self evaluation exercise - comhairle nan eilean siar · the report and the self evaluation...

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POLICY AND RESOURCES COMMITTEE: 6 DECEMBER 2012

SELF EVALUATION EXERCISE

Report by Director of Education and Children’s Services

PURPOSE OF REPORT To provide members with information about the self evaluation exercise around Quality Indicator 5.4 - Improving the quality of services to stakeholders.

COMPETENCE

1.1 There are no legal, financial or other constraints to the recommendation being implemented.

SUMMARY

2.1 When Audit Scotland reported on the scrutiny exercise known as BV2, one of the areas identified for improvement was self evaluation (SE). The report said; ‘The Comhairle does not have a self assessment process in place to support continuous improvement’.

2.2 It was agreed to use the framework “How Good is our Council” for this activity and an Internal Challenge Team (ICT), with representation from each department in the Comhairle, was set up.

2.3 Having looked at the framework, the team agreed to pilot a self evaluation exercise around Quality Indicator 5.4 which looks at the delivery of key processes. Each department carried out the S.E exercise thinking about their own service areas when asking the question “how good is our deliver of key processes?”

2.4 The ITC then met to look at the 6 evaluations (Appendix 3 to the Report), and considered how the Comhairle as a whole was performing in relation to the key question. The assessment with the relevant next steps is attached as Appendix 1 to the Report. It was felt that, as each evaluation exercise would highlight some follow-up activity, one such exercise per quarter would be enough until such time as officers became more familiar with the process. The team also agreed a programme of self evaluation activity for the next year - (Appendix 2 to the Report).

RECOMMENDATIONS

3.1 It is recommended that Members - a) note the Report and the self evaluation exercise; and b) approve the planned programme of self evaluation activity.

APPENDIX 1. Internal Challenge Team’s Evaluation of QI 5.4 2. Programme of Self Evaluation Activity 3. Departmental Self-Evaluation documents

CONTACT OFFICER: Seonag Mackinnon 01851 822430

BACKGROUND PAPERS: Consultation Reports

JMK/DS 28/11/12

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APPENDIX 1

COMHAIRLE NAN EILEAN SIAR INTERNAL CHALLENGE TEAM

HOW GOOD IS OUR COUNCIL?

SELF-EVALUATION - KEY AREA 5:

HOW GOOD IS OUR DELIVERY OF KEY PROCESSES

‘How Good is Our Council?’’ is intended to be used across Comhairle nan Eilean Siar to assist services and the Comhairle as a whole to evaluate how well it is doing in a rigorous, robust, systematic and consistent way. This framework, which was developed by Perth and Kinross Council, is meant to be used as a ‘toolkit’ to support the overall self-evaluation process and as guidance when undertaking any self-evaluation exercise - whether at individual Team, Division, Service or Comhairle level. The corporate approach to self-evaluation is based on the following high level questions:

1. What key outcomes have we achieved? 2. How well do we meet the needs of our stakeholders? 3. How good is our delivery of key processes? 4. How good is our management? 5. How good is our leadership? 6. What is our capacity for improvement?

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Key Area 5: Delivery of key processes the quality of services to stakeholders How good is our delivery of key processes? 5.4 Improving the quality of services to Stakeholders Questions you might ask • How effective are our methods for evaluating our services? • How clear and effective is our advice to services on self-evaluation, quality improvement and

performance reporting? • How effectively do we gather and use information from users, participants and other

stakeholders to improve our services? • How do we ensure that the roles and responsibilities of key staff ensure quality improvement in

our services? • To what extent do we carry out regular and rigorous audits of our services? • How effectively do we moderate services’ self-evaluation? • How effectively do we use information from self-evaluation to plan for improvements? • To what extent do we have a clear strategy for recording and reporting on our standards to our

stakeholders? Some ways of finding out • Improved trends in performance data - SPIs, local targets etc • Letters of appreciation • Minutes of meetings • Complaints records and outcomes • Published reports of outcomes of good practice • Best Value reviews • Self-evaluation exercises • Information from external audit/inspection • Improvement plans • Stakeholder feedback • Focus group meetings

Establishing the level - 5using the six point scale The key questions are designed to be used in conjunction with an evaluation scale in which the quality of provision can be evaluated against six levels of performance. The levels are: Level 6 excellent outstanding or sector leading

Level 5 very good major strengths

Level 4 good important strengths with areas for improvement

Level 3 adequate strengths just outweigh weaknesses

Level 2 weak important weaknesses

Level 1 unsatisfactory major weaknesses

Thank you for completing this questionnaire.

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COMHAIRLE NAN EILEAN SIAR HOW GOOD IS OUR COUNCIL? SELF-EVALUATION (EVALUATION BY INTERNAL CHALLENGE TEAM)

Key Area 5: Delivery of key processes in Key features: This indicator provides a basis for assessing how well services are evaluated, improved and reported to stakeholders. The Council should view improving the quality of services as a major priority and as a result, have robust, consistent and coherent arrangements for evaluating the quality of service delivery and monitoring the quality of outcomes for service users. A culture of support and challenge is an essential element in quality improvement along with a commitment to involve stakeholders in the evaluation and improvement of services. How good is our delivery of key processes? Date: 26 November 2012 5.4 Improving the quality of services to Stakeholders Level: ADEQUATE How are we doing? (Key strengths from self-evaluation)

How do we know? (What evidence do we have to support this view?)

• Although there have been significant improvements in the number of SDA performance across the Comhairle more information is required to support improvement.

