NORTH YORKSHIRE COUNCIL
AUDIT COMMITTEE
15 DECEMBER 2025
ASSESSMENT OF EFFECTIVENESS OF GOVERNANCE ARRANGEMENTS – HEALTH AND ADULT SERVICES
REPORT OF THE CORPORATE DIRECTOR – HAS
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1.0 PURPOSE OF THE REPORT |
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1.1 To inform members of the results of the annual review of governance completed by the Health and Adult Services Directorate. The review has compared the governance arrangements which have operated within the Directorate over the last year with the Council’s expected principles of good governance as set out in the local code of governance. |
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1.2 To provide details of the updated Risk Register, and the management of key risks for the Health and Adult Services Directorate. |
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2.0 Overall Assessment
2.1 The overall conclusion of the assessment of the effectiveness of governance arrangements for the Health and Adult Services Directorate is that the governance arrangements operating in the Directorate in the last year have met the Council’s expected principles of good governance, as set out in the Council’s local code of governance. The evidence for this is described in the sections below, particularly section 6 of this report.
3.0 BACKGROUND
3.1 The Accounts and Audit Regulations (2015) require the Council to conduct a review, at least annually, of the effectiveness of its internal control systems and to report the results as part of the Annual Governance Statement.
3.2 The Council has approved and adopted a local code of corporate governance which is consistent with the principles of the CIPFA/SOLACE Framework Delivering Good Governance in Local Government (2016). Annual reviews of the effectiveness of each Directorate’s governance arrangements are undertaken and reported in accordance with the Audit Committee’s agreed work programme.
3.3 This is the first report in this format on the Directorate’s governance arrangements. It covers the period from December 2024 through to November 2025. The format and content will be refined in future years following engagement with the Audit Committee through this and other directorate reports. The intention in this report is to provide an assessment of the effectiveness of established governance arrangements in the Health and Adult Services (HAS) directorate.
3.4 To deliver effective and efficient services, the directorate must have a solid foundation of good governance and sound financial management. The directorate has a broad range of governance arrangements in place as well as a strategic monitoring and oversight role to ensure good governance is in place.
3.5 The directorate aims to ensure that governance arrangements are proportionate and focused to enable services to deliver value for money across all of our activity. We will continue to amend and improve our governance arrangements in that regard. For example, in recent years, the directorate has established additional governance arrangements for contract management, climate change and capital delivery to strengthen and co-ordinate our oversight and actions. These – and other governance arrangements - are not static but evolve incrementally to respond to emerging requirements or gaps as well as other changes within the council or from external issues.
3.6 In carrying out an annual assessment of effectiveness of the directorate’s governance arrangements, we have considered:
- Outcomes and overall performance with regard to our statutory obligations and organisational objectives;
- Consideration of the directorate’s governance arrangements with regard to the principles, sub-principles, actions and evidence contained within the agreed North Yorkshire Council Local Code of Corporate Governance. The seven key principles include:
Principle A: Behaving with integrity, demonstrating strong commitment to ethical values, and respecting the rule of law
Principle B: Ensuring openness and comprehensive stakeholder engagement
Principle C: Defining outcomes in terms of sustainable economic, social and environmental benefits
Principle E: Developing the entity’s capacity, including the capability of its leadership and the individuals within it
Principle F: Managing risks and performance through robust internal control and strong public financial management
- Assurance from external inspection and regulators as well as from internal audit reports;
- The strategic risks identified through the Directorate Risk Register and the internal control frameworks that the directorate has in place to manage those risks;
4.0 ASSESSMENT OF EFFECTIVENESS
4.1 HAS 2030 is a document[1] which sets out how North Yorkshire’s Health and Adult Services (HAS) will change by 2030, including developing new services, improving existing services and saving £13 million by 2028. The HAS directorate comprises Public Health and Adult Social Care services and our plan has been developed by a cross-section of colleagues, as well as building on feedback we have had from people who use our services and their carers.
4.2 This working document will evolve over the next five years and will guide detailed service plans, as well as joint strategies with the NHS and other community partners. It should be read alongside the North Yorkshire Council Plan.
4.3 This document is effectively our Service Plan and it supports, among other priorities, the four key governance developments that were highlighted in the report to this Committee in December 2024:
· Financial Pressures and the Social Care Market
· Pressures arising from Hospitals
· Workforce
· CQC Assurance and Improvement Priorities
4.4 Section 5 of this report briefly summarises progress against these areas and provides an updated position on each. The second part of this report highlights a number of actions and checks to support the Directorate’s assessment of effectiveness.
