council corporate riskcouncilportal.cumbria.gov.uk/documents/s92715... · appendix 2 quarter 4 -...

Appendix 2 QUARTER 4 - REGISTER OF CORPORATE RISKS

1

COUNCIL CORPORATE RISK REGISTER – PROGRESS REPORT

(Quarter 4 - Progress to 31ST

March 2019)

From Quarter 2 onwards, direction of travel arrows will indicate whether progress for that quarter is:

better worse stayed the same since the last quarter

All changes made since Quarter 3 are highlighted in RED.


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1. PREVENTION OF & PLACEMENT SUFFICIENCY FOR CHILDREN LOOKED AFTER – Lynn Berryman

There is a risk that The Council is unable to implement adequate preventative measures to reduce the number of looked after children impacting on the sufficiency of appropriate placements.

Caused by Current controls & measures in place to manage the risk Quarter 1 planned improvements to controls & measures to manage the risk.

The ineffective

delivery of the CLA

Recovery Plan and

related programme of

activities

A CLA Recovery Plan is in place and progress is reported monthly to the Placement Commissioning Board which is chaired by the Assistant Director Children and Young People and to the Promoting Independence Programme Board which is chaired by the Executive Director People on a monthly basis, with a bi monthly report going to CMT.

Key aims of the CLA Recovery plan in respect of this risk are working towards; o An improved availability of local residential placements for children and young

people in Cumbria o An increase in the number of in-house foster carers o To ensure there are sufficient services to meet identified needs and these are based

on greatest need. o Reduction in the number of children looked after

Ongoing work is happening to update the recording systems with Finance to improve the quality of reporting provided to the weekly performance meeting and the monthly Programme Board.

The second site for the four bedded home has now been identified. 10 family resilience workers have now been recruited. An updated action plan is now in place. There will be a review of the scheme of delegation for agreeing external placements as long

term.

Unavailability of

appropriate

placements to match

young peoples

assessed needs

Current measures in place:

Analysis and tracking of placements and targeted work to ensure children are in the right place, for the right length of time and care planning and managerial oversight at every level addresses delay.

Control measures include;

Monthly Placement Commissioning Board which is responsible for developing a strategic programme for change to ensure successful oversight and delivery of key work streams including the Sufficiency Duty and key drivers, the CLA Recovery Plan, Regional Adoption Agency and Foster Carers for Cumbria – commissioned within the agreed legal frameworks.

Weekly Performance meetings at Assistant Director (AD)/Senior Manager level tracking entrants and exits.

Monthly District (Area Teams) Scrutiny Panels to challenge and track placements.

Legal Gateway Panel to manage the PLO process and agree initiation of legal proceedings and entrance to care.

Permanence Panel to ensure good placement planning overview and challenge to care planning and drift.

Long Term Tracking meetings and family finding processes (Fostering and adoption).

Commissioning oversight of contracts and discounts in respect of external placements.

Adoption Scorecard which provides challenge to our performance against national timescales for adoption.

Revised scheme of delegation for emergency placement agreement (Assistant Director authorisation).

A full child and family assessment for all children open will take place at least every 12 months which tightens planning and potential for rehabilitation

Targeted work from edge of care services for those most at risk of care in the next 3 months overseen by District Senior Managers.

Tracking of the use of the emergency beds at the weekly performance meeting chaired by AD.

Proposal has been agreed for an increase in internal residential provision (2 x 4 bed)

Work as part of the move to Regional Adoption Agency to look at best practice on the journey to adoption and how we implement in Cumbria

Set up of an Adoption Team to reduce time that children are placed in foster care before being placed in their adoptive placements

All actions identified by the review of all High Priority Children Looked After (CLA) cases will be monitored by the CLA Recovery Board and those in external residential provision are being tracked on a weekly basis by the relevant senior managers.


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being progressed via the corporate officer group (Strategic Investment Group) chaired by the Assistant Director Highways and Transport, current sites are being explored. One site has been agreed.

Analysis of the full CLA cohort and modelling for demand for this financial year but also for 19/20 taking place with AD and finance has been agreed and report presented to CMT.

A commissioning of placement group has been set up to review High Priority Children Looked After (CLA) cases with a view to improving outcomes for Children in Care and their families. This ensures that complex residential placements are appropriately commissioned and funded in accordance with the Care Planning for each child and young person. This group will report to the Placement Commissioning Board.

Ineffective

recruitment and

retention of Cumbria

foster carers

Foster carer steering group in place to monitor/challenge progress.

A recruitment campaign is in place with strong branding and community presence.

Fees have increased for Foster Carers which has resulted in an increase in foster carers’ morale and an increase in the number of IFA’s transferring to CCC fostering agency and new applications to become foster carers.

Foster carer mentoring scheme in place. Monitored at Placement Commissioning Board and DMT programme board and Corporate Parenting Board.

Reshaping of service to ensure improved support to carers within their local area is now in place.

Further capacity has been agreed to include in the fostering assessment team to increase the timeliness of new assessment, prioritising the IFA transfers.

Continue to align improved understanding of CLA cohort with recruitment of carers so that the need leads the activity.

The recruitment campaign is ongoing during Quarter 1.

Campaign for carers for complex children is starting in Quarter 1.

Ineffective ‘Signs of

safety’ (SoS) practice

model

‘Signs of safety’ project and implementation plan is in place and progress is reported to the Workforce & Practice Board and the LSCB business group

Regular facilitated practice lead sessions take place to provide leadership and embed practice.

The audit framework will be adjusted to include Signs of Safety practice.

Second development officer in place so more capacity to drive forward our signs of safety practice.

Signs of Safety 2019 high level project plan developed alongside district implementation plans, setting out clearly the expectations over the next 12 months and the activity that will take place to embed the model

SoS steering group continues to meet on a monthly basis to drive progress and reports monthly to the Workforce Practice Board which is chaired by the AD Children and Young People

Coaching sessions with our SoS consultant continue and the learning is embedded into practice through district based workshops supported by the SoS development officers.

We are seeking to learn from other authorities who have successfully embedded the model with a visit to North Yorkshire who are an outstanding authority planned for April – and a workshop with the founder of SoS Andrew Turnell taking place in Cumbria in May

Sharing examples of our own good practice through share point

SoS collaborative audit approach has been piloted successfully and we are looking to roll this out more widely

SoS group supervision sessions are taking place regularly

Resulting in

Main Impacts of risks to Customer & Council Links to Council Plan Delivery Plan Quarter 4 Risk Rating

Additional placement moves and /or placements at a distance for

children looked after. 1.15 The Children Looked After Strategy updated and the Children

Looked After Recovery Plan Implemented.

1.20 A strengths-based practice model, including Signs of Safety,

implemented and embedded across the People Directorate.

Q4 RISK RATING Likelihood x impact

20

Previous quarter

Current quarter

End Yr Target

DOT

20

20

20

4 5 4 5

Overspend of the CLA budget.

Reputational damage to the Council.

Partial or total interruption to service delivery to customers leading to

partial or non-delivery of corporate priorities.


4

Failure to meet statutory requirements under the Care Act; to meet

assessed social care needs and also to provide a sustainable care

market. This has the potential intervention by external commissioner

& reputational damage to CCC and NHS partners.

Significant financial impact due to Increased number of Delayed

Transfers of Care (DToC).


