15 - Report CCG 2022
North Ayrshire Council · 25 August 2022
Back to Integration Joint Board — 25 August 2022 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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Integrated Joint Board 25th August 2022 Subject : Clinical and Care Governance Group Update Purpose : The report is for :- • Awareness Recommendation : The IJB are asked to note the contents of this report. Direction Required to Council, Health Board or Both Direction to :- 1. No Direction Required 2. North Ayrshire Council 3. NHS Ayrshire & Arran 4. North Ayrshire Council and NHS Ayrshire & Arran Glossary of Terms CCGG Clinical Care Governance Group HB Health Board HSCP Health and Social Care Partnership LD Learning Disability NACPC North Ayrshire Child Protection Committee NHS AA NHS Ayrshire and Arran 1. EXECUTIVE SUMMARY 1.1 The Health and Social Care Partnership continue to provide robust arrangements for governance of partnership services and wider relevant provision in order to deliver statutory, policy and professional requirements and also the achievement of partnership quality ambitions. 1.2 This paper provides an update and overview of governance activity for the period August 2021 – August 2022 inclusive for consideration by the IJB. 2. BACKGROUND 2.1 As part of the integration of health and social care services, a National Clinical and Care Governance Framework was developed. Clinical and Care Governance is the system in which the Health and Social Care Partnership are accountable for continuously improving quality and safeguarding high standards of care. The Partnership has developed Clinical and Care Governance arrangements in line with the commitments and requirements contained in the Integration Scheme.
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The Clinical and Care Governance Group (CCGG) provide assurance to the IJB that: • Quality of care, effectiveness and efficiency drives decision-making about the planning, provision, organisation and management of services • The planning and delivery of services take full account of the perspective of patients and service users • Unacceptable clinical and care practice will be detected and addressed The Terms of Reference for the CCGG have been reviewed in the past 12 months and are included as Appendix 1 of this report. Over the past 12 months due to staff changes in the HSCP Lead Nurse role there is a new Chair for the CCGG and the newly appointed Chief Social Worker has also joined the group alongside the AHP Lead. With the addition of the Clinical Director for the HSCP a strong professional leadership will ensure that the role and function of the CCG is built upon strong partnership and collaboration. 2.2 The CCGG has met on a monthly basis with the exception of October and April when the meeting was cancelled due to service pressures related to ongoing Covid pandemic impact. Over the past 12 months the CCGG has discussed and reviewed a number of topics including: • 2020 National Scottish Drug related Death report • Highlight reports from Service and Professional leads • New clinical and social care guidelines • Service proposals and developments Community Link Worker overview NHS Ayrshire and Arran Maternity and Neonatal Psychological Interventions Service National Drug Mission Funding for Buvidal Medically Assisted Treatment (MAT) Standards Engagement Framework proposal Learning Disabilities Health Transitions report Review of Dementia Standards NAHSCP Performance Alcohol and Drug Management report • Significant Adverse Event review report action plans • Management of antidepressants in Primary care report • Enhanced Lithium Monitoring Service report • Update on Terms of Reference for Social Work Governance Board • Inspection reports and action plans from Health Improvement Scotland (HIS), Mental Welfare Commission (MWC) and Care Inspectorate • Children Services Inspection • Signs of Safety/ Safe and Together model • Benchmarking of Pressure Ulcer Data/Performance report • Safety Action Notices
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2.3 Mental Welfare Commission The Mental Welfare Commission (MWC) for Scotland’s mission and purpose is to be a leading and independent voice in promoting a society where people with mental illness, learning disabilities, dementia and related conditions are treated fairly, have their rights respected, and have appropriate support to live the life of their choice. To achieve this mission and purpose the Commission have identified four strategic priorities: • To challenge and to promote change • Focus on the most vulnerable • Increase their impact • Improve their efficiency and effectiveness Each year the MWC visits around 1,350 individuals in hospital, other care settings, and in their own homes to find out their views and check on their care and treatment. Where appropriate, they will also speak with friends and relatives. The Commission carries out their statutory duties by focussing on five main areas of work: • Visiting people • Monitoring the Acts • Investigations • Information and advice • Influencing and challenging Between April 2021 and March 2022 services across Ayrshire and Arran received positive overall feedback from the MWC following their visit. Of the seven announced visits the MWC made no recommendations for five of these with recommendations provided for the other two areas. As part of the MWC review process, wide consultation with staff, patients and families is undertaken to ensure that multiple aspects and views are considered. Some of the complementary feedback received highlighted: • Positive interaction between staff and patients • Knowledgeable staff • Good attention to meet physical health care needs • Strong links with advocacy Action plans on response to the MWC on the recommendations are provided as Appendix 2
