Building Pride in Cumbria
MANAGEMENT AUDIT UNIT
INTERNAL AUDIT REPORT
A REPORT FOR:
CUMBRIA STRATEGIC PARTNERSHIP
ON:
LOCAL AREA AGREEMENT – STRETCH TARGETS
Draft Report Issued: / December 2008Final Report Issued: / January 2009
1.0 INTRODUCTION
1.1 This audit review was carried out by Mike Roper (Principal Auditor – Accountable Bodies & Partnerships) as part of the Management Audit Unit's strategic plan of activity.
1.2 The previous review of LAA arrangements, including an evaluation of processes in place for recording and monitoring the performance of stretch target indicators was reported to the Cumbria Strategic Partnership Executive Board on 14th May 2008.
1.3 See Appendix A for a detailed list of staff from CCC & external partners who have assisted Management Audit with this review.
How This Audit Assists The Council To Achieve Its Goals
1.4 The Cumbria LAA sets out performance objectives across a range of outcomes, delivered in partnership with other organisations. These can be linked to the corporate themes set out in the Council Plan 2007-2010. CCC is responsible for ensuring the specified outcomes are achieved.
2.0 BACKGROUND
2.1 The LAA commenced on the 1st April 2007 as a three-year agreement between partners in Cumbria and the Government; setting key priorities to improve quality of life in the county. The agreement included fifteen performance indicators with “stretched*[1]” three-year targets, based on the provision of pump prime funding*[2] of £1,252m. Achievement of targets in each area will result in a proportionate share of reward monies totalling £15.1m (£1.26 m per area).
2.2 The full LAA has been refreshed from 2008/09, with the stretch targets retained as legacy indicators. No changes have been made to targets or timescales for the programme.
3.0 AUDIT SCOPE
3.1 The objective of the audit was to ensure:
· Agreed actions relating to previous recommendations for legacy (stretch) indicators have been appropriately embedded.
· Monitoring and reporting systems for legacy indicators not in place / reviewed at the time of the previous review are suitable and robust.
· Suitable, clear and complete audit trails are documented to support reported performance to the end of 2007/08 for all legacy targets.
· Methodology of forecasted performance to end of stretch target programme is reasonable.
· Actions have been identified to ensure stretched targets are achieved (including additional arrangements in place to mitigate any underperformance).
4.0 OVERALL EVALUATION, CONCLUSION & RECOMMENDATIONS
4.1 EVALUATION
4.1.1 The evaluation of controls is based on testing carried out at the time of the audit, usually based on sampling. Internal Audit assesses the controls operating in each audited area as ‘good’, ‘satisfactory’, ‘fair’ or ‘weak’. This assessment is based on the number and grading of recommendations made.
4.1.2 Overall Management Audit has assessed processes as satisfactory. However, given the potential financial value of these awards it is important that control issues identified in this report are applied to the remainder of the programme, which will include some verification of historic data.
4.2 CONCLUSIONS
4.2.1 Generally, processes for monitoring and reporting performance for the legacy indicators are suitable and robust, though inconsistencies have been identified in places between reported performance and source documentation. There is a need to simplify and refine particular processes as well as identifying areas where training is required to improve consistency.
4.2.2 There is the possibility that recorded performance is subject to scrutiny prior to the payment of award grants, so it is important that the responsible officers are confident of the accuracy of reported performance.
4.2.3 Progress against achieving targets is generally also progressing well to date; though areas of improvement have been identified. As timescales continue to tighten and targets become increasingly difficult to achieve it is important that progress is closely monitored on a timely basis and any emerging underperformance is identified, with remedial actions identified and monitored.
4.2.4 Particular focus is needed on those indicators currently under-target, to ensure proposed actions to improve performance are effective.
4.3 RECOMMENDATIONS
4.3.1 The recommendations made in this report are graded in accordance with their perceived importance. The grading falls into the following categories:
Grade 1: Major recommendation that indicates a fundamental control weakness that must be addressed.
Grade 2: Recommendation which should be addressed in order to establish a satisfactory level of internal control.
Grade 3: Minor recommendation made to improve the system under review.