• SDA returns/reports to Audit and Scrutiny Committee.

• Interplan advice from A Murray and F Knape. • Performance calendar. • Performance reports by Directors to service

committees. • Examples of departmental/corporate letters. • Staff Surveys and questionnaires. • Minutes of performance management

meetings.

• Good advice around business planning.

• Departments are planning with more focus on activity and this leads to better reporting.

• Much improved reporting on performance to Elected Members.

• Departmental and Corporate newsletters share information across the organisation.

• Staff surveys and employee questionnaires provide good information for improvement plans.

• Although there are examples of good levels of performance management at departmental levels there is a lack of consistency.

• Although there is self-evaluation across departments it is inconsistent and there is not enough evidence to demonstrate that it brings about improvement.

What are we going to do now? (Next steps) • SDAs to reflect more challenge and support.

• Corporate roll-out of customer services management tool to evaluate customer satisfaction/performance management.

• Initiate a performance management framework for the Comhairle.

key processes?

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APPENDIX 2 COMHAIRLE NAN EILEAN SIAR

INTERNAL CHALLENGE TEAM: SELF EVALUATION (BV2)

‘How Good is Our Council’ - A guide to evaluating Council Services using quality indicators ROLLING PROGRAMME OF SELF EVALUATION FOR COMHAIRLE NAN EILEAN SIAR Key Area 1: Key performance outcomes What key outcomes have we achieved? Quality Indicator Themes 1.1 Improvement in Performance • Performance data and measures showing trends over

time. • Overall quality of services provided by individual services

and across the Council as a whole. • Performance against aims, objectives and targets.

Key Area 5: Delivery of key processes How good is our delivery of key processes? Quality Indicator Themes 5.2 Developing, managing and

improving partnerships and relationships with service users and other stakeholders

• Involvement of service users and other key stakeholders in planning service delivery.

• Involvement of service users in developing service standards and monitoring performance.

Key Area 8: Resources How good is our management? Quality Indicator Themes 8.1 Partnership working • Clarity of purposes and aims.

• Service level agreements, roles and remits. • Working across agencies and disciplines. • Staff roles in partnerships.

Key Area 9: Leadership and direction How good is our leadership? Quality Indicator Themes 9.3 Leading people and developing

partnerships

• Developing leadership capacity. • Building and sustaining relationships. • Teamwork and partnerships.

9.4 Leadership of innovation, change and improvement

• Support and challenge. • Creativity, innovation and step change. • Continuous improvement.

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APPENDIX 3

COMHAIRLE NAN EILEAN SIAR INTERNAL CHALLENGE TEAM

HOW GOOD IS OUR COUNCIL? SELF-EVALUATION QUESTIONNAIRE- KEY AREA 5: HOW GOOD IS OUR DELIVERY OF KEY PROCESSES

‘How Good is Our Council?’’ is intended to be used across Comhairle nan Eilean Siar to assist services and the Comhairle as a whole to evaluate how well it is doing in a rigorous, robust, systematic and consistent way. This framework, which was developed by Perth and Kinross Council, is meant to be used as a ‘toolkit’ to support the overall self-evaluation process and as guidance when undertaking any self-evaluation exercise - whether at individual Team, Division, Service or Comhairle level. The corporate approach to self-evaluation is based on the following high level questions:

1. What key outcomes have we achieved? 2. How well do we meet the needs of our stakeholders? 3. How good is our delivery of key processes? 4. How good is our management? 5. How good is our leadership? 6. What is our capacity for improvement?

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Establishing the level - 5using the six point scale The key questions are designed to be used in conjunction with an evaluation scale in which the quality of provision can be evaluated against six levels of performance. The levels are: Level 6 excellent outstanding or sector leading

Level 5 very good major strengths

Level 4 good important strengths with areas for improvement

Level 3 adequate strengths just outweigh weaknesses

Level 2 weak important weaknesses

Level 1 unsatisfactory major weaknesses

There are many ways in which provision can merit a particular evaluation. Awarding levels is more of a professional skill than a technical process. However, the following general guidelines should be applied consistently:

• An evaluation of excellent applies to provision which is a model of its type. The experiences of, and outcomes achieved by, service users are of very high quality. An evaluation of excellent represents an outstanding standard of provision which exemplifies very best practice and is worth disseminating beyond the Council. It implies these very high levels of performance are sustainable and will be maintained.

• An evaluation of very good applies to provision characterised by major strengths. There are very few areas for improvement and any that do exist do not significantly diminish the experiences of service users. While an evaluation of very good represents a high standard of provision, it is a standard that should be achievable by all. It implies that it is fully appropriate to continue to make provision without significant adjustment. However, there is an expectation that the Council will take opportunities to improve and strive to raise performance to excellent.

• An evaluation of good applies to provision characterised by important strengths which, taken together, clearly outweigh any areas for improvement. An evaluation of good represents a standard of provision in which the strengths have a significant positive impact. However, the quality of the experiences of service users is diminished in some way by aspects in which improvement is required. It implies that the Council should seek to improve further the areas of important strength, but take action to address the areas for improvement.

• An evaluation of adequate applies to provision characterised by strengths which just outweigh weaknesses. An evaluation of adequate indicates that service users have access to basic levels off provision. It represents a standard where the strengths have a positive impact on the experiences of service users. However, while the weaknesses will not be important enough to have a substantially adverse impact, they will constrain the overall quality of service experienced by service users. It implies that Council should take action to address areas of weakness while building on strengths.