5.0 UPDATE ON KEY GOVERNANCE DEVELOPMENTS
Financial Pressures and the Social Care Market
5.1 The Directorate continues to experience financial pressures. The predicted overspend of £2.5m as at Q2 is lower than previous years (£7m in 2024/25), and the financial governance described in this report is helping to manage such pressures. Full details of the position can be found as part of the Executive Q2 report[2], but in particular, we continue to see very high levels of hospital discharge activity with costs exceeding the additional grant from central government. Hospital discharge activity averaged 16.3 discharges per day during Q2 compared with 15.2 per day recorded for Q1. For the year to date (Apr-Sep), activity this year has been running at broadly similar levels to those experienced during 2024/25. Work is ongoing with the NHS to review a fair apportionment of costs between agencies.
5.2 This pressure is a contributing factor to the short stay beds cost reductions being behind target at this stage. Moreover, additional senior management capacity has been moved to focus on the short stay pathways and targets.
5.3 Increasing numbers for DoLS (Deprivation of Liberty Safeguards) accounts for £800k of the overspend as we try to bring waiting times down for people. A new risk for this area has been added to the Risk Register (section 7).
5.4 Some progress has been made in bringing our average costs of packages of care down closer to national averages and in particular the rate we pay for home care is now 3.8% above the national average, compared with 7.8% last year and 19.5% in 2023/24.
5.5 The Directorate continues to look at ways of managing the market and controlling costs. An example of this is the approval, subject to individual business cases, and budget of £59.2m to build up to five Care and Support Hubs to replace the existing Elderly Person’s Homes in North Yorkshire. These are expected to release significant revenue savings with regard to dementia and intermediate care costs. A new risk regarding this project has been added to the Risk Register (section 7).
Pressures arising from hospitals
5.6 As described above, we continue to see cost pressures from hospital discharges and discussions are ongoing with the Integrated Care Boards (ICBs) to revisit how this pressure is funded.
5.7 The effect of this is being seen in the number of Short Stay packages of care. As shown below, a steady reduction in these continued up to December 2024 but at that stage they rose again and this is causing a financial pressure. As referred to below in the review of effectiveness (6.29), this is an area where actions are in place to ameliorate the financial impact to the Council and to ensure this trend is corrected.
Workforce
5.8 Section 6.23 - 6.25 highlight our governance arrangements in respect of workforce. However a summary of developments is provided below:
Recruitment and market position
5.9 In North Yorkshire, and as reflected nationally, we continue to see an upturn in the number of filled Adult Social Care roles. This has largely been driven by a rise in international recruitment, and the introduction of a Care Worker visa route in 2022. Skills for Care and Capacity Tracker data suggests the vacancy rate in North Yorkshire was 6.9% for 24/25 which is up very slightly from 6.4% in 23/24 against a 7% national figure within the sector.
5.10 During 2025 there has been a significant number of changes to immigration policy, including to the Health and Social Care Visa, this is in addition to the removal of ability for care workers dependents to come to the UK which ceased in 2024, this may be an indication as to the slight increase in vacancies.
Yorkshire and Humber International Recruitment (YHIR) Funded Programme
5.11 The focus of the international recruitment fund is to provide a matching service to migrant workers whose employer has had their licence revoked, to help them secure new ethical and compliant sponsorship.
5.12 According to UKVI there are 5,065 displaced care workers affected by revocation in Yorkshire and Humber (September 2025). 3,031 (59.8%) of these have sought support through the Yorkshire and Humber Regional Recruitment Project (YHIR) of which 1,927 (63.6%) were in-region and eligible. Of these, 430 people (22.3%) have been successfully placed in new roles, and additional 321 (16.7%) have discontinued support. The focus is to reach more displaced workers and place more workers with ethical, sustainable sponsors. DHSC confirm that Yorkshire and Humber are the highest performing region in terms of displaced worker matching.
5.13 Intelligence from both workers and providers indicates that there continues to be non-compliance with the requirements of sponsorship across the Yorkshire and Humber region, potentially both deliberate and through lack of proficiency from providers. This is being addressed by the YHIR project through close working with local Commissioning teams and reporting to the Sponsorship Alliance and Investigations Team, and Gangmasters Labour Abuse Authority where appropriate. It requires Project Workers to be diligent and knowledgeable about the sponsorship requirements. The programme also publishes advice and guidance, delivers webinars and proactively seeks to support providers with their understanding of their obligations and how to meet them in addition to supporting migrant workers ‘know their rights’ and gain pastoral support.
5.14 Our internal NYC vacancy position is reflective of the market, with a 4% vacancy rate for our Care Provider Services and 3% in our Social Care/Assessment Teams, which is carefully managed through an established vacancy panel.
5.15 This improved vacancy position has resulted in a continued decrease in agency spend during 2024/25 – a reduction in spend of just over 50% compared with 2023/24, which we project to continue to decrease into 25/26.
5.16 Given the sustainability issues linked to international recruitment and the growth we need to see within the workforce to support population projections, we know we need a continued focus on future pipelines of resource and talent and innovative approaches to recruitment.