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2.4 Risk Register The Operational Risk Register is tabled at CCGG for regular review and monitoring. The CCGG noted that none of the risks have increased since May 2021, and two new risks have been added. A further update to the risk register was completed in May 2022. The CCGG also reviewed emerging risks: • Pressure on Learning Disability Services SBAR • Paper tabled highlighted the pressures on the three Community Learning Disability Teams (CLDTs) of the rising demand for service provision due to increasing referrals from private care providers. • Inpatient Beds Availability Risk The report noted that pressures have been slowly rising and the main issues are around delayed discharges, guardianships, and MHO pressures. A pan-Ayrshire group is currently considering complex discharges and data analysis is ongoing to look at any patterns. 3. PROPOSALS 3.1 The Clinical and Care Governance group has recognised that over the course the past 2 years there has been considerable focus and effort in services across the HSCP to effectively and safely respond to the challenges of the Covid pandemic. This has reinforced the requirement and benefit of robustness around partnership governance framework with all staff contributing to quality and safe care. Over the coming 12 months the CCG will ensure each service contributes to the governance framework. 3.2 Anticipated Outcomes Further meeting dates for the North Ayrshire Health and Social Care Partnerships’ Clinical and Care Governance Group are planned for 2020/21, and future update reports will be provided to the Integration Joint Board. 3.3 Measuring Impact It is anticipated that through continuous quality improvement and enhanced reporting structures, the CCG will ensure services are safe, effective, person-centred and responsive to the ongoing needs of the population.
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4. IMPLICATIONS 4.1 Financial None 4.2 Human Resources None 4.3 Legal None 4.4 Equality/Socio-Economic None 4.5 Risk Governance contributes to risk management and risk mitigation activities. 4.6 Community Wealth Building None 4.7 Key Priorities As part of the integration of Health and social care services, a National Clinical and Care Governance Framework was developed. Clinical and Care Governance is the system in which the Health and Social Care Partnership are accountable for continuously improving quality and safeguarding high standards of care. 5. CONSULTATION None Caroline Cameron, Director Darren Fullarton, Lead Nurse/Associate Nurse Director Appendices Appendix 1, Terms Of Reference Appendix 2, MWC Action Plans
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Appendix 1 Clinical and Care Governance Group Background The main purpose of integration is to improve the wellbeing of people who use our health and social care services, of families, our communities and, in particular, those whose needs are complex and involve support from across health and social care at the same time. The North Ayrshire Health & Social Care Partnership (NAHSCP) Integration Scheme is intended to achieve the National Health and Wellbeing Outcomes prescribed by the Scottish Ministers in Regulations under section 5(1) of the Public Bodies (Joint Working) (Scotland) Act 2014 (hereinafter referred to as “the Act”). In Annex C of ‘Clinical and Care Governance of Integrated Health and Social Care Services’ (A Scottish Government publication) it contains the following description of clinical and care governance. 1. Clinical and care governance is the process by which accountability for the quality of health and social care is monitored and assured. It should create a culture where delivery of the highest quality of care and support is understood to be the responsibility of everyone working in the organisation - built upon partnership and collaboration within teams and between health and social care professionals and managers. 2. It is the way by which structures and processes assure Integration Joint Boards, Health Boards and Local Authorities that this is happening - whilst at the same time empowering clinical and care staff to contribute to the improvement of quality - making sure that there is a strong voice of the people and communities who use services. 3. Clinical and care governance should have a high profile, to ensure that quality of care is given the highest priority at every level within integrated services. Effective clinical and care governance will provide assurance to patients, service users, clinical and care staff and managers, Directors alike that: a. Quality of care, effectiveness and efficiency drives decision-making about the planning, provision, organisation and management of services; b. Unacceptable clinical and care practice will be detected and addressed 4. Effective clinical and care governance is not the sum of all these activities; rather it is the means by which these activities are brought together into this structured framework and linked to the corporate agenda of Integration Authorities, NHS Boards and Local Authorities. 5. A key purpose of clinical and care governance is to support staff in continuously improving the quality and safety of care. However, it will also ensure that wherever possible poor performance is identified and addressed. All health and social care
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professionals will remain accountable for their individual clinical and care decisions. 6. Many clinical and care governance issues will relate to the organisation and management of services rather than to individual clinical decisions. All aspects of the work of Integration Authorities, Health Boards and local authorities should be driven by and designed to support efforts to deliver the best possible quality of health and social care. Clinical and care governance, however, is principally concerned with those activities which directly affect the care, treatment and support people receive.