4.3.2 A total of seven recommendations have been made as a result of testing carried out, which have been split into individual appendices for each area as follows:
· Appendix C – Summary of Recommendations and Action Plan (for the attention of the LAA Stretch Target Coordinator - DSG).
· Appendix D – Summary of Recommendations and Action Plan (for the attention of the Head of Waste Management).
· Appendix E – Summary of Recommendations and Action Plan (for the attention of the Cumbria Strategic Partnership Manager).
· Appendix F – Summary of Recommendations and Action Plan (for the attention of the Acting Lead Officer Supporting People, Adult Social Care).
5.0 FOLLOW UP TO THE PREVIOUS AUDIT REVIEW
5.1 The previous review of the LAA, reported in May 2008 resulted in five agreed actions relating to the monitoring and reporting of stretch target indicators. This was followed up as part of this audit review, as detailed below:
RECOMMENDATION & GRADE / AGREED ACTION & DATE / ACTION TAKEN / COMMENTSEscalation processes agreed as part of the new LAA need to be invoked where underperformance or failure to report performance is identified. / 2 / Action included in report to CSP Executive Board on 14th May 2008, under ‘lessons learned’ in 2007-08. (New LAA effective from 30-06-08.) / No / Four indicators under target by the end of 2007/08. No actions identified to address underperforming areas as part of 2007/08 year-end reporting in May 2008.
RECOMMENDATION & GRADE / AGREED ACTION & DATE / ACTION TAKEN / COMMENTS
Supporting information received from District Councils to support average length of waiting time for major adaptions should be retained on file / 1 / a) County Manager for Physical Disabilities to keep a file of supporting information from district Councils for average waiting times for
Approval of Disabled Facilities Grants for major adaptations for each of the three years from 2007/8 to 2009/10.
b) An electronic copy of above to be maintained by Adult Social Care Performance Team
c) District Council information to be cross-checked with referrals made by OTs on Adult Social Care database by Performance Team.
d) Each of 6 District Council grants officers to be asked to sign Adult Social Care Data Quality Agreement by 15/5/08
e) Monitor action plan with 6 district councils at quarterly meetings (15/5/08) / In-part / Quarterly returns now standardised and retained upon receipt.
Data quality agreements signed by each district.
However, some anomalies still identified between returns and supporting documentation.
A copy of spreadsheets used to calculate the percentage of municipal waste recycled and composted should be retained on file. / 2 / A copy of the spreadsheets will be retained on file / Yes / Copy spreadsheets now retained on file.
A review of spreadsheets used to calculate the percentage of municipal waste recycled and composted should be carried out to ensure that information is recorded accurately / 2 / Spreadsheets will be reviewed on a monthly basis / No / Various inaccuracies identified between performance spreadsheet and raw data.
Quarterly reporting forms for the Department of Health recording the number of 4 week quitters will be supplied by Barbara Bellis the manager of the Stop Smoking Service. / 2 / Quarterly reporting forms for the Department of Health recording the number of 4 week quitters will be supplied by Barbara Bellis the manager of the Stop Smoking Service. / Yes / Relevant information made available during audit review.
5 DETAILED FINDINGS & RECOMMENDATIONS
6.1 Performance Information (Stretch Targets).
6.2.1 Discussions were held with responsible officers for each indicator (see appendix A) and audit testing was carried out in line with the scope detailed in section 3.1. An individual summary of findings for each indicator can be found in the table at Appendix B.
2007/08 Performance
6.2.2 Generally, performance reported for the end of the first year of the stretch programme, as reported to the CSP Executive in May 2008 (based on information within Performance Plus), was agreed to supporting systems (bespoke databases / spreadsheet records etc.). A sample of records was also traced to supporting source documentation. Some discrepancies have been identified as detailed below:
Average Length of Waiting Times for Major Adaptions
6.2.3 Performance of 22.49 weeks to the end of 2007/08 was calculated using erroneous data. A recalculation of performance once these records had been removed / corrected resulted in actual performance for the year of 25.2 weeks, still well within the target for the year of 39 weeks.