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2. WORKFORCE CAPACITY, SKILLS, RELATIONSHIPS, SAFETY & WELLBEING – Paul Robinson & Dan Barton

There is a risk that The Council does not have the workforce capacity, skills or relationships to deliver the Council Plan or experiences a significant impact to the safety and welfare of the workforce.

Caused by Current controls & measures in place to manage the risk Quarter 1 planned improvements to controls & measures to manage the risk

Workforce Plan 2018-

2022 not delivered.

Workforce Plan Delivery Plan agreed by Cabinet

Action owners assigned and performance management arrangements in place

with monthly monitoring through Organisational Change Senior Management

Team

Prioritisation exercise undertaken to ensure resources deployed to priority

actions to ensure delivery alongside capacity challenges.

Externally Provided Workforce (EPW) project chaired by AD Organisational

change to ensure 2018/19 Council Plan target of 15% EPW marginal cost

reduction is achieved.

Report planned for Cabinet in June 2019 to review the 2018/19 progress and to prioritise actions for the

2019/20 Workforce Plan Delivery Plan

All Workforce Plan Delivery Plan actions for Quarter 1 2019/20 will continue to be performance

managed and progress reported through SMT, DMTs and overview through Performance Framework to

CMT and Cabinet.

AD Organisational Change oversees progress at monthly SMT with regular updates discussed in Lead

Member and Shadow Portfolio Holder 121 meetings.

Monthly meetings between Senior Manager, Learning and Skills and Manager, Learning & Skills set up

to ensure cohesion and monitor progress against allocated actions.

Additional Workforce Plan focus relating to CQC Action Plan Workforce work stream. EPW Strategy

Group continues to meet monthly chaired by AD Organisational Change.

Leadership & Management Programme launched at Managers Conference October 2018 continues to

be rolled out and reviewed. Management Development programme and Team Leader programme due

to be rolled out Q1 19/20, with Leadership conferences and Excellence Awards events planned for Q1.

Innovation Fund and MTFP approved and proposal contained in the Budget proposal consultation, to

increase internal capacity for learning and skills, and reduced reliance on externally procured training.

High staff absence

levels

A focus on absence and attendance will continue across all areas, with

monthly reporting to Directorate Management Team and Corporate

Management Team.

Deep dive’ absence clinics at Assistant Director and Senior Manager level to

address longer term complex cases with the support of the Council’s

Employee Health & Wellbeing professionals will continue.

Scrutiny Performance Working Group received detailed update March 2019

with regular performance focus through Scrutiny Management Board. Audit &

Assurance Committee receive regular risk updates to ensure controls remain

in place to minimise absence risks

Workforce Plan 2018-2022 has a significant focus on staff wellbeing and

engagement, with initiatives intended to positively affect attendance and staff

wellbeing. Council achieved Better Health at Work ‘Gold’ Award and now have

plans in place to strive for the maximum ‘Continuing Excellence’ accreditation

Winter 2018 Flu vaccination programme resulted in good take up rates.

Health and Safety governance and increased profile an ongoing priority.

The 2017/18 year-end position in March 2018 was 11.92 WDL per FTE. The 2018/19 Q4 year-end

position (end March 2019) is 12.49 WDL – a deterioration on previous year.

Absence continues to be a high priority for all services with continued and dedicated support provided

in high impact areas with the new absence procedure launched in Sept 2018 being progressed and AD

clinics with OH Physician reprogrammed throughout 2019 for complex long term cases.

A deep dive to understand stress related absence commissioned by CMT in Q4 will continue

throughout Q1

SMTs, DMTs, CMT, Cabinet and Scrutiny Management Board will continue to receive ongoing regular

updates on performance.

Hepatitis B programme funding approved and training progressing and will be rolled out once

vaccinations become available nationally.

Health, Safety and Wellbeing programme will continue linked to agreed ‘Th!nk Safe Be Safe’ brand and

agreed messages of the month.

Support and advice will be strengthened for teams progressing staff reshaping as this has shown a

correlation to absence rates.


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Ineffective Health,

Safety and Wellbeing

management

Responsibility for health and safety being refocused at all levels supported by the corporate health and safety team who provides the ‘competent person’ support.

Cabinet agreed the 2018/19 Corporate Health Safety and Wellbeing Policy Statement October 2018 and displayed on intranet and displayed in all Council buildings. IOSH Leading Safely programme well attended.

Health & Safety Committees across all directorates refreshed with Senior Officer and Trade Union co-chair arrangements in place and well attended.

Corporate and Directorate level risk assessments reviewed to ensure resources focused on areas of higher risk.

Health and Safety a standing agenda item at all DMT’s and at CMT providing an opportunity to immediately escalate matters of significant concern.

Corporate Mental Health programme progressing as planned.

Th!nk Safe Be Safe brand established with monthly messages of the month overseen by Lead Member, AD Organisational Change and TU H&S Chair.

Refreshed Health, Safety & Wellbeing governance arrangements embedding with events and communication programme continuing under the ‘Th!nk Safe Be Safe’ brand. Monthly safety and wellbeing messages will continue. Senior members, officers and trade union representatives that attended IOSH Leading Safely training courses in Q4 now applying the learning.

Additional capacity recruited to strengthen Fire health and safety in place with further plans progressing to further strengthen capacity to support schools.

Corporate mental health programme will continue through Quarter 1 with innovative Fire Engine ‘wrap’ an example to market the programme

Full programme of 33 operational health and Safety procedures being re launched in Q1 as per internal audit recommendations. Wider evidence being collated ahead of internal audit follow up audit which will take place in April to May 2019.

Higher risk service areas to refresh risk assessments and associated assurance statements with improvement plans if and when required.

Better Health at Work Gold Award achieved in December 2018 and Council will now progress

actions to aim for the ‘Continuing Excellence’ criteria where resources allow.

CMT have standing Health and Safety item as standing agenda item each week

Service Reviews

negatively impact on

capacity or delivery of

services.

As part of strategic planning for 2018/19 and beyond, a programme of deep dive service reviews continues with regular planned meetings between management and recognised Trade Unions.

Where any concerns are raised by staff or Trade Union representatives, they are considered and addressed as promptly as possible.

Service Review activity will be closely managed through DMTs and CMT to ensure delivery of required change, whilst carefully managing the potential impact and implications on both financial and non-financial resources and the delivery of statutory services.

All service reviews planned for Quarter 1 will follow agreed Management of Change process with regular updates to recognised Trade Unions and Portfolio Holders.

Capacity and availability challenges being regularly reviewed to balance pace with risks.

Industrial Relationships

between the Council

and Trade Unions.

Service Reviews are closely managed in consultation with recognised Trade Unions using agreed management of change process.

JCG and HR1 meetings will continue to be held corporately and within each Directorate in line with agreed framework.

Refreshed Health & Safety Committees with Union co-chairs in place.

Any issues of concern are discussed promptly and proportionately with a commitment to review any policies of concern to negotiate an agreed position with Trade Union colleagues locally and regionally wherever required.

JCG and HR1 meetings will continue to be held corporately and within each Directorate in line with agreed framework and commitment to discuss any staffing related issues.

Policy Group continues to meet to negotiate any revisions to policy.

Plans are in place for greater Trade Union involvement at earlier stages of initiatives to ensure greater co-production. If issues of concern are raised by Trade Union colleagues, then they are considered promptly through agreed escalation and dispute resolution procedures.

