8 - IJB Report CCG 2023
North Ayrshire Council · 24 August 2023
Back to Integration Joint Board — 24 August 2023 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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Integration Joint Board 24 August 2023 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 the achievement of partnership quality ambitions. 1.2 This paper provides an update and overview of governance activity for the period August 2022 – August 2023 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 are included as Appendix 1 of this report. The HSCP a strong professional leadership across services and professional leads to ensure that the role and function of the CCGG is built upon strong partnership and collaboration. 2.2 The CCGG has met on a monthly basis with the exception of June and July when the meeting was adjourned as the group was not quorate. The next NA CCGG is scheduled for 30th August 2023. The CCGG has a standing agenda that ensures routine consideration of: • Public Protection • Professional Updates • Heads of Service updates • Adverse Events • Complaints/Enquiries • Inspection Reports/Action Plans/SPSO • Workforce • Consultation and Safety Action Notices • Infection Control and Infection The CCGG has also had specific updates and assurance reports on: • The Promise • Equalities Action Plan • Pharmacy developments • Maternity and Neonatal Psychological Intervention (MNPI) service • Ayrshire Mental Health Conversation: Priorities and Outcomes • Signs of Safety Framework • CAMHS Referrals Mitigation 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.
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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 2022 and March 2023 mental health services across Ayrshire and Arran received 8 visits from the MWC. Of the six announced visits the MWC made recommendations for four of these. The MWC made recommendations following the two unannounced visits. An assurance report providing details of all visits, recommendations and action plans and thematic reports was developed by the NA CCGG and presented to the NHS Ayrshire and Arran Healthcare Governance Group in July 2023. 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 • Caring and enthusiastic approach from staff • Detailed risk assessments • Environment bright, cheerful and dementia friendly • Patients and family spoke highly of staff and were positive about the care, treatment and support offered • Warm and supportive interactions between staff and patients observed • Care plans detailed, and person centred • Ayrshire Risk Assessment Framework embedded into practice • Evidence of patient involvement within MDT process • Physical environment to a high standard • Good evidence of family engagement • Use of the “Positive Behaviour Support” model • Excellent nursing leadership • Staff approachable and supportive Action plans in response to the MWC 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 last update was to the December 2022 meeting and the next update will be on 30th August 2023. This report outlines: a) New risks Ref Description Risk Rating ORR35 Analogue to Digital Implementation 15 High ORR36 CAMHS – Referral to Treatment Target 16 High ORR37 Delivery of Neuro Diversity Specification 20 Very High b) Reduced score risk Ref Description Risk Rating Nov 22 Risk Rating May 23 ORR24 Covid Impact on Workforce 20 Very High 16 High c) Risks removed from the register Ref Description Reason for Removal ORR29 IT infrastructure at the Three Towns to support NAC staff (Social Work Team) The IT issues have been resolved. The CCGG will consider if any of the operational risks need to be escalated to the Partnership Senior Management Team (PSMT) for consideration for inclusion on the Strategic Risk Register. The CCGG also reviewed emerging risks: • CAMHS Referrals Mitigation Report (March 2023 CCGG) • Speech and Language Therapy (SLT) Service (March 2023 CCGG) 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. The CCGG will continue to ensure that staff in each service have the opportunity to contribute to the governance framework. Further meeting dates for the North Ayrshire Health and Social Care Partnerships’ Clinical and Care Governance Group are planned for 2023/4, and future update reports will be provided to the Integration Joint Board. 3.2 Anticipated Outcomes
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Strong clinical and care governance arrangements will ensure the quality of health and social care is monitored and assured and where risks emerge that those are able to be responded to in a safe way involving key stakeholders. 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. 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. The CCGG has clear links with service and professional governance groups, including the Social Work Governance Board. The Chair of CCGG is working closely with professional and service leads to review opportunities to further strengthen the approach to Clinical and Care Governance for the North Ayrshire HSCP. 