• An evaluation of weak applies to provision which has some strengths, but where there are important weaknesses. In general, an evaluation of weak may be arrived at in a number of circumstances. While there may be some strengths, the important weaknesses will, either individually or collectively, be sufficient to diminish the experience of service users in substantial ways. It implies the need for structured and planned action on the part of the Council in service provision.

• An evaluation of unsatisfactory applies when there are major weaknesses in provision requiring immediate remedial action. The experience of service users is at risk in significant respects. In almost all cases, staff responsible for provision evaluated as unsatisfactory will require support from senior managers in planning and carrying out the necessary actions to effect improvement. This may involve working alongside staff from other services or agencies in, or beyond, the Council.

Thank you for completing this questionnaire.

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Key Area 5: Delivery of key processes the quality of services to stakeholders How good is our delivery of key processes? 5.4 Improving the quality of services to Stakeholders Questions you might ask • How effective are our methods for evaluating our services? • How clear and effective is our advice to services on self-evaluation, quality improvement and

performance reporting? • How effectively do we gather and use information from users, participants and other

stakeholders to improve our services? • How do we ensure that the roles and responsibilities of key staff ensure quality improvement in

our services? • To what extent do we carry out regular and rigorous audits of our services? • How effectively do we moderate services’ self-evaluation? • How effectively do we use information from self-evaluation to plan for improvements? • To what extent do we have a clear strategy for recording and reporting on our standards to our

stakeholders? Some ways of finding out • Improved trends in performance data - SPIs, local targets etc • Letters of appreciation • Minutes of meetings • Complaints records and outcomes • Published reports of outcomes of good practice • Best Value reviews • Self-evaluation exercises • Information from external audit/inspection • Improvement plans • Stakeholder feedback • Focus group meetings

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COMHAIRLE NAN EILEAN SIAR Internal Challenge Team HOW GOOD IS OUR COUNCIL? SELF-EVALUATION

NAME DATE October 2012

TITLE DEPT/SECTION Chief Executive

KEY AREA 5: DELIVERY OF KEY PROCESSES

Quality Indicator 5.4 Improving the quality of services to Stakeholders Key features: This indicator provides a basis for assessing how well services are evaluated, improved and reported to stakeholders. The Council should view improving the quality of services as a major priority and as a result, have robust, consistent and coherent arrangements for evaluating the quality of service delivery and monitoring the quality of outcomes for service users. A culture of support and challenge is an essential element in quality improvement along with a commitment to involve stakeholders in the evaluation and improvement of services.

Theme 5.4.1 Arrangements for quality assurance and improvement

Illustration QI Level 5 RANKING: 6 5 4 3 2 1 • The Council provides clear advice to establishments and Services

on quality improvement, development planning, standards and quality reporting, and professional review and development.

• There is rigorous validation of service self-evaluation. The roles and responsibilities of key staff in ensuring quality improvement and monitoring and evaluating the work of establishments and Services are clearly understood.

• There is a well-developed culture of support and challenge across the Council.

Theme 5.4.2 Support and challenge

Illustration QI Level 5 RANKING: 6 5 4 3 2 1 • Robust discussions on performance lead to the identification of

strengths and areas of underperformance.

• The Council provides strong advice and support to staff in Services to help them make improvements.

• Identified strengths are routinely celebrated and built upon by the Council and its Services.

• Equally, identification of areas of under-performance, or those requiring attention, result in the development of detailed action plans that impact positively on the quality of provision.

• Officers provide strong support through direct input and targeted resources.

HOW GOOD IS OUR DELIVERY OF EDUCATION PROCESSES?

Ranking: 6. Excellent 5. Very Good 4. Good 3. Adequate 2. Weak 1. Unsatisfactory

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Theme 5.4.3 Evaluating outcomes, and feedback from service users and other stakeholders

Illustration QI Level 5 RANKING: 6 5 4 3 2 1 • Effective procedures are in place for carrying out rigorous audits to

inform the planning, design and delivery of services. These are based on a range of appropriate measurement and monitoring techniques.

• The Council has developed systematic approaches to gathering and analysing stakeholders’ views.

• Results are used to identify issues for further investigation and action.

• Information is also gathered from regular visits to Services, performance reports and inspection reports.

• Senior managers are confident and accurate in their use, and interpretation, of a wide range of performance data.

Theme 5.4.4 Planning for improvement and monitoring progress

Illustration QI Level 5 RANKING: 6 5 4 3 2 1 • Quality indicators and accreditation schemes are used as a sound

basis for self-evaluation and planning for improvement.

• The information from performance data and stakeholders’ views are used to set priorities and targets for improvement.

• These targets are included in Business Management and Improvement Plans and result in effective action.

• The Council rigorously evaluates the effectiveness of its improvement strategies in relation to their impact on the quality of the services it delivers.

Theme 5.4.5 Reporting progress to stakeholders

Illustration QI Level 5 RANKING: 6 5 4 3 2 1 • There is an overarching strategy to record and report publicly on

performance standards.

• The information is provided to key stakeholders in a form that is accessible, evaluative and well presented.

• The timing of reports informs decision-making and leads to improvements in planning and provision.

• Reports are appropriately linked to agreed priorities.

• Strengths and areas for further improvement are clearly identified.

• There are many examples of significant improvements to outcomes and impact that have resulted from the Council’s arrangements for self-evaluation and quality improvement.