Increased Health & Safety working. Both Officers and Trade Unions jointly committed to greater co-production and informal resolution of issues. An example is a joint approach to improved Health and Safety governance, visits and communications materials.

Resulting in


Pace and change objectives from service reviews is not met. Delivery of the Workforce Plan 2018-22 sets out

how the Council will engage, empower, support

and develop the workforce now and into the future

to deliver the Council Plan.

Q4 RISK RATING (Likelihood x Impact)

20

Previous quarter

Current quarter

End Yr Target

DOT

20

20

15

4

5

4

5

Absence exceeds targets leading to capacity issues and increased costs due to

shift cover requirements or Externally Provided Workforce (EPW)

Non delivery of identified workforce skills and apprenticeship targets.

Trade Union relationship challenges with increased numbers of grievances,

formal disputes or industrial action.

Major injury, illness or fatality as a result of insufficient or ineffective health and

safety arrangements.


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3. CARE NEEDS & DELIVER CONTINUITY OF CARE – Jo Atkinson

There is a risk that

There is a risk that the Council is unable to meet eligible care needs and deliver continuity of care


Home Care &

Residential Care for

service users over 65

years.

Increased demand,

market challenges and

overall system

challenges including

insufficient capacity in

the care market

(including problems

recruiting or retaining

CCC staff and

managers)

Alternative Delivery Models

Cumbria Care recruitment is well underway and 11 teams have been appointed to deliver an in-house shift based homecare service. Based on initial discussions with the independent sector, this recruitment has had a limited impact on their own recruitment and retention of staff.

A block contracting model has been developed with one of our homecare providers to deliver care in two extra rural locations in Eden. This model has allowed the provider to recruit staff members to deliver care on a block basis, which has improved their recruitment and retention of staff, and capacity in these hard to reach areas.

System Review

During Quarter 4 a whole system review was carried out by the Care Quality Commission (CQC), the report has been published and an action plan developed that aims to support system wide improvements.

Oversight of progress against the CQC action plan will be provided by the Health & Wellbeing Board.

Internal audit has carried out an audit on Homecare, their report is expected in Quarter 2/Quarter3 2018/19.

Alternative Delivery Models

Shift based contracting models are being developed with both Cumbria Care and our framework homecare providers to improve staff stability in rural areas and areas of high demand. The current block contracts have safeguarded the delivery of some of our current care packages and allowed for some previously unmet care packages to be delivered.

Cumbria Care has a number of active shift based teams delivering care in Barrow, Carlisle, Copeland and South Lakeland

Recruitment is currently on hold with Cumbria Care teams in west Cumbria due to the modernisation programme but it is intended to commence recruitment in Eden during April. An additional £494k has been made available for 2019/20 through the iBCF to increase capacity within Cumbria Care teams.

CQC Action Plan

Explore new ways of contracting with providers to enable longer term relationships and support a robust and stable market – including workforce.

Problems recruiting and

retaining independent

sector care staff and

managers

Care staff The recruitment campaign between Cumbria Care, NHS colleagues and the

Independent Sector, through the Proud to Care Cumbria website, will continue with the aim of addressing County and sector wide recruitment challenges.

Sustainable market

The Council continues to work closely with the Clinical Commissioning Group to develop more robust plans that will support developing a sustainable market.

CQC Action Plan – A workstream for Workforce is in place to address 4 key areas: Produce a system wide workforce strategy Address recruitment, retention and skills issues across all sectors, including

third sector Develop new system-wide workforce models Link Health & Care workforce activity to wider socio-economic activity

Care staff

Additional funding has been made available through the iBCF to further develop the recruitment campaign. Discussions are taking place with the Learning and Development lead to establish how this links in to the wider workforce strategy

CQC Action Plan – Workforce Workstream

Conduct an assessment of system wide workforce challenges in order to develop a co-ordinated approach within a system wide workforce strategy.

Conduct workforce audits to identify reasons for exiting care jobs and assess level of job satisfaction

Identify cross sectorial pilot apprenticeship and traineeship standards and programmes.

Systematic relationships with the University and Colleges are being established to identify access and progression routes to careers in heath and care.

Identify service areas to pilot new workforce models.

Engage with Districts and Cumbria Local Enterprise Partnership to ensure Health & Care workforce needs are integrated within the wider Housing & Industrial strategies

A plan to ensure support at home services and residential services is in development; to reflect local need that supports the place based commissioning approach and responds to the Continuing Health Care action plan.


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Failure to deliver care

services & deliver

regulatory standards of

the CQC.

Performance

During the system review in Quarter 4, no concerns have been raised by CQC

The Quality and Care Governance line management arrangements have now been transferred to the Senior Managers for Commissioning. This will ensure that information gathered regarding the quality of services is fed back into the commissioning cycle.

Multidisciplinary radar meetings are in place to receive and monitor early indicators of Quality concerns. This information is provided by the Quality & Care Governance Team.

Weekly meetings take place using a performance dashboard and exception report to address ongoing performance matters.

The Quality and Care Governance team conduct routine scheduled audits and monitor performance to improve standards on an ongoing basis.

Performance

A schedule of Directorate level quarterly performance monitoring reports will be in place to monitor a range of quality indicators to enable rigorous challenge.

The Quality and Care Governance team will continue to conduct routine scheduled audits and monitor performance to drive ongoing improvements to standards.

Services may not

provide vulnerable

people with a safe and

caring environment in

which they are

supported appropriately

Performance

System controls are in place to provide assurance at a number of levels. These are designed to provide ongoing checks that people are supported appropriately and safely

Controls include: - Social work assessment and review - Independent advocacy - Alerts to LADO should any concerns be identified - Safeguarding process - Intelligence gathering to inform the early indicator (RADAR) process - Quality Improvement Process (multi agency) - Care and Treatment Reviews (CTR) and Care Education Treatment Reviews (CETR) - CTR and CETR include multiple agencies, families, independent advocates and

experts by experience - Regular liaison with CQC

Performance

Ongoing review to ensure the controls that are in place continue to be effective.

Resulting in


Customer complaints. 1.25 In-house delivery of high quality support at home,

enabling us to achieve our ambition of a mixed market

economy of domiciliary care in Cumbria

1.33 The implementation of the Council’s actions to deliver the

improvements set out in the Health and Wellbeing Boards’

response to the Care Quality Commission’s Local System

review of Cumbria Completed.


15

Previous quarter Current quarter End Yr Target

DOT

15

15

15

3

5

3

5

Failure to meet statutory requirements under the Care Act; to meet

assessed social care needs and also to provide a sustainable care market.

This has the potential intervention by external commissioner & reputational

damage to CCC and NHS partners.

Partial or total interruption to service delivery to customers leading to partial

or non-delivery of corporate priorities.

Significant financial impact due to Increased number of Delayed Transfers

of Care (DToC).


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4.DELIVER A FINANCIALLY SUSTAINABLE AUTHORITY – Julie Crellin

There is a risk that the Council’s revenue budget is insufficient to fund services over the medium term


Slippage and non-delivery of existing savings

Monthly financial monitoring and reporting via Directorate Management Teams and Corporate Management Team – with quarterly reporting to Cabinet.

Programme Boards within Directorates to manage key projects linked to the Medium Term Financial Plan – and identify remediation activities where required.