Wider workforce matters
5.17 The HAS People Strategy Group (made up of a cross section of HAS Managers and Officers), has co-produced a workforce development plan for HAS addressing the key corporate People Strategy Themes. This will include specific actions and plans addressing recruitment and attraction, retention (incl. employee wellbeing), engagement and delivering a one-Council approach.
5.18 The biggest current workforce challenge relates to absence from work due to ill health. The number of days lost due to sickness per FTE for 24/25 was 13.31, which was well above the target of 8 days per FTE, but a slight decrease from 13.56 days lost per FTE in 23/24.
5.19 The main reason for absence continues to be stress, depression and anxiety which has been consistent across the year, accounting for just under 40% all absences, followed by musculo-skeletal problems.
5.20 The HR team is continuing to work closely with managers to ensure proactive absence management and to reduce absence rates. A HAS Workforce Wellbeing group is now well established and has developed a specific targeted HAS action plan, specifically focussed on absences related to Mental Health and Musculo-Skeletal conditions. As part of the “Get Britain Working” Trailblazer, alongside the Environment Directorate, we are piloting a referral scheme into a preventative funded offer for staff in Harrogate and Selby who are experiencing work-related challenges due to musculoskeletal (MSK) conditions. The goal is to improve health, wellbeing, and functional ability, reduce MSK-related absenteeism, and support individuals in staying in or returning to work. We will analyse the impact of this scheme in April 2026 to influence and shape any ongoing prevention offer.
5.21 The launch of a revised and streamlined corporate Attendance Management Policy will bring together a more focussed and consistent management of absence across the new Council, with new refreshed resources, including a focus on Wellbeing Passports to support people back to work earlier.
Fair Pay Deal
5.22 There is no pre-existing law on sectoral agreements in the social care sector and for those staff employed by private organisations salaries, terms and conditions are set by individual employers.
5.23 In October 2024, the Government published the Employment Rights Bill. A key aim of the legislation is to enable the creation of an Adult Social Care Fair Pay Agreement for the Adult Social Care (ASC) sector.
5.24 The Department of Health and Social Care are currently consulting on the arrangements for the establishment of the Social Care Negotiating Body (ASCNB) and Fair Pay Agreements (FPAs). Whilst this is welcomed by the sector to support an equitable and fair set of terms and conditions to appropriately recognise the skilled workforce in adult social care, the process does pose some risks.
5.25 We are working with ADASS, the LGA and other Local Authorities to respond to the consultation which runs to mid-January 2026, which includes the following points:
· Sufficient funding will be required to ensure that Fair Pay Agreements (FPAs) can be implemented without adversely impacting local government budgets, services and jobs. Once the body has been established, sufficient resourcing will need to be provided for employers to be able to deliver and implement the agreements reached by the ASCNB. Uplifts to pay, terms and conditions will need to be funded by central government and passed to councils/ employers to ensure they can be implemented without putting further strain on budgets and potential market fragility risk.
· Local Government representation on the ASCNB both as an employer and in relation to its role as social care commissioners. The proposed employer structure does not give sufficient representation to Local Government as substantial direct employers of care workforces.
· Equal Pay risks to councils could increase as a result of creation of a different negotiating body for directly employed staff. Given that front-line care workers employed by councils earn, on average, above the rates paid by private sector care employers (and more favourable terms and conditions, such as Local Government Pension Scheme) the initial fair pay agreements are unlikely to be of benefit to council-employed adult social care staff. The consultation suggests that workers can be covered by the ASCNB as well as another negotiating body, but this is not the case for those staff covered by the Local Government Services NJC. The constitution of the ‘Green Book’ precludes those covered by it from also being covered by another negotiating body so this would remove adult social care staff from the ‘Green Book’ pay settlements etc. If council-employed ASC staff are included within the scope of the FPA this could raise concerns in relation to differential rates of pay/pay rises being applicable to adults’ and children’s social care staff. In addition to those providing care, those in scope also includes qualified Social Workers and Occupational Therapists.
5.26 Consultation on the proposals closes on 15 January 2026.
CQC Assurance Framework and Improvement Priorities
5.27 North Yorkshire Council has now been inspected and has received an overall rating of “Good.” As can be seen from the diagram below, this was a very strong “Good” and at the time of writing was the 4th highest outcome for any Council in England (with around half of all council results now published).
5.28 Action planning has commenced across all domains covered within the CQC assessment where feedback and recommendations have been made, these are largely in line with existing plans detailed within HAS 2030 and adult social care improvement priorities which form part of our journey of continuous improvement.
6.0 REVIEW OF GOVERNANCE
6.1 A review of the Directorate’s governance and comparison against the principles was undertaken in November 2025 and the following sections summarise this. While this is a continuous process there are no omissions to report at this stage to the Committee.