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OVERALL EVALUATION: QI 5.4 - GOOD EVIDENCE REF • 5.4.1 Arrangements for quality assurance and improvement • All SDA completed in line with agreed timescales, but there is a need for rigorous

quality assurance. This is being taken forward with a report due to be presented to CMT on 14/11/12.

• Clear advice and guidance on business planning and support is provided to departments on request.

• Internal audit reports on performance management and SPIs/LPIs and Best Value Reviews.

• Good internal policies and procedures eg employee handbook • Corporate Induction • Stakeholder consultation on corporate strategy and business planning

• 5.4.2 Support and challenge • Quarterly performance reports on progress against business plan objectives

although these tend to be historical • Chief Executive’s presentation to P&R every Committee series • Interdepartmental Performance Management Group • We have a real time online performance monitoring system • Corporate MOWG and Improvement Plan based on BV2 audit report

• 5.4.3 Evaluating Outcomes and feedback • Best Value Reviews • Internal Audit • Benchmarking HR reports • Annual PI submission to Audit Scotland • JCC and LNC for Trade Union engagement • SLA’s in place in some areas • Employee Survey carried out in 2012 with action plan to address key areas of

concern • WIEPEG for Emergency Planning engagement • Equalities network including DESG • Health and Safety Committees in each department with feedback to JCC • Consultation on services, budget, corporate strategy • SPI guidance and procedures to ensure integrity of information

• 5.4.4 Planning for Improvement and monitoring progress • IIP in place • Corporate improvement plan based on BV2 audit report • Employee survey action plan • Service Business plans in place • Corporate strategy approved 2012 – 17 • Healthy Working Lives in place with Bronze Award

• 5.4.5 Reporting Progress to Stakeholders • Annual public performance report • E-sgire near completion and launch • Quarterly/end of year performance report • SOA report to Scottish Government • Chief Executive presentation to P&R every Committee series • Reports on business planning and SPIs/LPIs to Committee • Reports to Community Planning on council business • Employee newsletter

IMPACT ON SERVICE: QI 5.4 EVIDENCE REF External assessment and scrutiny for example Audit Scotland and IIP has raised

awareness of the importance of continuous improvement leading to more self assessment and self evaluation

Better service delivery Better communication and consultation over recent years with our community

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EVIDENCE: QI 5.4 SOURCE 1. Corporate strategy Corporate policy

2. Service business plans and progress reports Corporate policy

3. SOA Community Planning

4. Employee Handbook HR

5. Business plan guidance Corporate policy

6. Performance reports Corporate policy

7. SPI/LPI annual submission Corporate policy

8. Committee Reports Executive Office

9. Committee Minutes Executive Office

10. CMT Minutes and reports Executive Office

11. PMG Minutes Corporate policy

12. JCC and LNC Minutes HR

13. DESG Minutes OD

14. OHCPP Reports and Minutes Community Planning

15. H&S Committee Minutes HR

16. WIEPEG Minutes and Facebook page HR

17. Corporate Improvement Plan and Corporate MOWG Minutes Executive Office

18. Employee Survey Action Plan OD

19. Employee Newsletter OD

20. Public Performance Calendar Corporate policy

21. Best Value Reviews OD

22. IIP OD

ACTION PLANS: QI 5.4 BUS. PLAN REF

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NAME DATE 02 November 2012

TITLE DEPT/SECTION Development

















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OVERALL EVALUATION: QI 5.4 - 3 ADEQUATE EVIDENCE REF • 5.4.1 Arrangements for quality assurance and improvement • All SDA completed in line with agreed timescales, • Up to date Job descriptions • Internal Audit quality assurance policy • Good Internal Auditor procedures • Performance monitoring

1 2 3 4 20

• 5.4.2 Support and challenge • Discussions on performance identify strengths and underperformance • Advice and support • Celebrate success • Identification of strengths and underperformance • Support through direct input and targeted resources

1/10 6/7 5/8 5/9 11

• 5.4.3 Evaluating Outcomes and feedback • Effective procedures, measurement and monitoring techniques • Gathering and analyzing stakeholders views • Results used to identify issues • Information, performance reports and inspection reports • Use of performance data

10/12/13 14/15/16

10/17 13/19/20 10/13/19

• 5.4.4 Planning for Improvement and monitoring progress • Quality indicators, self evaluation, planning for improvement • Performance, stakeholders views used to set priorities etc • Targets used in Business plans, effective action • Evaluates effectiveness, impact on quality of service delivery

21/22

5/10/14 23

5/10/24

• 5.4.5 Reporting Progress to Stakeholders • Overarching strategy to record and report on performance standards • Information – accessible, evaluative and well presented • Timing of reports leads to improvements • Reports linked to agreed priorities • Strengths, areas for improvement clearly identified • Examples of significant improvement, as a result of self evaluation

25 25 20 23

23/26 8

IMPACT ON SERVICE: QI 5.4 EVIDENCE REF Ongoing improvement of Departmental processs. Identification of staff resources to work on processes and improvement actions EVIDENCE: QI 5.4 SOURCE 1. SDA completed in line with guidelines Committee report

2. Up to date job descriptions Job descriptions 3. Internal Audit quality assurance policy Policy 4. Good Internal Auditor Policy 5. Service Plans Committee report 6. Departmental Training Plan Committee Report

7. E-mail re training given/provided E-mail Mgrs 8. Staff newsletter/staff news Server/Intranet 9. Internal Audit action plans PM 10. Section/Service/Department meetings Agendas/minutes 11. Procedure lists Sections 12. Procedures for Internal Monitoring Sections

13. Performance Monitoring Uniform System

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14. Public/Community Consultations Development

15. Business Surveys C&ES, EC Dev 16. Customer Services Survey Planning & BC

17. Formal Complaints handling and Learning Dept

18. Follow up meeting re SLA Business Mng

19. Audit reports Internal Audit

20. Performance reports Interplan

21. Investors in People Improvement Plan

22. External Schemes/Codes compliance National schemes/plans

23. Business Plans, quarterly progress reports Interplan

24. Audit Scotland reports Internal Audit

25. Public Performance Reporting Comhairle

26. Statutory performance Indicators All

ACTION PLANS: QI 5.4 BUS. PLAN REF The Department needs to develop greater consistency across sections and evidence

more robust analysis of data linked to more effective targeting on impact and outcomes.