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 its 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 10 and 11 Visit date: 17th May 2022 Date final report sent to service: Draft 20th July 2022 Recommendation Action planned Timescale Responsible person 1. Managers should ensure that nursing one-to-one sessions/ interventions are highlighted and clearly documented. SCN have communicated to registered nurse group when recording on CarePartner patient’s one-to-one session’s descriptor box will be used to record this intervention. Resulting in this being clearly visible when reviewing all patients CarePartner activities. This will be monitored through record keeping audits. Monthly SCN and DCN 2. Managers should audit consent to treatment documentation to ensure that treatment is legally authorised. Consent to treatment documentation is part of ward audit rolling programme within wards 10 and 11. Weekly SCN and DCN Name of person completing this form: Signature: SCN P Rennie/SCNA Peden/CNM D McGill Date: 29/07/22
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Service response to local visit recommendations Name of service: Woodland View, Ward 7A Visit date: 14 June 2022 Date final report sent to service: 7 September 2022 Recommendation Action planned Timescale Responsible person 1. Managers should carry out an audit of the nursing care plan reviews to ensure that they fully reflect the patients’ progress towards stated care goals, and that the recording of the reviews are consistent across all care plans. Care Plan Audit pro forma has been developed and is in place. In place SCN / Service Manager 2. Managers should ensure that as well as regularly auditing delayed discharges processes. That work should continue alongside partners to expedite discharge. 1. All patients who are currently recorded as delayed discharge are under the Care Programme Approach with regular meetings held to allow communication with partners to expedite discharge. 2. For patients who originate from local authority areas out with Ayrshire, there are regular meetings involving senior managers from North Ayrshire Health & Social Care partnership to engage with Already in place at time of recommendation RMOs / SCN / service manager
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other local authorities regarding ways to expedite discharge. We have involved a professional advisor from the Scottish Government in these cases. 3. All delayed discharges are recorded on Trakcare and audited accordingly. 3. Managers should ensure consent to treatment documentation is audited to ensure that treatment is legally authorised. 1. Weekly MDT updates are prepared and this document includes expiry dates for legal documentation which are reviewed by the MDT 2. Nursing staff carry out regular checks / audits to ensure appropriate documentation is in place and within date. 3. The Mental Health Administrator notifies the RMO whenever legal documentation is required or due to expire Already in place at time of recommendation RMOs / nursing team / Mental Health Administrator Name of person completing this form: Signature: Date: 25.1.23
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Service response to local visit recommendations Name of service: Woodland View, Ward 8 Visit date: 2 Nov 2022 Date final report sent to service: 7 Dec 2022 Recommendation Action planned Timescale Responsible person 1. Managers should ensure that as well as regularly auditing delayed discharge processes that work should continue alongside partners to expedite discharge. Delayed discharges are reviewed regularly through bed management structure, 4 weekly delayed discharge meetings are taking place to discuss all relevant patients alongside social work and community colleagues. In addition to this the pathway work is ongoing within Ward 8 working with other in patient areas to review and monitor the safe transitions of patients in and out of Ward 8. With regards to a specific individual from another Board area discussions are ongoing, and now including Scottish Delayed discharge process ongoing Pathway work July 2023 General Manager ACH/ CNM Rehab & Forensic Services
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Government on an advisory basis, with the Board and HSCP who originally placed the individual to identify an alternative provision. Name of person completing this form: William Lauder Signature: Date: 06/04/23 Service response to local visit recommendations Name of service: East Ayrshire Community Hospital, Marchburn Ward Visit date: 8 May 2022 Date final report sent to service: 3 August 2022 Recommendation Action planned Timescale Status Responsible person
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1. Managers should carry out an audit to ensure that care plan reviews are consistent, and that there is clarity around content, actions and patient progress. • Monthly audits of care plans via the Quality Improvement Portal will commence, involving auditing 100% of Patient care plans. This will be undertaken by all trained staff and nominated by the SCN. The SCN will present audit results and proposed additional improvements monthly to Clinical Nurse Manager (CNM) until evidence of 100% compliance is available. • During the weekly multi-disciplinary team meeting the medical and nursing staff will review all ARAFs and any updates will then be reflected into patient care plans which will be audited as part of monthly audit notes above. 01/12/2022 Completed Completed Tracey McAllister, SCN Marchburn Ward Tracey McAllister, SCN Marchburn Ward 2. Managers should review staffing arrangements to • Establish a benchmark with internal and external wards. 01/12/2022 Completed Linda Boyd, Senior Manager ensure that patients have access to the full range of professionals required to meet their needs. • Recruitment for the nursing vacancies for 1.0 WTE Band 5 and 2.0 WTE Band 6. • Submit funding request to create parity with Clonbeith Ward Completed Completed Completed Tracey McAllister, SCN Marchburn Ward Linda Boyd, Senior Manager Lindsay Collins, Clinical Nurse