Review of reserves on regular basis – to accommodate budget fluctuations in year

People DMT Programme Board – improved forecasting of financial impacts of CLA Recovery Plan to include the quarterly monitoring of actual activity against profiled targets on a scheme by scheme basis. This will allow for the further analysis of the relative impact of interventions, both financial and service delivery, and assist in the identification of where future resource should be effectively deployed to ensure the delivery of savings and mitigations.

Promoting independence Programme Board to monitor and evaluate the delivery and 2018/19 financial impact of the Promoting Independence Programme.

Report to go to CMT in Quarter 1 2019/20 updating progress of the CLA recovery plan, future actions to be delivered and corresponding updated financial projections for 2019/20

Report to CMT on 10th April detailing assurance framework for delivery of MTFP savings which includes service specific monitoring, involvement of DMT’s, Transformation Boards, other boards (eg Demand Management Project Group) and CMT. Detailed information can be obtained from the CMT report.

Monthly updates on savings delivery as part of the budget monitoring report and bi-monthly updates from Transformation Programmes on delivery of MTFP savings

Setting unrealistic

budgets (both income

and expenditure)

Strategic planning process in place to identify budget options for approval by Assistant Directors and Directors including preparation of detailed templates and standing items on CMT and ELT agendas.

Process in place to secure consideration and approval of budget options by Cabinet for consideration by Council e.g. budget workshops held with Lead Members, agreement of budget consultation report for November Cabinet.

Role of Director of Finance to provide assurance over the robustness of assumptions underpinning the Council’s budget.

Demand management and forecasting of key assumptions relating to expenditure and income e.g. forecast grant settlements, inflation assumptions re pay etc to feed into budget options preparation.

Budget Planning Group chaired by Director of Finance with representation from Directorates to review production of strategic planning options and overall approach.

Review of Council fees and charges undertaken by Directorate Management Teams

2020/21 Strategic Planning process to begin in April 2019 through engagement with DMT’s and

Transformation Boards

Budget Planning Group, chaired by the S151 Officer, to be established with a remit to;

o co-ordinate and plan the approach to developing future budgets;

o provide an overview of activities concerned with current budget performance to report, where

appropriate, to CMT on further actions required (including bringing together core offer options);

o identify and test additional opportunities to support financial sustainability;

o ensure completeness of report to CMT in relation to Strategic Planning Updates and Budget

Monitoring Updates on a regular basis

Production of a 10 year financial planning model

Overspending of budgets

Monthly financial monitoring (as above)

Rigorous assessment and authorisation of significant areas of expenditure e.g. care packages for vulnerable children and adults.

Operate risk based approach to deploy Finance team resources to assist budget holders in key areas of budget risk.

Implementation of revised financial decision making delegations by People Services in respect of

commissioned care packages and support to provide improved challenge of decisions and better

assessment of VFM over the longer term.

Development of demand models within specific services areas to allow improved future forecasting


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of financial impacts.

Children Looked After action plan in place to manage and reduce expenditure in this overspending

area.

Improved budget monitoring process reducing the time taken for budget monitoring reports to be

presented to CMT resulting in earlier corporate notification of the budget posiiton and therefore

earlier agreement of mitigating actions should they be required.

Underachieving of income budgets

Monthly financial monitoring (as above)

Quarterly meetings with District Council Technical Finance Officers – to review forecasts of Business Rates Income (and appeals) and Council Tax receipts.

Undertake risk assessment of income recording in key areas of the business to ensure consistency

of approach in recording income receivable. Further improvements likely to follow after assessment.

Uncertainty of local government funding framework

Horizon scanning by Finance of government announcements and funding/technical consultations – to ensure reasonableness of planning assumptions.

Active participation in national groups e.g. Society of County Treasurers, North West ADASS Group (adult social care), LGA and CCN.

Responding to LGF settlement 2019/10.

Hosting of HMT/MHCLG visit on 25th Sept, sharing the Council’s approach to Strategic Planning and recent experience of managing within constrained resources.

Submission of Business Rates Retention for 2019/10 to MCHLG in Sept (CCC and 6 District Councils).

Provisional Local Government Settlement evaluated and budget model and gap updated.

Continue to review and evaluate funding announcements that are made out with the Governments

Budget.

.

Resulting in


Reduced or non-delivery of services impacting on service users 4.7 All services delivered in line with their 2018/19 revenue budget as set out by Council in Feb 2018. 4.11 A Total of £38.829 million of new savings to be delivered in 2018/19.

Q4 RISK RATING likelihood x impact

15

Previous quarter

Current quarter

End Year Target

DOT

15

15 15

3 5 3 5

Significant budget overspends & unsustainable drawing on reserves

Reputational damage to the Council

Intervention by central government


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5. INFORMATION SECURITY ARRANGEMENTS – Paul Robinson & Simon Higgins

There is a risk: The Council will experience a significant information security incident.


Inadequate

information

security

arrangements

ICT Plan in place with Security a key element of Delivery Plan.

Information Security Management System including all policies adhering to ISO 27001 principles is in place and proactively maintained.

Suite of Information & System Security Policies accessible on In-touch

Annual Public Services Network (PSN), PCI DSS & IG Toolkit compliance maintained and supported by the external IT Health Check (ITHC).

Routine monitoring of ICT networks and systems in place. Vulnerabilities highlighted, addressed and managed through Service Now as a project task with exception reports to Senior Manager ICT and AD Organisational Change.

Routine ICT system penetration tests to check system vulnerabilities – incorporated into the annual IT Health Check. Externally hosted systems including those “in the cloud” incorporated into the annual ITHC.

Participation in National Cyber Security Centre free service initiatives including web check, public sector Domain Name System & Cyber Info Sharing Partnership continue.

There is an ongoing assessment of cyber threat via cyber security partners; the National Cyber Security Centre (NCSC), North West WARP including weekly threat reports and the NHS Cumbria Cyber Group.

Council received 2nd highest LGA cyber-security rating of ‘Green / Amber’ in Oct 18 with a number of strengths recognised. Report concluded that the council is compliant with the UK Government’s ‘Minimum Cyber Security Standard’ and the NCSC’s cyber security lifecycle with all areas scoring green.

ICT Business Continuity arrangements being refreshed and exercised.

GDPR Phase 1 Action Plan complete and passed to business as usual phase.

GDPR Phase 2 action Plan in place with implementation led by Data Protection Officer and AD Customer & Community Services following handover from AD Organisational Change who led Phase 1. Monthly Data Protection Working Group will drive developments and further embed data protection culture.

Migration to the new E5 ERP / financial system is complete with the legacy E5 ERP / financial system now decommissioned and all ancillary work completed.

The Data Security & Protection Toolkit (DSP Toolkit) is to replace the current IG Toolkit. Quarter 4 saw the completion of the Council’s submission as to compliance against the new toolkit 100 mandatory requirements. Submission deadline of 31st March 2019 was achieved successfully. This allows continued health data sharing.

A number of systems now hosted externally in the cloud or on suppliers own premises and NCSC guidance now recommends that externally hosted systems are incorporated into the annual CCC IT Health Check. The cloud based systems that are categorised as the highest risk were prioritised for inclusion and suppliers notified. All cloud hosted systems checked passed the ITHC successfully.