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Terms of Reference 1.0 Introduction The Clinical and Care Governance Group is identified as a sub group of the North Ayrshire Health and Social Care Partnership, Integration Joint Board (IJB). The approved Terms of Reference and information on the composition and frequency of the group will be considered as an integral part of the standing orders of the Integrated Joint Board. The Group will be known as the Clinical and Care Governance Group of the Integration Joint Board and will be a sub group of the Integration Joint Board. 2.0 Remit To provide assurance to the IJB as follows: • On the quality and safety of health and social care partnership services. • That staff across the Partnership are supported to provide quality services and are appropriately skilled and registered to discharge their professional responsibilities. • That proposed changes in practice, within one professional group, do not adversely impact upon another profession, and that there is a whole system approach to improvement. • That services are able to learn and develop from service user and carer experiences and that effective mechanisms are in place to do so. • That self-evaluation and quality assurance mechanisms are in place to inform improvement. • That a systematic and proportionate approach to the review of critical incidents, significant incidents and near misses is embedded in the Partnership; and pan-Ayrshire where this relates to mental health services. • That findings of critical incidents, significant events and near misses, locally and nationally, are considered and used to review and improve practice. • That services commissioned through registered, third and independent sector have appropriate contract monitoring arrangements in place and that those services are delivered to a high standard. • That medical devices (and where required - devices to support care), that are used, are sourced and maintained appropriately. • That appropriate links to Infection Control structures are in place. • That a learning culture is encouraged and that good practice and success is shared widely. • That current Partnership governance structures report into and through the Clinical & Care Governance Group. • That practice improvement plans are delivered, as appropriate. • That all Health and Care arrangements are developed with service users at the centre.
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3.0 Group Membership The Clinical and Care Governance Group will be chaired by the Lead Nurse, on behalf of the Chief Officer. The Group will report to the Chief Officer and through the Chief Officer to the Integration Joint Board. The Vice Chair of the Group will be the Clinical Director who will cover the meeting in the Chair’s absence. The group will comprise of the following members: • Lead Nurse • Clinical Director • Lead Allied Health Professional • Chief Social Work Officer • Associate Medical Director, Mental Health Services • Director of Public Health or representative • Head of Children, Families & Justice Services • Head of Health and Community Care • Head of Mental Health • Quality Improvement Lead • Psychology Professional Lead • Carer Representative • Risk Management Representative • Governance Representative (NHS) Service Users and Carers, Third and Independent sector representation will be sought via the IJB. The Chair and members will be appointed by the IJB. Group membership will be reviewed annually and the first meeting of the year. 4.0 Quorum Four members including two of the professional leads will constitute a quorum. The professional leads are: • Clinical Director • Lead Nurse • Lead Allied Health Professional • Chief Social Work Officer • Associate Medical Director, Mental Health Services • Assistant Director of Public Health • Clinical Director for Psychological Services
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Members will be asked to identify deputies to attend in their absence however they will not be included in quorum numbers. 5.0 Attendance The group may co-opt additional advisors as required. 6.0 Frequency of Meetings The Group will meet every 4 weeks. The Chair may, at any time, convene additional meetings of the group. 7.0 Authority The group is authorised to investigate any matters which fall within its terms of reference and obtain external professional advice. The group may form sub- groups to support its functions. The group is authorised to seek and obtain any information it requires from any employee whilst taking account of policy, legal rights and responsibilities. 