Principle A: Behaving with integrity, demonstrating strong commitment to ethical values, and respecting the rule of law
6.2 The Directorate complies with the Council’s Standards of Conduct Policy which applies to all employees. Failure to observe the standard set out in this Policy and related documents will be regarded as serious, and any breach will render an employee liable to disciplinary action, which may include dismissal. In addition, there is a requirement for officers who manage budgets to complete a Register of Employee interests form, and an annual “related parties questionnaire” - declarations are also reviewed as part of the annual IPM process. There is a published Whistleblowing Policy and Managers Guidance available – of which all complaints raised are flagged with our auditors, Veritau.
6.3 To maintain an ethical practice a Conflict of Interest register is in place for staff, which includes measures such as blocking access to the Liquidlogic Adults (LLA) system where appropriate. Any gifts received staff are handled transparently and donated to services where suitable.
6.4 To ensure appropriate ethical behaviour of external suppliers, the Directorate relies on:
· External validation e.g. Regulator of Social Housing for Supported Living / Housing providers, TSA for TEC services
· Clear policies – e.g. Sustainability Policy (for the market and providers); Top Up Policy
· Focus in contract management on building trusted relationship with providers (transparency and fairness)
· Strong provider engagement – forums, surgeries, ICG contract in place
· Independent Care Group (ICG) involvement in annual fee conversation
Principle B: Ensuring openness and comprehensive stakeholder engagement
6.5 The Directorate promotes openness and transparency through clear communication and robust governance processes. Engagement with providers is supported by communication at groups such as Care Connected and Partners in Care, which ensure regular dialogue and collaboration. The Quality Pathway underpins work with external providers, embedding standards and encouraging openness, while actively promoting whistleblowing to safeguard integrity. These arrangements foster internal challenge, self-assessment, and stakeholder confidence in the Directorate’s commitment to transparency. A quarterly Q&A session is held with the DASS and other senior leadership team members where people are able to come and ask questions or challenge the Directorate.
6.6 Health and Adult Services have a dedicated Involvement Team whose function is to oversee and monitor engagement activity across the Directorate. The team are made up of specialist engagement officers who support the directorate in undertaking a variety of engagement projects. In addition, the team support in the facilitation of user-led groups and forums such as the North Yorkshire Disability Forum and its local groups and the North Yorkshire Learning Disability Partnership Board.
6.7 A HAS Involvement Framework and charter was launched in October 2024, setting out the Directorate’s commitment to the involvement of people with lived experience and setting out expected standards of all HAS staff to engage with those using our services and families and carers in their work. As part of this a new level of governance and monitoring of engagement activity will now take place, monitored by a new Strategic Co-Production Board which will oversee and plan strategies and policies for co-production across Adult Social Care and Public Health for the year ahead. It will also review the HAS engagement forward plan, setting out all Directorate engagement projects, twice a year. The group is chaired by the Director of Public Health and includes people with lived experience.
6.8 Under this new governance process, at the end of a project, individual involvement projects will be asked to assess and score the work against a set of criteria linked to the Involvement Charter. People with lived/living experience and communities who have been involved will be invited to be involved in this process, including providing feedback about their experiences. This will then be shared with the strategic board. The results from these will be aggregated and scores publicly reported annually as part of an Involvement Annual report, which will also celebrate the pieces of work that have taken place throughout the year and will be a co-designed and produced document.
6.9 The Directorate helps to ensure openness and comprehensive stakeholder engagement via the following partnerships:
· Thriving Communities Partnership: brings together representatives from statutory and third sector partners across the county and is the key leadership body for the VCSE sector, working with the Council and the NHS and other bodies. The overarching purpose of the Partnership is to work collaboratively towards a shared vision for community and voluntary, community and social enterprise sector (VCSE) development.
· North Yorkshire Safeguarding Adults Board: brings together a combination of NHS, Police, local government, independent and voluntary sector and community partners seeking to ensure that adults who may be vulnerable are well and safe.
· North Yorkshire Place Board - the North Yorkshire Health and Care Partnership (NYHCP): includes health and care organisations from across North Yorkshire who are working together to improve the health of our population.
· The North Yorkshire Market Development Board: oversees the Council’s Care Act duties relating to market shaping and oversight of care market. It facilitates collaboration with partners to ensure provision of health and care is aligned with the diverse needs of local communities and contributes to meeting the Place Board objectives.
· The North Yorkshire Health and Wellbeing Board: a statutory committee of North Yorkshire Council and provides a forum where political, clinical, professional and community leaders from across our health and care system come together to improve the health and wellbeing of our local population and reduce health inequalities.