Enhanced ICT Programme Monitoring in place with strengthened performance management and incident reports being implemented which will include outstanding vulnerability scanning tasks created by Information Security within Service Now for action.

The 2019 annual PSN self-assessment has been signed by the Chief Executive and submitted. The assessment will take place later in 2019 with actions to mitigate risks progressing on an ongoing basis. Information Security team worked closely with the NCC Group who have conducted the ITHC to ensure proactive knowledge and skills transfer to CCC.

Project tasks have been created within Service Now to address critical and high vulnerabilities highlighted within the report. Remediation project plans have been submitted to PSN as part of the annual accreditation process.

A planned programme of ICT system resilience health checks commissioned in Q4 will commence in Q1 2019/20 as the full migration of the Council Data Centre confirmed as decommissioned. Technical capacity is refocused on system stability and resilience and will include increased security as well as performance.

Q1 2019/20 work will continue to progress areas of the LGA cyber security report to aim to achieve all levels the top ‘green rating’ including Governance, Documented risk assessments, Structures and policies; Leadership, reporting and ownership; and Training and awareness.

Q4 has seen the development of the InTouch request portal which enables permission to the sought to take electronic devices outside the United Kingdom border. The portal will be launched in Q1. All requests will be risk assessed by the Information Security Team and submitted to SIRO for approval.

Lack of Training ,

Awareness &

Ongoing learning

Mandatory GDPR & Information Security e-learning course in place and routinely updated to reflect data breach investigations to address/prevent further occurrence.

GDPR training exception reporting highlights staff and members not trained however significant progress made in this area with GDPR training targets now met.

ELT committed to ensure all Managers target those employees who are ‘hard to reach’ to ensure a minimum of 95% mandatory training completion with over 94% complete. Automatic reminders are sent to remind those employees who have not completed the on-line training course and further reminders are issued close to the expiry date of completed training. Plans progressing to restart the annual training programme in Q1 to ensure rolling 12 month training compliance.


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Statutory Data Protection Officer providing dedicated GDPR expertise, advice and support.

Information Security drop in sessions and workshops held as a joint approach with the Data Protection Officer and Records Management Team.

Ongoing Information Security and Cyber awareness programme will continue. The latest updates will be incorporated into the training for release in April 2019.

The Council Senior Information Risk Officer will continue to chair weekly meetings to consider Data Protection, GDPR and Cyber Security matters to ensure ongoing profile and prompt consideration of any issues.

Human error Incident reporting framework, procedure & on line incident form in place & recently revised to meet GDPR requirements.

Weekly SIRO meeting & data breach reporting in place to enable effective response to breaches, tracking, learning and ICO referral assessments.

A communications campaign is ongoing to increase staff awareness, reminder training and data risk issues including breach causes and learning.

Data breaches, near misses, causes and actions continue to be collated to central database to improve

targeted action and learning sharing following weekly discussion at SIRO meeting and escalation to CMT if

and when required.

Corporate Governance Group & Monitoring Officer created sub group to drive communications and cross

Directorate Learning which will continue in Quarter 1 2019/20.

Resulting in

Main Impacts of risks to customer & Council Links to Council Plan Delivery Plan Quarter 4 Risk Rating

Disclosure of personal data leading to personal distress, damage and

embarrassment and potential liability claims.

4.1 – The Council’s new GDPR responsibilities fulfilled.

Delivery of the ICT Plan & Strategy

Objective 2 – Achieve risk reduction and increased

information security whilst providing effective service

provision, with the aim of protecting ICT networks from

intrusion and cyber-attacks and to take effective actions to

protect the data held within our systems whilst enabling

effective service delivery.


15

Previous quarter

Current quarter

End Yr Target

DOT

15

15

10

3

5

3

5

Data breach leading to financial penalties & intervention by the ICO;

fines of up to 20 million euros or 4% of Gross budget.

Partial or total interruption to service delivery to customers, suppliers or

partners leading to partial or non-delivery of corporate priorities.

Significant reputational impact to the Council & partners


Financial impact


13

6. WASTE MANGEMENT CONTRACT – Stephen Hall

There is a risk that The Council’s strategic waste management contract does not deliver the services to the level required


Poor contract resourcing and non-delivery to contract specification

Contract Management – Governance & Controls

Governance and oversight of the waste management contract continues to be provided by the Senior Officer Programme Board, chaired by the Executive Director Economy & Infrastructure

A Waste Contract Improvement Plan and Programme is in place to manage contract performance and contract relationships and includes a programme Risk Register

Regular Contract BRAG reports go to Corporate Management Team (CMT)

A high level overview of operational issues and potential new deductions issues is being briefed internally and managed through the risk register.

Regular engagement meetings take place with contractor at both Senior and operational levels

The Waste Operations team regularly monitor performance in line with the contracted performance criteria

Regular updates to Corporate Management Team & Lead Members have been taking place to updated regards options for the mitigation of financial risk and resolution of the historical disputes.

An initial set of agreed maintenance metrics have been developed and will be monitored.

Strategic Board Meeting with Supplier Managing Director took place in January and engagement at high level with the supplier will continue.

Reviews

Internal Audit has undertaken a review of the Programme Board activities the outcome of which will be used to improve programme controls.

The programme team are conducting an internal review of the programme strategy and risks to allow reconsideration of targets by the Executive Director.

The Waste operations team continues to monitor performance closely in line with the contracted performance criteria.

The programme team will continue to work with the Internal Audit Service and other Corporate Risk Management initiatives to ensure the proper controls are in place for this programme.

Work has commenced on a review of the contingency arrangements for the service as recommended by the Amey lessons learned plan.

Changes in the market in relation to the disposal of waste streams

The market for both recovered fuel and extracting recyclates remains depressed and the Council continues to work with Renewi to secure a longer term contract for the fuel offtake, and mitigate financial pressures going forward.

Work is ongoing to secure a longer term contract for the fuel offtake, and mitigate financial pressures going forward.

Changes in Government Policy & Waste Legislation

The Policy team and the Waste Operations Team will continue to monitor changes in waste legislation linked to National Waste Resources Strategy and the impact of Brexit and advise on the impact of these changes to the service.

The recently released (18/12/18) UK Government Resource and Waste Strategy has been reviewed and the potential impacts and opportunities for Cumbria County Council and wider Cumbria (as the County’s Waste Disposal Authority) have been identified.

A number of consultations have been released by DEFRA which will support the final outcome of the Strategy – the Council is working to develop a response to these consultations and intends to engage with a range of public sector and industry partners to encourage optimisation of the final strategy.

Resulting in


Reduced levels of service to the public 2.19 Develop options to increase diversion of waste from landfill. Q4 RISK RATING likelihood x impact

15

Previous quarter Current quarter End Yr Target

DOT

15

15

10

3 5 3 5

Non-compliance to statutory obligations


Financial impact


14

7.LEARNING DISABILITY PARTNERSHIP ARRANGEMENTS – Jo Atkinson


The Council & Clinical Commissioning Groups (CCG’s) are unable to commission services and develop plans for the small number of Individuals with complex support needs.


Not having assurances on

financial resource transfer into

the health and social care

economy in Cumbria

Discussions continue to take place between the CCG(s) and Council regarding future pooled fund arrangements,

The appointment of the Senior Manager Commissioning in March 2018 has led to improved engagement & clarity of responsibilities with the CCG.