8.0 Duties The Group shall be responsible for the oversight of clinical and care governance within North Ayrshire Health and Social Care Partnership and specifically it will: • Consider matters relating to; professional governance relevant to Strategic Plan development, service user feedback and complaints, standards, education, learning, continuous improvement and inspection activity. • Provide advice to the strategic planning group, audit and performance committee and locality groups within the Council area. The strategic planning group, audit and performance committee and locality groups may seek relevant advice directly from the Group. • Provide assurance to IJB on the operation of clinical and care governance within the Health and Social Care Partnership in compliance with relevant national standards, highlighting problems and action being taken where appropriate. • When clinical and care governance issues relating to Lead Partnership Services are being considered, the Clinical and Care Governance Group for the Lead Partner will obtain input from the Clinical and Care Governance Groups of the other Health and Social Care Partnerships. • When Clinical and Care Governance issues relating to Public Health are being considered, the Clinical and Care Governance Group will obtain input from the Public Health Governance Group. • The Integration Joint Board may seek advice on clinical and care governance directly from the Clinical and Care Governance Group. In addition, the Integration Joint Board may directly take into consideration the professional views of the professional leads as outlined previously.
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• Receive minutes and annual reports from the sub-groups established by the Clinical and Care Governance Group in order to provide assurance and accountability. • The group will monitor and review risks falling within it’s remit. 9.0 Conduct of Business Meetings of the group will be called by the Chair of the group. The agenda and supporting papers will be sent to members five working days prior to the date of the meeting. 10.0 Reporting Arrangements Minutes will be kept of the proceedings of the group and will be circulated in draft within five working days to the Chair of the meeting and within three working days thereafter to group members, prior to consideration at a subsequent meeting of the committee. The Chair of the group shall provide assurance on the work of the group and the approved minutes will be submitted to the IJB for information. The group will conduct an annual review of its role, function and achievements. The group will hold a repository for annual reports from Stakeholder Groups
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Appendix 2 Service response to local visit recommendations Name of service: Woodland View, Ward 9 Visit date: 31 May 2021 Date final report sent to service: 10 August 2021 Recommendation Action planned Timescale Responsible person 1. Managers should ensure that as well as regularly auditing the delayed discharge processes, that work continues alongside partners to expedite discharge. Adult delayed discharge group (multi agency group with inpatient and community staff) meet fortnightly to review any patients identified as being a delayed discharge, exploring all options and supports required to facilitate discharge for patients. Ongoing SCN/ Bed Manager/CNM 2. Managers should ensure consent to treatment documentation is audited to ensure that treatment is legally authorised Consent to treatment documentation is part of ward audit rolling programme. Monthly SCN/DCN 3. Managers should ask guardians to provide a copy of any guardianship order granted and to make sure that this is filed appropriately. Exploring centralised system where Mental Health Act administrator is co- ordinating uploading all appropriate guardianship paperwork for patients on to patients electronic record (Care partner) across all 3 partnerships. Ongoing CNM/ Mental Health Act Administrator Name of person completing this form: Signature: Tricia McGuiness SCN/David McGill CNM Date: 26/08/21
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Name of service: Woodland View, Wards 3 and 4 Visit date: 3 February 2022 Date final report sent to service: 6 April 2022 Recommendation Action planned Timescale Responsible person 1. Managers should audit the quality and consistency of care planning and reviews. 2. Managers should ensure staff have access to training in Adults with Incapacity (Scotland) Act 2000 to ensure their practical understanding of this legislation. Care planning training is being delivered to R/Ns on a 1:1 basis with audits of the quality being carried out further to this. Aim is to have 90% having completed this. Currently at 62% AWI LearnPro module has been developed and will be put onto the system. Aim is to have 90% of R/Ns initially will complete this with N/As to follow By end October ‘22 On system by end July ‘22 90% of R/Ns completed by end Nov ’22. 90% of N/As completed by end March ’23. Lynne Murray Lynne Murray Lynne Murray Lynne Murray Name of person completing this form: Signature: Date: 09.06.22