHM records should be added to the Information Asset Register and appropriate assurances obtained regarding compliance with GDPR requirements, including document retention requirements.

See R1 above Medium Data Protection Officer

30 November 2019

15

Rec No.

ISSUE RECOMMENDATION Management Comments Priority Officer Responsible

Due date

12 There is currently only one performance indicator for the IHM service that measures caseload. This is unlikely to provide a full picture of service performance or achievement of overall objectives.

As part of the development of a formal service plan/specification (see R1), establish a broader range of SMART performance indicators (PIs) linked to service aims and objectives. These should cover both inputs and outcomes and each PI should have a clear definition and realistic target.

See R1 above High People Manager

30 November 2019

13 There is a lack of clarity over the current PI definition and no evidence or working papers to support the reported performance.

A full audit trail should be maintained to provide evidence of the completeness and accuracy of all reported performance indicators. In cases where the indicator is extracted from a ‘live’ document, a ‘snapshot’ of the live record should be taken and retained at the time of the calculation.

See R1 above Medium People Manager

30 November 2019

14 Staff performance monitoring is relatively light-touch and there are no individual performance targets. Appraisals are not up-to-date and it is not possible to clearly demonstrate efficiency or effectiveness of individual members of the team.

Annual staff appraisals should be completed for all members of the team. All staff should have individual and collective SMART performance targets linked to service and corporate aims and objectives. Regular one-to-one meetings should be held between the Team Leader and IHM Officers to discuss, monitor and review performance and any training and development needs (see also R6 above).

See R1 above Medium People Manager

30 November 2019

15 Documentation provided to tenants does not clearly specify the precise services being provided for the fee paid. Consequently, there is a lack of transparency and accountability and scope for misunderstanding.

Formal support agreements should be reviewed and updated to ensure that the specific support services provided are clearly recorded within the agreement so that customers can hold the Council to account in the event of non-delivery.

See R1 above Medium People Manager

30 November 2019

16 There are no formal arrangements for gathering customer views on the services they receive. This, together with a general absence of performance information means it is not possible to clearly demonstrate value for money.

Undertake annual customer surveys to obtain, measure and monitor customer views on service quality and VFM. Survey results should be included in corporate or service performance measures and used to inform any future decisions on service development.

See R1 above Medium People Manager

30 November 2019

16

Rec No.

ISSUE RECOMMENDATION Management Comments Priority Officer Responsible

Due date

17 Budgetary control is sound but costs are increasing and the 2019/20 budget has only remained within the approved HRA contribution cap after recharges to the general fund. Officers have been unable to provide an explanation for the basis of these recharges.

The basis of recharges to the general fund and other HRA services should be clearly evidenced and justified to ensure transparency and continued compliance with the approved funding cap.

See R1 above Medium People Manager

30 November 2019

17

GLOSSARY

The Auditor’s Opinion The Auditor’s Opinion for the assignment is based on the fieldwork carried out to evaluate the design of the controls upon which management relay and to establish the extent to which controls are being complied with. The tables below explain what the opinions mean.

Compliance Assurances

Level Control environment assurance Compliance assurance

Substantial

There are minimal control weaknesses that present very low risk to the control environment.

The control environment has substantially operated as intended although some minor errors have been detected.

Good There are minor control weaknesses that present low risk to the control environment.

The control environment has largely operated as intended although some errors have been detected.

Satisfactory

There are some control weaknesses that present a medium risk to the control environment.

The control environment has mainly operated as intended although errors have been detected.

Limited

There are significant control weaknesses that present a high risk to the control environment.

The control environment has not operated as intended. Significant errors have been detected.

No

There are fundamental control weaknesses that present an unacceptable level of risk to the control environment.

The control environment has fundamentally broken down and is open to significant error or abuse.

Organisational Impact

Level Definition

Major The weaknesses identified during the review have left the Council open to significant risk. If the risk materialises it would have a major impact upon the organisation as a whole.

Moderate The weaknesses identified during the review have left the Council open to medium risk. If the risk materialises it would have a moderate impact upon the organisation as a whole.

Minor The weaknesses identified during the review have left the Council open to low risk. This could have a minor impact on the organisation as a whole.

Category of Recommendations The Auditor prioritises recommendations to give management an indication of their importance and how urgent it is that they be implemented. By implementing recommendations made managers can mitigate risks to the achievement of service objectives for the area(s) covered by the assignment.

Priority Impact & Timescale

High Action is imperative to ensure that the objectives for the area under review are met.

Medium Requires actions to avoid exposure to significant risks in achieving objectives for the area.

Low Action recommended to enhance control or improve operational efficiency.