An Additional Needs Framework has been out to tender with the closing date of 9th July. 35 providers have bid and these will be evaluated over the next 3 weeks, the framework will go live from September and will support the development of future services

Interim arrangements are in place to manage new Continuing

Health Care (CHC) packages until all policy and procedures are in

place.

Work will continue to develop local policies and procedures that ensure organisations are operating within national frameworks and are discharging their statutory responsibilities. This will be undertaken through a small task and finish group,

Progress in addressing the outstanding issues in relation to CHC will be monitored via the Health & Wellbeing Board through the CQC action plan.

Discussion continues to take place with both CCG(s) regarding the future commissioning and funding arrangements that had previously been undertaken through the Learning Disability Pooled Fund. Both CCG’s have indicated their preference moving forward.

A joint S117 process has been developed alongside a standard operating procedure. Work is underway to develop staff training.

The interim Partnership Agreement remains in place. It sets out partner expectations in relation to joint working particularly in relation to S117 and Continuing Health Care.

The Interim partnership agreement sets out the expectation in relation to funding in- patient provision in assessment and treatment services.

A successful staff development day took place in February that included key staff from CCGs, CPFT and the Local Authority. Future meeting dates are being planned to further develop a joined up approach.

An additional needs framework has been agreed through Cabinet – and is "live”. The Framework includes 22 Providers, 8 which are new to Cumbria who can meet the needs of individuals who meet the criteria set out in “Transforming Care”. The first group of individuals for whom we are seeking support have been identified and will soon be tendered.

CQC Action Plan

CHC commissioning arrangements continue to be reviewed prior to Standard Operating Procedures being agreed.

Review governance arrangements and principles for local resolution to include package sign off and disputes. An agreed disputes process is now in place.

Develop System Dashboard agreeing cross sector KPIs and trajectories. A lack of availability of suitable

and affordable service and

support providers. Limited

capacity within existing service

and support providers.

Work underway with existing providers supporting the development of their service offer. This includes linking in with regional and national training/workforce opportunities e.g. In Positive Behaviour Support.

Additional needs framework has been procured with 22 Providers, 8 of whom are new to Cumbria. Start date 22nd October 2018.

Regular meetings with key Providers are in place

Additional needs Framework is in place

Commissioning and operational attendance at Learning Disability and mental health provider forums

A summit is being planned with providers to help them understand local need and to understand what support social care providers need to meet that need.

The development of an enhanced community model in North Cumbria has strengthened the local system to support providers and prevent in patient admission. The learning from this will be used to support pan Cumbria Providers.

Funding has been secured to develop individual life planning as a tool in Cumbria. This is a person centred approach that supports a bespoke approach to identifying support


15

Resulting in


Failure to meet statutory requirements leading to reputational

damage to CCC and individuals not having their care needs met

close to home.

1.18 A joint Council and NHS commissioning strategy for services for people

with a learning disability and/or autism developed.

The plan to develop a joint commissioning strategy is underway.


15

Previous quarter

Current quarter

End Yr Target

DOT

15 15 10

3 5

3

5


16

8. COMMISSIONING STRATEGY - Jo Atkinson


The Council does not fully deliver its commissioning strategy for adult social care, reducing the demand for it’s services and making best and effective us of it’s resources


The approach to

prevention not being

effective or not being

demonstrated to be

effective

Ongoing reshaping of Day Services through engagement with Local Area Committees to develop services in line with Commissioning Strategy

The new residential care framework is in place with 99% of homes in

Cumbria now signed up to the new contracting arrangements.

The wider review of Home Care Services is well underway.

The rollout of remodelling of older adults day services will continue on a district basis. Review work will continue in relation all other day service provision.

Trade Unions have been engaged around the future shaping of the services. Work will continue through the Local Area Committees and Area Managers to ensure Members are regularly updated

Quarter 3 is the first full quarter for residential and nursing monitoring information under new contracts.

the pace of review of

Day Services not

delivering expected

outcomes

Ongoing reshaping of Day Services, including engagement with Local Committees, Trade Unions, staff and the public

Business case agreed for the recruitment of social work staff to carry out reviews on people who access day services.

Recruitment is underway with some posts having been filled but not currently up to full capacity. Reviews are underway as part of the Promoting Independence programme and some of those people identified will be accessing day services. Additional priority cohorts of people that would likely benefit from the Promoting Independence programme will be identified.

the scale and pace of

delivery of the Extra

Care Housing (ECH)

Programme

Applications have been made under Extra Care “grant programme” and are being progressed for recommended award decision. Potential awards that were deferred during Q2 have been re-evaluated and recommendations made for decision by the Executive Director.

Development Framework mini-competitions for developments on Council owned sites have taken place and are currently being evaluated.

Grants and mini-competitions will be awarded

Priority delivery areas identified for 2019-20 together with potential Council sites to release under the Development Framework.

Further grant window to be opened on a targeted basis, pending the outcome of further mini-competitions to deliver schemes on Council owned sites via the Development Framework.

Resulting in


Financial impact due to the inability to reduce demand for services

as well as not diverting service users away from residential or

nursing care


12

Previous quarter

Current quarter

End Yr Target

DOT

12

12

12

3 4 3 4

Reputational impact and Loss of confidence in the Council


17

9. MANAGEMENT OF SIGNIFICANT CONTRACTS – Jo Atkinson


The Council has a failure in a ‘significant contract’.


Lack of timely closure of non-compliance issues, resulting in dispute escalation. Supplier/Market Failure to deliver the service required

Strengthen Contract Management – Performance, Risk Management & Internal Audit findings Governance and oversight provided by: - The Corporate Governance framework review was completed in February 2019 - Quarterly Reports on ‘significant contracts’ and the Amey Lessons Learned action plan are provided to DMT’s, CMT & Audit & Assurance Committee. Improvement Plans Amey Lessons Learned Action Plan is in place and being embedded in the organisation (Addressing lessons learned and Zurich Municipal Risk Management recommendations. Seven Themes from the Amey Lessons Learned findings require the following to occur in order to manage the risk:

1. Robust contract documentation 2. Strong contract management 3. Effective performance, information and risk management 4. Robust relationship management 5. Clear decision framework 6. Audit and peer reviews receiving prompt action and tracking 7. Legal Advice and communications to be as early as possible

As referenced above, the Zurich Municipal Contract Risk Management Review report and recommendations, dated 27 April 2018 is integrated into a single action plan. Combining the actions from the Improvement Plan and ZM report above will provide more robust assurance in relation to enhanced rigour; the embedding of such as routine, and the development of a more Learning Organisation type approach to reviewing and improving performance.

Strengthen Contract Management – Performance, Risk Management & Internal Audit findings

The Contracts Register is reviewed and risk assessed by directorates in relation to organisational impact should the contract fail

Embedding clear governance to challenge underperformance promptly

Ensuring Audit recommendations receive prompt action

Ensuring Peer/Internal Gateway reviews, where appropriate/proportionate, are acted upon

Strengthening processes, such as contract Exemption and Modification requests, in relation to contract and corporate risks

Proactively identifying and risk managing gaps in contract documentation/procedures

Developing ‘one team’/matrix management approach to problem-solving

Recording and taking actions on decisions clearly and promptly

Seeking and acting upon legal advice promptly

Investing in commercial aspects of contractual relationships.