· Improvement and Inspection Leadership Board: to ensure North Yorkshire Council’s Health and Adult Services Directorate is prepared for the CQC’s new assurance process, and the Directorate uses this process as an opportunity to embed continuous improvement in how well it meets its statutory obligations moving forward
· Integrated Community Health and Social Care Board: provides strategic direction on the operational delivery of the services delivered by HARA (Harrogate and Rural Alliance). Implementation of the decisions taken by the board shall be under the overall direction of the Alliance Director as the lead operational manager, as reflected in the Partnership Framework
· North Yorkshire and York Place Quality Board: looks at quality issues across the NY and Y system reporting / escalating to the ICB system quality group as appropriate.
· Carers Round Table: a forum set up in April 2024 to provide a regular opportunity for an unstructured and open discussion between HAS and the lead VCSE organisations providing support to carers about the key areas that impact on strategic support to adult unpaid carers. It is an opportunity to explore areas of shared concern, develop a better understanding of the factors that impact on carers’ lives and work better together.
· North Yorkshire Learning Disability Partnership Board: co-chaired by person with a learning disability and/or autism and independent co-chair. Aims to improve lives of people with a learning disability and/or autism. Includes a subgroup for Health and Wellbeing.
Principle C: Defining outcomes in terms of sustainable economic, social and environmental benefits
6.10 HASLT (Leadership Team) members are responsible for ensuring that they discharge the Duty to Pay Due Regard under the Equality Act 2010 Public Sector Duties on new, or significant changes to, policy, strategy and services. This is evidenced through the completion of equality impact assessments (EIAs), and HASLT as a body has responsibility for ensuring that EIAs are completed to a satisfactory standard and prepared at the appropriate stages to inform decision-making. HASLT is supported in this by the HAS Equity, Equality and Inclusion steering group, which in turn is represented on the Corporate Equality, Inclusion and Diversity Steering Group.
6.11 The above process is informed by inclusive and accessible involvement and consultation, with proactive outreach to seldom-heard groups (see Principle B), and intersectional data-gathering and analysis.
6.12 A Directorate Environmental Action plan is in place. This identifies key projects and priorities such as capital builds and impacts on mileage from staffing changes / restructures. Environmental Impact Assessments are completed for commissioned services.
6.13 The Directorate uses the following tools to support the achievement of value for money and achievement against priorities:
· Business Cases for proposed projects with financial outlay
· Weekly Budget and Scrutiny meetings with all senior managers to report on progress against financial targets, highlight any emerging issues and agree action plans
· Quarterly Finance and Performance meetings with the Corporate Director to report on progress against financial targets, highlight any emerging issues and agree action plans value
· Weekly Adult Social Care Leadership Team and HAS Leadership Team meetings, Public Health Involvement and Governance Teams and a monthly HAS Transformation Board.
6.14 Procurement regulations are followed for all commissioned services. Choice Policy/Top Up Agreement/Direct Payments promote choice and fair access. Sustainability Policy focuses on VFM. The brokerage/sourcing process is clear about best value/best match: The Council has a robust ‘Best Value, Best Match’ brokerage process, which considers a weighting of price with ability to deliver other requirements of a package of care.
6.15 Our Market Position Statement and Strategic Market Development Plan sets out our commissioning intentions to ensure sustainable market and involves collaboration with providers and other commissioners (Health).
Principle D: Determining the interventions necessary to optimise the achievement of the intended outcomes
6.16 We are committed to becoming an effective performing council that supports the development of its employees. The Directorate has refreshed the formal Supervision Policy in 2025 which sets out clear guidance and expectations around Supervision (1:1) meetings. IPM is a process of continuous performance conversations which culminate in an end of year IPM review (appraisal). This provides an opportunity for all employees to recognise how they contribute to team priorities, broader service plans and ultimately to the success of the council. IPM has an annual cycle, starting on 1 April and culminating in annual appraisal by 31 March. Service planning takes place around September to plan for the forthcoming financial year and align with corporate aims. Service discussions inform the creation of objectives for the appraisal year ahead. Within HAS, this includes objectives to support the delivery of HAS 2030 and our 7 Improvement Priorities. All employees, apart from casual (relief) workers, will have an end of year mandatory appraisal. Completions are tracked and outstanding IPMs are chased by the HR Advisory Team. To help employees and managers to prepare for IPM reviews there are a number of guides, FAQs and training available. Where performance is identified as being not at the standard required, we have formal processes in place, including the Probation Policy for those employees who are new into role, a Developing Performance process and ultimately a Capability process where satisfactory levels of performance cannot be achieved through informal support. Support and guidance is provided to managers through the HR Advisory Team).
6.17 As above, our Market Position Statement and Strategic Market Development plan sets out how we are working collaboratively with partners and providers to develop and shape the market. Service plan, Annual Appraisals and Team meetings are aligned with strategies and projects.