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NAME DATE 2 November 2012

TITLE DEPT/SECTION Education and Children’s Services






x


x

• There is a well-developed culture of support and challenge across the Council. x



strengths and areas of underperformance. x

• The Council provides strong advice and support to staff in Services to help them make improvements. x

• Identified strengths are routinely celebrated and built upon by the Council and its Services. x


x

• Officers provide strong support through direct input and targeted resources. x



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x

• The Council has developed systematic approaches to gathering and analysing stakeholders’ views. x

• Results are used to identify issues for further investigation and action. x

• Information is also gathered from regular visits to Services, performance reports and inspection reports. x

• Senior managers are confident and accurate in their use, and interpretation, of a wide range of performance data. x



basis for self-evaluation and planning for improvement. x

• The information from performance data and stakeholders’ views are used to set priorities and targets for improvement. x

• These targets are included in Business Management and Improvement Plans and result in effective action. x


x



performance standards. x

• The information is provided to key stakeholders in a form that is accessible, evaluative and well presented. x

• The timing of reports informs decision-making and leads to improvements in planning and provision. x

• Reports are appropriately linked to agreed priorities. x

• Strengths and areas for further improvement are clearly identified. x


x

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OVERALL EVALUATION: QI 5.4 - GOOD EVIDENCE REF • The Department has good improvement strategies and performance processes in

place. There are effective quality assurance systems, support and challenge mechanisms and robust auditing of service provision in place. This ensures that improvement Action Plans are regularly monitored.

1-27

• Education and Children Services is subject to regular external scrutiny and benchmarking against national and comparator authority performance in a wide range of service delivery areas. Particularly in relation to attendance, attainment and vulnerable young people

• Children and Families has been the subject of a recent Care Inspectorate ISLA inspection which identified a significant range of areas for improvement which we are currently addressing.

IMPACT ON SERVICE: QI 5.4 EVIDENCE REF In terms of education, external evaluation and internal monitoring suggests we do

well nationally and in relation to our comparator authorities, usually performing in the top 33% of local authorities.

EVIDENCE: QI 5.4 SOURCE 1. Quality Improvement Section and Policy and Procedures QIOs 2. Robust business planning processes and procedures Interplan 3. Business Plan Interplan 4. Training Plan B Maclean 5. Financial Plan B Chisholm 6. Estate Plan I Smith 7. Risk Management Plan I Smith 8. Quality Improvement calendar of events and audits B Maclean 9. Standards and Quality Report D A Macleod 10. PRD Reviews B Maclean 11. Schedule of self evaluation across all schools and service areas QIOs 12. Self evaluations of schools and sections QIOs/HOS 13. School visit records D Smith 14. PPMG minutes D Smith 15. Section/Team Meeting minutes D Smith/C Bell 16. Care Inspectorate ISLA inspection and progress reports D Smith 17. External/Internal Inspection Report Website 18. How Good is our Service? Administration C Bell 19. Committee Reports D Smith/Website 20. SQA performance analysis reports D Smith 21. Competency, attendance, sickness monitoring L Smith 22. Analysis of complaints D Smith 23. School Estate survey I Smith 24. Stakeholders surveys D Smith 25. Comhairle staff questionnaire CX Dept 26. HT and Parent Council questionnaires D Smith 27. Area Improvement Plan arising from BV2 CX Dept

ACTION PLANS: QI 5.4 BUS. PLAN REF Department needs to develop greater consistency across sections and evidence

more robust analysis of data linked to more effective targeting on impact and outcomes.

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NAME DATE October 2012

TITLE DEPT/SECTION F & C R

















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OVERALL EVALUATION: QI 5.4 - GOOD EVIDENCE REF • 5.4.1 Arrangements for quality assurance and improvement • All SDA completed in line with agreed timescales, • Up to date Job descriptions • Internal Audit quality assurance policy • Good Internal Auditor procedures • IT online portal – issues clearly identified, follow up by agreed timescale • Project Reviews

1 2 3 4

TBC TBC

• 5.4.2 Support and challenge • Discussions on performance identify strengths and underperformance • Advice and support • Celebrate success • Identification of strengths and underperformance • Support through direct input and targeted resources

1

6/7 8

5/9/10 11

• 5.4.3 Evaluating Outcomes and feedback • Effective procedures, measurement and monitoring techniques • Gathering and analyzing stakeholders views • Results used to identify issues • Information, performance reports and inspection reports • Use of performance data

12/13

14/15/16 17/18 19/20

19

• 5.4.4 Planning for Improvement and monitoring progress • Quality indicators, self evaluation, planning for improvement • Performance, stakeholders views used to set priorities etc • Targets used in Business plans, effective action • Evaluates effectiveness, impact on quality of service delivery