Challenging underperformance, financial issues and/or timeliness promptly

A corporate approach/point of contact regarding initial early advice about contract disputes.

Lack of adherence to key Contractual terms/requirements Allowing various non –compliance and/or contract Change Controls to over accumulate.

Strengthen Processes & Procedures Current Strategy & Procedures -Sustainable Procurement Strategy -Contract procedure Rules -Corporate Contract Management Workbook and Guidance Procedure -Step by step guide to Commissioning, Procurement and Contract Management process, including links to Risk Management guidance -Ensuring adequate Business Continuity arrangements are considered and in place, as required

Strengthen Processes & Procedures

Implemented ‘Speak up’ arrangements to supplement ‘Whistleblowing’ policy.

Clarifying ownership at all stages throughout the commissioning/procurement/contract management lifecycle

Implementing a Learning Organisational approach to improving due process and realising benefits/performance outcomes

Strengthen Capacity and Capability Listed below are the top four most ‘Significant Contracts’ at Quarter 4. (As this is a ‘live’ process these will change in terms of contract risk and/or no longer be such, whilst new ones may be identified):

Connect (CNDR).

Residential Care.

Extra Care Housing.

Renewi (Waste).

Strengthen Capacity and Capability In order to further strengthen capability at specific business levels, a more tailored assessment is currently being undertaken through L & D, in addition to, a more robust oversight of contracts corporately. This will involve:

Continuing to embed roles and responsibilities during the commissioning/procurement/contract management lifecycle

Engaging with directorates to conduct a Training Needs Analysis for relevant Contract Management staff (Developing tailored training modules)


18

Roles and responsibilities are defined within the new Good Practice Contract Management Framework workbook. Contract Management, Corporate Governance & Risk Management training delivered to establish baseline understanding of good Contract Management.

Embedding individuals with appropriate skills, knowledge and experience.

Ensuring Boards have the appropriate skills, knowledge and experience to improve the effectiveness of delivered services.

Resulting in


Significant Contract(s) not demonstrating Value for Money. The effective management of significant and other

contracts is a cross cutting risk and has an extensive

impact on the delivery of the CPDP outcomes and

deliverables.


10

Previous quarter Current quarter End Yr target

DOT

15 10 12

3

5

2

5

Significant Contract & commercial consideration costs

Significant Contract breach/material breach, resulting in formal escalation of

disputes/early termination of contract

Reputational damage to the Council.


19

10.COMPLY WITH REGULATORY FRAMEWORKS & ACHIEVE GOOD INSPECTION RESULTS - Lynn Berryman, Fiona Musgrave, Dan Barton & Steve Healey

There is a risk that The Council fails to meet the standards set out within the regulatory CQC, Ofsted, SEND & HMICFRS frameworks.

Project specific

actions

Current controls & measures in place to manage the risk Quarter 1 planned improvements to controls & measures to manage the risk.

OFSTED Continuous Improvement Board & DMT Programme Board provide oversight of progress against the Children’s Plan, which consists of 10 recommendations

Ongoing engagement & good working relationship with Ofsted.

Weekly & Monthly Performance monitoring against KPI’s

Self-assessment has been completed and has been presented to the North West Director of Children Services for Ofsted. The letter confirming any actions or recommendations will be fed into the NW Peer Challenge Process.

Self-assessment is being refreshed in Quarter 1.

Auditing and performance management continues to be a key priority across the service with challenges still existing in pockets across the county.

Preparatory inspection meetings will now take place bi-monthly and chaired by AD Children & Young People.

CQC Governance & Oversight is provided by the Cumbria Health & Wellbeing Board

Reviewed Membership & Terms of Reference for Health & Wellbeing Board and refreshed the governance framework for the ways of working and decision making.

Health & Wellbeing Strategy in place

Health & Care Systems in North Cumbria & Morecambe Bay, leadership, governance, strategies & performance management in place.

Care Quality Commission Local System Review Action Plan for Cumbria in place to address 10 areas of improvement in four priority areas: ICT, Workforce, Communications & Engagement & Commissioning

A deep dive into the ICT workstream has been completed and assurances offered to the HWBB in January 2019. Work has been prioritised to deliver compatible Wi-Fi in all Cumbria NHS and LA for our workforces.

A deep dive on the workforce workstream has been completed and good progress is being made with a plan in place to deliver the remainder of the actions.

Identify Services that could trail blaze new workforce model

Develop & deliver a shared communications & engagement plan re digital uptake

Review the Health & Wellbeing Strategy, including priorities, Performance Management Framework and links to ICS.

HMICFRS

Dedicated Fire Reform team now established to lead, manage and coordinate the preparation and inspection

Updates on progress presented to Corporate Management Team (CMT) & to Cabinet Briefing

Attend National and Regional Briefing Sessions

An internal Fire and Rescue self-assessment has been carried out which has been benchmarked against the HMICFRS judgement criteria

Presentation have been delivered to Communities and Place Scrutiny Board and have agreed to establish a scrutiny working group to further support preparations

HMICFRS is a standing agenda on weekly Directorate Leadership Team meetings to ensure workloads are progressed

A progress update is verbally presented to the Service Management Team on a monthly basis

Service wide communications take place to ensure all staff are aware of the inspection and what the service is doing to prepare.

Regular contact is maintained with a dedicated Service Liaison lead from the inspection team.

All data requests are accommodated

Dates have been announced. CFRS discovery week will be w/c 22 April and the main fieldwork week will be w/c 17 June. Timetable for discovery week is in place and organisation of logistics will be completed early April. Timetables for fieldwork week will be agreed with HMICFRS in May.

Self-assessment submitted on 1 April.

Strategic briefing to be developed ahead of meeting with the inspectors is on 29 May 2019 with support from Communications, Performance and Intelligence and Audit teams.

Self-assessment and strategic briefing to be shared with ELT on 1 May.

Working group is meeting more frequently to ensure preparations are in place.

Sessions for staff being delivered from March – May to ensure they are aware of what is involved, the learning from other services and messages from the self-assessment

Significant communications activity underway and planned with additional support from the Communications team

SEND

(special educational

need (SEN),

disability or

additional needs)

The Council’s SEND Inspection Preparation Group provides monthly partnership oversight of inspection preparation.

Group has incorporated feedback from recent neighbouring inspections.

Governance provided by Children With Disabilities group of the Children’s Trust Board.

Updates provided to Health and Wellbeing Board.

Partnership Self Evaluation Form (SEF) and improvement plan being rewritten in readiness for SEND Inspection.

Audit of EHCPs added to the People monthly audit cycle.

The Local Authority SEND Inspection was completed during the week commencing 15.3.19.

The system Self Evaluation was largely validated, the direction of travel positive and there were no surprises about the areas requiring further improvement.

In anticipation of the SEND report publication, the County Council and Health partners are continuing to work on more robust development planning and higher level governance to focus on delivery for CYP with SEND.

More detail will be made available following publication of the inspection report.


20

Resulting in


Failure to deliver services to public/customers This is a cross cutting risk addressing the Council’s capacity to

meet regulatory standards and delivery good inspection results in

the listed areas above and as such it’s impact to CPDP is

extensive.

1.33 The implementation of the Council’s actions to deliver the

improvements set out in the Health and Wellbeing Boards’

response to the Care Quality Commission’s Local System review

of Cumbria Completed.