6.18 The Leadership Team has links to key Business Partners across the organisation – such as Technology, Customer and Communications – to ensure the Directorate is highlighting any issues corporately.
6.19 Our proposed procurement of a new Approved Provider List (APL) will have a clear focus on maximising social value.
Principle E: Developing the entity’s capacity, including the capability of its leadership and the individuals within it
6.20 The Directorate’s Governance Framework recognises the need for robust governance and enables us to provide assurances that we operate within a framework of sound processes, continuous learning, and quality improvement. The framework consolidates all governance processes into a unified structure. These processes are subject to annual review, both by those accountable for their implementation and by individuals who access our services, ensuring transparency, accountability, and ongoing refinement.
6.21 Regular meetings between the Executive Member and Senior Officers underpin strategic decision-making and policy formulation, including regular scrutiny of financial and performance data, serious incident information and practice quality. The council Executive and Overview and Scrutiny Committees routinely hold the service to account and conducts an annual deep dive into Adult Social Care. The directorate has robust reporting and decision-making processes, with decisions taken at a range of leadership meetings covering the overall directorate and specific programmes. Specific Directorate level guidance on the Council and Directorate’s approach to decision-making and report writing has been produced to assist officers in navigating the process.
6.22 Health and Adult Services has a well-established Scheme of Delegation and Sub delegation, which is reviewed on an annual basis and is subject to approval by HASLT. This is a structured, documented process within Health & Adult Services that clearly outlines which functions, powers and decision-making authorities are officially transferred to committees, individuals, or other levels of staff. The purpose of this is to ensure clarity on roles, improve efficiency and maintain accountability and transparency in decision making.
6.23 Our People Strategy 2023 to 2025 is our workforce plan. Within HAS, we have a well-established People Strategy Group which includes representatives across all parts of the Directorate who have contributed to the shaping of the HAS People Strategy, based around the 4 pillars of Retain Staff, Attraction for All, Engage and Listen and One Council. This has resulted in a Directorate action plan, with key colleagues from the Directorate and HR teams leading on Task and Finish group work. For example, one of the workstreams is reviewing our 2024 Staff Survey feedback in relation to engagement and have developed. Another well-developed piece of work relates to our approach to supporting employee health and wellbeing, with specific focus on Mental Health and Musculoskeletal conditions. In addition, we have a Workforce Plan which sets out specific plans to address the sector wide workforce of providers of adult social care across North Yorkshire. Our People Strategy and workforce plan also aligns with the national and sector wide Workforce Strategy for Adult Social Care in England, which was co-produced across the sector alongside partners such as Skills for Care, ADASS and provider organisations of adult social care. The aim of the strategy is to ‘ensure that we have enough of the right people with the right skills to provide the best possible care and support for the people who draw on it’. provision is a bespoke nurse-led service with the support of occupational health physicians when required on a consultation basis for complex occupational health cases.
6.24 We have a structured Learning and Development offer with all staff having access to the required statutory and mandatory training required for roles set out in a training matrix, as well as enhanced developmental opportunities and leadership development programmes. All training is managed via a single learning management system called Learning Zone from which compliance and monitoring of training completions are reported, and it hosts individual learner records. We have a clearly defined career development process through use of apprenticeships and targeted development, and offer coaching, mentoring and leadership development. We have a dedicated team supporting newly qualified social work staff and a robust ASYE programme. All training, learning and development activity is managed by a dedicated Learning and Development function who are responsible for all quality, budget and recording of learning and development activity for the council, and manage the Growth and Skills Levy.
6.25 This complements a Council-wide significant Health and Wellbeing Offer[3]. across the Council.
Principle F: Managing risks and performance through robust internal control and strong public financial management
6.26 The Directorate manages risk through a structured and collaborative approach. The HAS Risk Management Group meets monthly to review and monitor key risks, ensuring timely action. A risk-based approach is applied to the social care market to identify areas requiring support, complemented by sustainability processes such as Care Cubed. Financial and business sustainability and finance and performance considerations are embedded in this process. To mitigate operational risks, information is gathered and uploaded to the Resilience Direct database to prepare for potential cyber-attacks or IT system failures.
6.27 Health and Adult Services holds a monthly meeting of the Directorate’s Information Governance Group (DIGG) to oversee data security and compliance. This group provides direction, guidance, and assurance on all information governance matters. The group monitors information risks and any emerging issues, develops and coordinates action plans and any other related activities to ensure the effective application of the Council’s Information Governance Strategy.
6.28 Market risks are further scrutinised through the Quality Market Sustainability Meeting and the Review Board. Additionally, there are strong links with Veritau for audit and assurance and with North Yorkshire Police for counter fraud and anti-corruption measures as well as safeguarding and security collaboration. These arrangements ensure risks are continuously monitored, reviewed, and managed effectively.