21/22

15 23

24/25/26/27

• 5.4.5 Reporting Progress to Stakeholders • Overarching strategy to record and report on performance standards • Information – accessible, evaluative and well presented • Timing of reports leads to improvements • Reports linked to agreed priorities • Strengths, areas for improvement clearly identified • Examples of significant improvement, as a result of self evaluation

28 28

20/29/30 23

23/31/32 8/33

IMPACT ON SERVICE: QI 5.4 EVIDENCE REF EVIDENCE: QI 5.4 SOURCE 1. SDA completed in line with guidelines Committee report

2. Up to date job descriptions Job descriptions 3. Internal Audit quality assurance policy Policy 4. Good Internal Auditor Policy 5. Capability assessments 6. Departmental Training Plan Committee Report

7. E-mail re training given/provided E-mail Mgrs 8. Staff newsletter/staff news Server/Intranet 9. Internal Audit action plans PM 10. NDR action plan HMK 11. Procedure lists e.g. Systems admin, payroll etc Sections 12. Procedure list for implementing Intelligent Scanning Exchequer Services

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13. Council Officer Review Exchequer Services 14. SLA process Exchequer Services

15. Procurement Survey Exchequer Services 16. Customer Services Survey IT & CS

17. Formal Complaints handling and Learning Dept

18. Follow up meeting re SLA Business Mng

19. Audit reports Internal Audit

20. Performance reports Interplan

21. Procurement Capability Assessment Exchequer Services

22. Best practice Council Tax/Payroll Exchequer Services

23. Business Plans, quarterly progress reports Interplan

24. Audit Scotland reports Internal Audit

25. IT portal to improve service delivery IT & CS

26. AF used to develop what users want Accountancy

27. Budget Setting Process Accountancy

28. Internal Audit end of year reporting Internal Audit

29. Procurement report Exchequer Services

30. Debt recovery report Exchequer Services

31. Statutory performance Indicators All

32. Steering Groups All

33. Roll out of special delivery e.g. IPADs to Members IT & CS

ACTION PLANS: QI 5.4 BUS. PLAN REF 5.4.1 HMK to draft Quality Assurance policy for approval by DMT 5.4.2 AM to gather evidence for progress on projects 5.4.3 HMK Revs and Bens analysing stakeholders views 5.4.4 AM Benchmarking with other Island Authorities/Local Government website 5.4.4 AM evaluation of how well the IT portal is working 5.4.5 Use of website/pay slips etc to display performance

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NAME Aman Toor DATE 16th November 2012

TITLE Service Improvement Officer, Social and Community Services

DEPT/SECTION Social and Community Services






X


X

• There is a well-developed culture of support and challenge across the Council. X



strengths and areas of underperformance. X

• The Council provides strong advice and support to staff in Services to help them make improvements. X

• Identified strengths are routinely celebrated and built upon by the Council and its Services. X


X

• Officers provide strong support through direct input and targeted resources. X



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X

• The Council has developed systematic approaches to gathering and analysing stakeholders’ views. X

• Results are used to identify issues for further investigation and action. X

• Information is also gathered from regular visits to Services, performance reports and inspection reports. X

• Senior managers are confident and accurate in their use, and interpretation, of a wide range of performance data. X



basis for self-evaluation and planning for improvement. X

• The information from performance data and stakeholders’ views are used to set priorities and targets for improvement. X

• These targets are included in Business Management and Improvement Plans and result in effective action. X


X



performance standards. X

• The information is provided to key stakeholders in a form that is accessible, evaluative and well presented. X

• The timing of reports informs decision-making and leads to improvements in planning and provision. X

• Reports are appropriately linked to agreed priorities. X

• Strengths and areas for further improvement are clearly identified. X


X

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OVERALL EVALUATION: QI 5.4 - ADEQUATE EVIDENCE REF • The Department has a real variety in standards in relation to self evaluation,

improvement planning, etc. There are some areas of very strong performance, with significant areas of weakness amongst some sections. There is clarity around where improvement needs to occur and work is underway top address these issues.

• Social and Community Services Department has been the subject of a recent Care Inspectorate ISLA inspection which identified a significant range of areas for improvement which we are currently addressing. This has been followed up by supported self evaluation, in the main concentrating on Adult Support and Protection. Clear areas for improvement have been identifies

IMPACT ON SERVICE: QI 5.4 EVIDENCE REF Successful HLF Lottery Bid £4.6 million for new museum and archive to open in 2014 Archives Newsletters (example) Blog http://blogserver.cne-siar.gov.uk/wp-archivist/ Website http://www.tasglann.org.uk/en Media coverage e.g. Hebrides News re Archives Letter to Alasdair Allan re Archives Letter to Angus Macneil re Archives Refurbishment of Stornoway Library 2009/2010 see PLQIM acceptance letter A significant increase in reader development events for the public 2009 -

2012 e.g. Acts of Trust, a project initiated by Western Isles Libraries won the multi-arts category in the British Awards for Excellence in Storytelling. The results of nationwide voting were announced in a ceremony in York, last Saturday evening. The project was devised by Ian Stephen, as storyteller and Christine Morrison as visual artist. It was supported by Shetland Arts, who developed and administered a series of five Reader in Residence posts throughout Scotland, last year. http://www.capefarewell.com/seachange/acts-of-trust-ian-stephen-christine-morrison/

Installation of new Library management System 2012 see Dynix system Committee Report and current committee LMS Update report Nov 2012