10

Previous quarter

Current quarter

End Yr Target

DOT

10

10

10

2 5 2 5

Failing to meet legislative requirements causing poor inspection

results, intervention by the regulator and potential loss of service(s)



21

11.SAFEGUARDING OF CHILDREN AND ADULTS - Lynn Berryman & Fiona Musgrave

There is a risk that there may be a serious failure in protecting children and adults at risk of abuse or neglect


Staff shortages: a lack of capacity or capability

Children’s Workforce Strategy; staff shortages still exist in West Cumbria and shortages have been met in the North and South of the County.

Following a recent reshaping it has been identified that the current Safeguarding Adult Manager does not have the staffing structure to support the development of safeguarding practice adult social care services. A review of current vacant posts has been undertaken to identify additional resource to support the Safeguarding Adult Manager

Safer Families Project in West Cumbria started in October 2018.

Staff shortages in West Cumbria continue to be addressed through proactive recruitment campaigns and transfers of children to Carlisle and Barrow.

The Safeguarding Adults Service Manager is to present an options proposal to members of DMT for consideration in pursuit of strengthening capacity within operational services for safeguarding practice.

The Adult Social Care restructure includes a growth bid to develop the transformation of the service which will enable the development of strength based approaches to free up capacity and improve staff wellbeing.

A recruitment campaign is being updated and will be launched in May 2019.

Policies, procedures

& protocols not being

clear, up to date,

understood and

adhered to

The Workforce & Practice Board provides management oversight Children:

A Policy Framework is in place and continues to be updated using TriX

An Audit Quality Assurance Framework is in place

A supervision Policy is in place Adults:

Adult Social Care are currently exploring adopting the TriX system to support this area of work.

Children’s Practice standards will be signed off and implemented.

Within Adults, the Strategic Investment Group approved capital investment to enable Adult Social Care to adopt the TriX system and a project group is now being drawn together and lessons from the implementation in children’s services will be used.

A new Safeguarding Case File Audit process will be introduced to provide assurance that policies, procedures and protocols are effectively understood and adhered to. The results of the audit will be provided to the teams and service areas to assist them in identifying key areas for improvement and learning.

There has been a recognition that performance in terms of adult safeguarding cases was not where we would want it to be. The service has undertaken a review of cases to ensure that people in Cumbria are safe, that processes are working appropriately and that we have plans in place to improve current performance. This review was reported to CMT in Quarter 3.

training and supervision being ineffective or inadequate

Performance measures for Supervision in Children’s Services are in place and monitored on a monthly basis

In Adult Social Care a new supervision tool is being developed to staff development.

Safeguarding Training is mandatory and compliance will be monitored.

The Children’s Workforce training plan is under review.

In Adults, work continues via the Countywide Workforce Development Group to develop a new Supervision Policy.

The Safeguarding Passport has been refreshed and is applicable to all staff groups within Adult Services. The passport has been uploaded to iTrent to monitor compliance and engagement. Briefings to staff will be provided via the CSAB news update.

Practice Learning Hubs are undertaken in each division on a quarterly basis by the Safeguarding Service Manager to provide regular updates on any key policy or practice updates. The sessions also provide an opportunity for practitioners to reflect and discuss key practice issues relating to Safeguarding Adults.

Breakdown of partner relationships.

Cumbria Local Safeguarding Children Board (LSCB), business plan and performance monitoring is in place to provide oversight, challenge partners and monitor partners individually and collectively.

The Cumbria Safeguarding Adult Board has engaged in a number of Board Development Sessions commissioned by the new Independent Chair. Key partners to the Board are now also identified as Chairs to the Board Sub-groups to support engagement and agency ownership.

2017-18 Annual Reports and 2018-21 Business Plans signed off for the LSCB and the CSAB.

A further CSA Board Development session took place on 2nd October with all partner organisations in attendance. Focused action plans resulting from this have been developed and residual actions will be incorporated into the 2019-20 Strategic Plan. A new scorecard is being developed to increase assurance and oversight.

The new legislative framework for Children’s Safeguarding Arrangements is being overseen by a “Executive Board” for the Safeguarding Partners. The plan for the new arrangements is being developed with the strategic partners and will be published ahead of the 29 June 2019 deadline, ready for implementation on the 29 September 2019.

An LSCB Peer Review too place on the 6-7 March 2019 focussing on readiness for the new safeguarding arrangements – feedback has been largely positive with the LGA suggesting the LSCB is a strong partnership, is well-led and is in a good place to move forward with it’s plans.

Further development sessions for Cumbria Safeguarding Adult Board is being planned to continue the progress that has been made to date.


22

Resulting in


Serious injury or death to a child, young person or adult


10

Previous quarter

Current quarter

End Yr Target

DOT

10

10

10

2

5

2

5

Investigations carried out by - A safeguarding Adults review (SAR) or

Serious Case review (SCR)

Liability claims against the Council



23

12. HEALTH & SOCIAL CARE INTEGRATION – Fiona Musgrave

There is a risk that The Council will not be able to maintain the pace required to deliver a fully integrated Health & Care Service aligned to ICC’s


Competing priorities within CCC (due to financial challenges)

Currently reviewing the integration arrangements and exploring opportunities for co-location of health and care services to maintain current management arrangements to deliver against CCC MTFP’s whilst delivering improved joined up services to the people of Cumbria.

Pilot co-location of health and care teams identified in the Eden ICC a memorandum of understanding is being developed that will be the blueprint for future co-location opportunities.

On-going discussion about future team forms and phased implementation of phased integration of Reablement and Rehabilitation supported by a section 75 agreements in the North.

Transfer of learning between North and South Cumbria ICC development to ensure more consistent delivery.

Paper describing the current position and plans going forward – presented to CMT in February 2019.

Presentation to ELT to widen organisational understanding and buy-in

People Team Brief included and integration item - ready for the April brief.

Internal Integration Board established to ensure direction of travel fits with organisational expectations, communication and engagement improves and the Integration agenda is being driven according to Council priorities.

Phase 3 for both North and South systems is being agreed signed off.

Eden ICC and Eden Social Care are now co-located in the Lonsdale Unit in Penrith Hospital. The work to evaluate the success of this move and any lessons has been completed and results are expected in the coming weeks.

Work is well underway to implement the first phase of Reablement and rehabilitation integration – with the implementation of the pilot now expected to start on 8 April 2019.

Development of a robust OD plan to support managers and practitioners with new ways of working and working across organisational boundaries.

Learning from both the North and South Systems was shared at a joint event in November which was well-attended by both systems and was supported by CLIC and BLIC. Further events are planned for the spring.

Sign off of ICC phase 2 in North Cumbria has been agreed by the SLB at their meeting in January with a focus on community development and population health.

Resulting in


Failure to deliver a well- integrated service to our customers/the public 1.2 Integration of health and care services within Integrated Care

Communities in Cumbria planned.

1.9 The initial integration of health and care services within

Integrated Care in Cumbria Implemented.


8

Previous quarter

Current quarter

End Yr Target

DOT

8 8

8

2

4

2

4

Failure to meet legislative requirements

Failure to deliver CCC CPDP outcomes/partnership outcomes

Reputational damage to the Council/Partnerships

council corporate riskcouncilportal.cumbria.gov.uk/documents/s92715... · appendix 2 quarter 4 -...

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