6.29 Financial Risks are picked up through ongoing monthly monitoring and remedial actions are put in place where targets are not being met – e.g. the work with the ICB around discharge costs and plans to tackle short stay costs mentioned above.
6.30 As with other directorates, Executive, Key, and other Decisions may be taken by Full Council, Executive, Executive Members, or officers (or a combination of these).
6.31 Regular “Keep In Touch” meetings are held with the HAS Executive Member and the overall directorate leadership team (HASLT), and other officers where relevant, while a formal HAS Executive Member meeting is held normally once a month where decisions are taken openly and transparently. This formal meeting is noted on the Council’s Forward Plan and papers are published on the website, as are any decisions taken.
6.32 Feeding into these, internal Control and Decision-making is managed through a system consisting of separate leadership teams for Adult Social Care and Public Health. These report to the overall directorate leadership team (HASLT) which is, chaired by the Corporate Director and consisting of the Directorate’s Assistant Directors, Director of Public Health Head of Human Resources, Assistant Director – Resources, and Communications Business Partner. These all meet weekly.
6.33 HASLT is joined by other officers from Finance, Performance, Transformation and the Head of Business Support on a monthly team as the directorate’s Transformation Board to monitor and review all projects which contribute to our Transformation and Medium Term Financial Strategies.
Principle G: Implementing good practices in transparency, reporting and audit to deliver effective accountability
6.34 The Directorate has robust arrangements to respond promptly to external audit, inspection, and regulatory action, and actively welcomes external challenge as a driver for improvement. We engage fully with the Care Quality Commission (CQC) through assurance processes and inspections of regulated activities, ensuring compliance and continuous improvement. Recent examples include a three-stage peer review in Adult Social Care in preparation for CQC assurance and a Public Health peer review, demonstrating our commitment to external scrutiny. Independent feedback is sought through Healthwatch reports, and research such as Achieving Closure informs our approach to provider sustainability and service quality.
6.34 A strong culture of continuous improvement underpins this work, with priorities identified through feedback from people, data benchmarking, peer reviews, and CQC inspections. This approach reflects the council’s IACT values (Inclusive, Ambitious, Creative, Together). Within the Governance Team, dedicated Continuous Learning Officers assist with structured lessons learned processes following safeguarding adult reviews or other significant events such as provider failure, ensuring insights are captured and resilience strengthened. This process is now led through a new Learning and Improvement Group which will reduce duplication and support in improving practice. In addition, the Integrated Quality Team promotes joint working and shared tools across partners, translating recommendations into practical improvements for providers.
6.35 There is a focus in contract management on building trusted relationship with providers through and, as above, we regularly involve providers and their representative group – the ICG – in forums, surgeries and consult with them regarding annual fee uplifts and cost of care exercises.
6.36 The Directorate has a dedicated Governance Team who manage and oversee responses to statutory responsibilities such as Freedom of Information Requests, Subject Access Requests and complaints, including liaison with the Local Government Social Care Ombudsman. The Governance Team produces quarterly and annual reports that report on and assesses compliance on these responsibilities. These reports support effective and timely monitoring of performance and compliance, providing a mechanism for proactive management, escalation and the implementation of action plans should any performance issues arise.
7.0 DIRECTORATE RISK REGISTER
7.1 The Directorate Risk Register (DRR) is the end product of a systematic process that initially identifies risks at Service Unit level and then aggregates these via a sieving process to Directorate level. A similar process sieves Directorate level risks into the Corporate Risk Register.
7.2 The Council uses a 5x5 risk assessment ranging from very low to very high in terms of both likelihood and impact: Once the likelihood and impact for a risk have been assessed, the risk scoring is calculated, using the table below.
|
Likelihood |
Very High |
5 |
10 |
15 |
20 |
25 |
|
High |
4 |
8 |
12 |
16 |
20 |
|
|
Medium |
3 |
6 |
9 |
12 |
15 |
|
|
Low |
2 |
4 |
6 |
8 |
10 |
|
|
Very Low |
1 |
2 |
3 |
4 |
5 |
|
|
|
|
Very Low |
Low |
Medium |
High |
Very High |
|
|
|
Impact |
||||
7.3 Once a risk has been assessed, the required action is determined by the following table.
|
Colour |
Score |
Assessment |
Required Action |
|
|
1 - 2 |
Very Low (tolerate) |
Risk should not appear in risk register. |
|
|
3 - 4 |
Low (tolerate) |
Regular monitoring, action plan not essential, acceptable just to maintain current controls. |
|
|
5 - 9 |
Medium (treat) |
Frequent monitoring, action plan required. |
|
|
10-12 |
Medium High (treat) |
Frequent monitoring, action plan required to prevent from becoming a red risk. |
|
|
15 - 16 |
High (treat) |
Constant monitoring, action plan required and escalation to next level for consideration / inclusion. |
|
|
20 - 25 |
Very High (treat / terminate) |
Constant monitoring, action plan required and escalation to next level with request for inclusion. Consider terminating activity (if an option) where score cannot be reduced by risk mitigation. |
7.4 The detailed DRR is shown at Appendix A. This shows a range of key risks and the risk reduction actions designed to minimise them together with a ranking of the risks both at the present time and after mitigating action.