EVIDENCE: QI 5.4 SOURCE 1. Business Plan 2. Training Plan 3. IIP evaluation 4. Care Homes Survey results/analysis/action planning 5. MOWG reports re Tasglann and archive projects 6. Consultation regarding Ardisuileach 7. LAC redesign report and work 8. Appraisals 9. PMG minutes 10. Section/Team Meeting minutes 11. Care Inspectorate ISLA inspection and progress reports 12. Committee Reports 13. CSWO report 14. Competency, attendance, sickness monitoring 15. Analysis of complaints 16. Stakeholders surveys 17. Comhairle staff questionnaire 18. Museum nan Eilean and Western Isles Libraries Facebook Pages 19. Accreditation Process (Museum Galleries Scotland) 20. Public consultation and responses on the development of the HLF Lews Castle

http://blogserver.cne-siar.gov.uk/wp-archivist/

http://www.tasglann.org.uk/en

http://www.capefarewell.com/seachange/acts-of-trust-ian-stephen-christine-morrison/


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Museum and Archive Project – views influenced action plans 21. Framework of consultation groups & presentations to Councillors, minutes available 22. Consistent trail of Committee Reports re Projects and significant developments 23. HLF Lews Castle Business Plan 24. HLF Lews Castle Activity Plan 25. Project Reports re archives 26. Report on Archival provision commissioned form Dundee University 2009 27. Press Release – Launch of Tasglann 28. Assessment – ARMS Validation Statement 29. Consultation – Steering Group membership and example of Steering Group Minutes

re archives 30. Hebridean Archives Action Plan and spreadsheet July 2010 – March 2013 31. Successful HLF Lottery Bid £4.6 million for new museum and archive to open in 2014 32. Archives Newsletters (example) 33. Blog http://blogserver.cne-siar.gov.uk/wp-archivist/ 34. Website http://www.tasglann.org.uk/en 35. Media coverage e.g. Hebrides News re Archives 36. Letter to Alasdair Allan re Archives 37. Letter to Angus Macneil re Archives

38. Community Education Learning Database 39. Interplan Actions, Tasks and PIs 40. CLD Team Self Evaluations 41. CLD Strategy monitoring reports 42. Employability Strategy monitoring reports 43. HMIE Inspection Reports 44. SDS Audits 45. SQA Audits 46. ESF Audits 47. External Verification Reports 48. Learning & Development Annual Report 49. CLD Team Planning & Quality Improvement Framework 50. CLD Performance Management & Planning Framework 51. Training Evaluations 52. National Training Programme exit interviews and questionnaires 53. National Training Programme employer questionnaires 54. Staff Appraisals linked to business plan objectives 55. SVQ Awards Ceremony 56. CLD Learning Community Groups minutes and self evaluations 57. Members Information Bulletin reports

58. Skills Development Scotland – Annual Quality Development Plan 59. Community Education Learning Database 60. Interplan Actions, Tasks and PIs 61. CLD Team Self Evaluations 62. CLD Strategy monitoring reports 63. Employability Strategy monitoring reports 64. HMIE Inspection Reports 65. SDS Audits 66. SQA Audits 67. ESF Audits 68. External Verification Reports 69. Learning & Development Annual Report 70. CLD Team Planning & Quality Improvement Framework 71. CLD Performance Management & Planning Framework 72. Training Evaluations 73. National Training Programme exit interviews and questionnaires 74. National Training Programme employer questionnaires 75. Staff Appraisals linked to business plan objectives 76. SVQ Awards Ceremony 77. CLD Learning Community Groups minutes and self evaluations 78. Members Information Bulletin reports 79. Refurbishment of Stornoway Library 2009/2010 see PLQIM acceptance letter

http://blogserver.cne-siar.gov.uk/wp-archivist/

http://www.tasglann.org.uk/en

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80. A significant increase in reader development events for the public 2009 -2012 e.g. Acts of Trust, a project initiated by Western Isles Libraries won the multi-arts category in the British Awards for Excellence in Storytelling. The results of nationwide voting were announced in a ceremony in York, last Saturday evening. The project was devised by Ian Stephen, as storyteller and Christine Morrison as visual artist. It was supported by Shetland Arts, who developed and administered a series of five Reader in Residence posts throughout Scotland, last year. http://www.capefarewell.com/seachange/acts-of-trust-ian-stephen-christine-morrison/

81. Installation of new Library management System 2012 see Dynix system Committee Report and current committee LMS Update report Nov 2012

82. See CnEs SLIC PLQIM Self Evaluation report July 09 83. See Committee Report re PLQIM self evaluation October 2009 84. See Final Library Survey Results 27 Jan 2011 (Public consultation Library Opening

Hours) 85. Interplan action narrative fulfils progress report related to PLQIM Action Plan 86. PLQIM Action Plan Oct 2009 - 2011 87. Institute of Qualified Lifeguards (IQL) externally verify our Lifeguard training and

management processes on an annual basis

88. inspected by Scottish Athletics to accredit our track and training facilities every five years

ACTION PLANS: QI 5.4 BUS. PLAN REF The Department needs to develop greater consistency across sections and evidence

more robust analysis of data, self evaluation, stakeholder and staff consultation and outcomes analysis linked to more service and action planning.



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NAME DATE November 2012

TITLE DEPT/SECTION TECHNICAL SERVICES




Illustration QI Level 5 RANKING: 6 5 4 3 2 1 • The Department provides clear advice to establishments and

Services on quality improvement, development planning, standards and quality reporting, and professional review and development.