6.2.4 It is not clear from the agreement with GONW whether the final stretch target is based on performance in the final year, or for the cumulative length of the project. If it transpires to be the latter, adjustments will need to be made to performance to date.
6.2.5 Errors were due to both the last minute nature of the calculation being carried out and inconsistencies in the format of the quarterly returns provided by the District councils. A Stretch Target Coordinator has since been employed to monitor processes in place for this indicator. A standard return has now been developed to be completed by the districts on a quarterly basis.
6.2.6 Inconsistencies were identified between the 2008/09 quarter one returns and supporting documentation. These differences impact on the accuracy of reported performance. The County Coordinator is aware of these anomalies and is intending to roll out further training and development to ensure information is recorded consistently.
Percentage of municipal waste recycled and composted.
6.2.7 A number of apparent anomalies were identified between reported performance and source data provided to support this indicator, with audit trails incomplete in places. Anomalies have been forwarded to Waste Management Unit. A review of landfill data indicated initial Waste Management figures were generally accurate. Instances were also identified that recycled data reviewed was also generally accurate, though this review has not been complete. It is important Waste Management are able to demonstrate to external inspectors that reported performance accurately reconciles to supporting documentation.
6.2.8 Processes for reporting data are currently cumbersome, with data being input to various different spreadsheets prior to being used in the indicator calculation. This increases the risk of erroneous data being included, as spreadsheets have not always been updated as new figures are received.
6.2.9 As from 2008/09 a new database system is to be introduced, which will automatically provide this information from source data supplied by providers, simplifying the input process. However, this will only be used for one of the three years of the stretch programme. Assurances are still required that clear audit trails can be established for data from 2007/08 and 2008/09.
6.2.10 There were also difficulties in tracing audit trails due to a responsible member of staff leaving the authority. Audit trails need to be established that are clearly documented and relatively simple to follow. This will enable staff to check data more easily prior to submission and will also allow external inspectors to verify information.
6.2.11 It was not possible to trace data submitted relating to HWRC (Household Waste Recycling Centres) data to supporting transaction spreadsheets, as this information has not been provided to CCC (due to changes in the providers processes) since December 2007. The Performance Manager is currently in discussions with the provider to establish processes which will allow Waste Management to perform monthly audits of this data.
6.2.12 Further exercises are still being carried out my Management Audit to confirm data for two of the indicators:
· SP Service users (16+) who are supported to establish and maintain independent living.
· Percentage reduction in the number of Prolific & Priority Offenders.
6.2.13 MAU will report results from these exercises separately, once completed.
Projected performance 2009/10
6.2.14 Lead officers for each indicator provided the Performance Unit with projected performance for the end of the stretch target programme for their respective targets, as detailed in Appendix B. Eleven of the twelve indicators are currently forecast to achieve the stretch target by the end of the 2009/10 project.
6.2.15 Of these eleven, eight are achieving their target to date, indicating they are capable of achieving the 2009/10 stretch target. However, there is no room for complacency; as targets continue to be stretched they will become harder to achieve; resources will become tighter and actions to improve performance further may become more challenging, particularly within the current economic climate. Timescales for turning around any fluctuations from target will also become increasingly shorter.
6.2.16 As at 30th September 2008 four indicators were identified as underperforming. Actions have been identified by responsible officer to address underperformance, to ensure achievement of final targets (see below for more details). Assurances are required that these action plans are effective and that targets begin to be achieved within these areas.
Number of people stopped smoking for four weeks.
6.2.17 As at the end of 2007/08 this indicator was underperforming by 20%. Performance to September 2008 is still under by a similar rate, however it has improved from this time last year. Performance is expected to continue to improve partly due to extra funding and partly due to seasonal variations (more quitters in January).
Percentage of repeat victims of domestic violence.
6.2.18 As at the end of 2007/08 this indicator was underperforming by 7.5%. Performance to September 2008 is under by 4%. The overall performance figure does not demonstrate improvements in areas where action plans have been fully implemented and are now achieving the target. Actions have now been rolled out county-wide and the indicator is expected to be within target by the end of the programme.
Number of fire related deaths and injuries per 100,000 population.