7.5 A summary of the DRR is also attached at Appendix B. As well as providing a quick overview of the risks and their ranking, it also provides details of the change or movement in the ranking of the risk since the last review in the left-hand column.
7.6 A six-month update review of the register will take place in April 2026.
7.7 The register retains the 10 risks from last year although, through a constant process of review, the details within these – and their risk ratings – have in some cases been amended in response to changing circumstances. Two new risks have been added:
· HAS 14 – Care and Support Hubs (see 5.5 above)
· HAS 15 – Deprivation of Liberty Safeguards (DoLS – see 5.3 above)
7.8 The table of Risk Ratings below shows how the financial-related pressures remain a key risk.
|
2024/25 |
2025/26 |
2025/26 |
||
|
Current |
Target |
|||
|
HAS 6 |
Financial Pressures |
20 |
20 |
16 |
|
HAS 2 |
Major Failure due to Quality and/or Economic Issues in the Care Market |
16 |
16 |
16 |
|
HAS 4 |
Managing Waiting Lists |
16 |
16 |
16 |
|
HAS 5 |
In-House Social Care Provider Services |
16 |
16 |
12 |
|
HAS 7 |
Working with the NHS |
12 |
16 |
12 |
|
HAS 8 |
Public Health |
12 |
16 |
12 |
|
HAS 15 |
Deprivation of Liberty Safeguards (DoLS) |
12 |
12 |
|
|
HAS 3 |
Workforce Recruitment and Retention |
12 |
12 |
12 |
|
HAS 9 |
Safeguarding Arrangements |
12 |
12 |
12 |
|
HAS 11 |
Information Governance and Health & Safety |
12 |
12 |
8 |
|
HAS 14 |
Care and Support Hubs |
12 |
6 |
|
|
HAS 10 |
CQC Assurance |
12 |
8 |
8 |
7.9 This is reflected in the work currently being undertaken on the financial recovery plan and market management with important review and reporting actions as highlighted in the register and in our assessment of effectiveness, particularly in Principles C and D above.
7.10 The review of the Risk Register also highlights increased risks in Working with the NHS and Public Health. In the first of these uncertainties around ICBs and a significant cut in their workforce should be noted as a risk to the Council.
7.11 There may also be a risk from the ICB reducing staffing to their capacity and resilience in responding to health protection incidents. The Director of Public Health has a statutory duty to ensure plans are in place to protect the health of the population and so will be monitoring this risk very closely.
8.0 FINANCIAL IMPLICATIONS
8.1 There are no direct financial implications as a result of this report.
9.0 LEGAL IMPLICATIONS
9.1 There are no direct legal implications as a result of this report.
10.0 EQUALITIES IMPLICATIONS
10.1 There are no direct equalities implications as a result of this report.
11.0 CLIMATE CHANGE IMPLICATIONS
11.1 There are no direct climate change implications as a result of this report.
12.0 REASONS FOR RECOMMENDATIONS
12.1 This report has highlighted a number of existing sources of assurance that help to determine the effectiveness of governance arrangements in practical terms. The review concludes that:
· the directorate has not experienced any major governance failures during the last year.
· the Risk Register has been working well and senior managers have actively engaged with the detailed review.
· Internal Audit have undertaken a number of reviews to provide assurance. Although improvements have been identified in some areas, these are not regarded as significant.
· There are no major gaps or weaknesses identified when considering the outcomes and practical implementation of the North Yorkshire Local Code of Corporate Governance
12.2 This high-level review concludes that the governance arrangements operating in the Directorate over the last year have met the Council’s expected principles of good governance, as set out in the Council’s local code of governance.
13.0 RECOMMENDATIONS
13.1 That the Committee:
i. Notes the review of the effectiveness of governance arrangements in the Health and Adult Services Directorate.
ii. Notes the Directorate Risk Register for the Health and Adult Services Directorate; and
iii. Provides feedback and comments on the Health and Adult Services Directorate Risk Register and any other related internal control issues.
APPENDICES:
· Appendix A – Directorate Risk Register – Detailed
· Appendix B – Directorate Risk Register – Summary
BACKGROUND DOCUMENTS: None
Richard Webb
Corporate Director – Health and Adult Services
December 2025
Report Author – Anton Hodge, Assistant Director – Resources
Presenter of Report – Richard Webb, Corporate Director – Health and Adult Services