• There is a well-developed culture of support and challenge across the Department.




• The Department provides strong advice and support to staff in Services to help them make improvements.

• Identified strengths are routinely celebrated and built upon by the Department and its Services.





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• The Department has developed systematic approaches to gathering and analysing stakeholders’ views.









• The Department rigorously evaluates the effectiveness of its improvement strategies in relation to their impact on the quality of the services it delivers.








• There are many examples of significant improvements to outcomes and impact that have resulted from the Department’s arrangements for self-evaluation and quality improvement.

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OVERALL EVALUATION: QI 5.4 GOOD EVIDENCE REF Arrangements for Quality Assurance and Improvement • Significant improvement in SDA performance in last 2-3 years; quality assurance to

be scrutinized through corporate QA questionnaire approved in principle by CMT in November 2012

• Improved focus on Business Planning process and incorporation of Key Tasks and Performance Indicators at quarterly reporting to Comhairle through corporate performance management arrangements

• Monthly meetings of departmental Performance Management Group scrutinizing financial and non-financial performance at Period End

• Good level of consultation with Heads of Service and Managers through Directorate and DMT meetings and with workforce through team meetings and business unit Health & Safety Committees

• Large number of Statutory Performance Indicators (SPIs) covering departmental services and operations – especially with regard to waste management and property-related asset management

Support and Challenge • Good level of support provided to managers and workforce provided through monthly

PMG meetings focusing on financial and non-financial performance; room for improvement in ensuring areas of poor performance are recorded and improvement action agreed and cascaded to respective teams

• Quarterly departmental newsletter provides opportunity for entire department to be made aware of progress against agreed targets and areas for improvement; also provides opportunity for management to provide recognition

• High level of informal discussions within teams and increased collaboration between business units facilitated by existing management and meetings/forums arrangements

Evaluating Outcomes and Feedback • Regular and rigorous analysis of progress relative to programmed Key tasks and PIs

through PMG and quarterly outputs from Interplan reported to Comhairle • Reasonable number of direct user surveys assessing levels of customer satisfaction,

eg Abattoir Users, Piers and Harbour Users, public transport customers, Creed Amenity Site Users’ survey.

• Reasonable level of consultation in development and implementation of key corporate and departmental policies and strategies, eg Corporate Asset Management, Waste Strategy; further room for improvement in coverage of direct user and area-based customer satisfaction surveys to inform review and, where necessary, redesign of service delivery

• Increased embedding of performance management will ensure greater focus on inclusion of meaningful and SMART Key Actions and PIs in Business Plan 2013/14

• Development of Improvement Action Plan arising from outcomes of Employee Survey 2012

• Seeking to retain IiP accreditation (November 2012)

Planning for Improvement and Monitoring Progress • Increased focus on performance monitoring and reporting through departmental

PMG and DMT; room for improvement in monitoring of progress of improvement actions and addressing of poor performance

Reporting Progress to Stakeholders • Corporate reporting of performance to key stakeholders through annual Public

Performance Report • Departmental reporting of performance to Comhairle and general public through

Quarterly Performance Management Reporting • Monthly reporting of financial and non-financial performance through PMG

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IMPACT ON SERVICE: QI 5.4 EVIDENCE REF Continuing significant focus on health and safety being reinforced through consistent and regular communications and Directorate and DMT leading by example

Increased collaboration between business units and service areas Increased focus on performance management Increased focus on consultation with key stakeholders, customers and service users to inform review and design of services

EVIDENCE: QI 5.4 SOURCE 1. Comhairle Corporate Strategy Consultation

2. Comhairle Budget Strategy Consultation

3. Comhairle Corporate Asset Management Plan Consultation

4. Corporate Newsletters (E-Ceangall)

5. Comhairle’s Annual Public Performance Report

6. IiP Accreditation – review Plan and Assessment Outcomes

7. Internal Audit Reviews (including management responses and 6 month Follow-Ups)

8. SDAs Interview Records and Mid-term Reviews

9. Department Training Plan 2012/13

10. Road Condition Surveys and annual DTS Reports to Comhairle

11. Waste Management and Tidiness – Peer Group Review outcomes

12. Quarterly Performance Management Reports to Comhairle

13. Quarterly and Annual Submissions of SPI data

14. Quarterly Departmental Newsletters

15. Monthly Period-End Reports – Financial and Non Financial Performance indicators

16. TS Directorate Meetings – Agendas and Minutes

17. Notes of Actions and Issues arising from Ward Visits

18. Minutes of Principals Meetings

19. Minutes of Health and Safety Committee Meetings

20. Feedback from Pier and Marine Fuel User Questionnaires

21. Feedback from Waste Strategy Consultation

22. Feedback from Creed Amenity Site Consultation

ACTION PLANS: QI 5.4 BUS. PLAN REF Continued focus on health and safety; reinforcement of messages through regular and consistent H&S Committees ensuring engagement with workforce and providing avenues for providing feedback

Ensure scale and nature of workforce is proportionate to workload and expectations of key stakeholders are managed in a proactive way

Development of departmental resilience through increased collaboration and flexibility of workforce to meets stakeholders’ demand as best as possible

Increased focus on monitoring and reporting of financial and non-financial performance, with particular emphasis on addressing areas of poor performance

Increased focus on formal measurement of customer satisfaction and use of results and other feedback to inform review and design of services going forward

Ensure effective recognition of achievements of teams and individuals through formal and informal means

self evaluation exercise - comhairle nan eilean siar · the report and the self evaluation...

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