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• Continue to perform 2 monthly reviews of the recorded risk on the corporate risk register. • WTE Clinical Psychologist has been appointed, to start post May 2023, with dedicated direct input to 3 organic mental health wards including Marchburn Ward. o There is ongoing nondedicated direct access via referral and strategic indirect input via the wider Psychology service • There is currently no dedicated AHP resource to Marchburn. This has been delivered on case by case basis. AHP service to undertake a workforce review utilising HIS workforce tools and common staffing method to identify recommendations. June 2023 Completed Completed Manager Dr Ying Tey, Consultant Clinical Psychologist Lianne McInally, AHP Senior Manager
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• Funding to resource the recommended AHP model to be explored. • Post-COVID restrictions on face to face assessments have been lifted and so ‘NHS Near Me’ for wider MDT reviews were not felt to be required. In Progress Completed Lianne McInally, AHP Senior Manager Tracey McAllister, SCN Marchburn Ward 3. Managers should undertake an audit to ensure that where there is a proxy decision maker, a copy of the powers granted are on file. • The family/NOK of all patients who currently have a Power of Attorney/Guardian were requested by letter to supply the most up to date copy of the powers. These have now all been received and uploaded on Care Partner. • Monthly audits of all patient files and Care Partner will be undertaken to ensure compliance in the future and uploaded to Quality Improvement Portal. This will be undertaken by all trained staff and nominated by the SCN. The SCN will present audit results and proposed additional improvements monthly to Clinical Nurse Manager (CNM) until evidence of 100% compliance is available. 01/10/2022 10/11/2022 Completed Completed Tracey McAllister, SCN Marchburn Ward Tracey McAllister, SCN Marchburn Ward
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4. Managers should ensure that section 47 treatment plans are completed, accessible and correctly filed in accordance with the AWI Code of Practice (3rd edition). • The nursing staff will implement checklists for use during the weekly MDT meetings, similar to the current medical staff checklists, to ensure all necessary paperwork is completed and filled appropriately. Electronic copies will be uploaded to Care Partner and paper copies kept within the ‘Legal’ section of paper case notes • Ann McArthur, ASP Lead, will offer updates to all staff on Adult with Incapacity (Scotland) Act 2000 and Adult Support & Protection Act 2007. Training dates have been arranged for 25th, 27th and 28th October. All trained staff (except those on long term absence) have been allocated to attend a session. • All trained staff were allocated by the SCN the LearnPro module on Adults with Incapacity and 100% have completed this. As part of the regular staff 1:1 with the SCN/DCN there will also be a discussion of how AWI is applied in daily practice. 01/12/2022 Completed Completed Completed Tracey McAllister, SCN Marchburn Ward Tracey McAllister, SCN Marchburn Ward Tracey McAllister, SCN Marchburn Ward
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5. Managers should review ward activities to ensure they best meet the patient’s needs, within a specialist complex dementia care unit. • Our previous and current patient and carer feedback has indicated that many activities supported by the ward team are well rated. • Music & More is a music and dance session which runs monthly. • 6 large, interactive sensory pictures were purchased and have been wall mounted for patients to engage with as they walk with purpose around the environment. • Memory boxes for each patient have been purchased and wall- mounted outside each bedroom area. Staff are currently working with patient’s family to reflect person-centred care. • Two rooms have been identified and equipped to provide Namaste and sensory activities. • The garden is being utilised for therapeutic mindfulness and exercise. A bid has been submitted for funding to create a sleepover space within the ward for loved ones of people with dementia to ensure they remain connected to each other. • New ward furniture was purchased and in place with clusters of seating 01/03/2023 Completed Tracey McAllister, SCN Marchburn Ward
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to encourage patients to engage in meaningful conversation Name of person completing this form: Marie Furniss Signature: Date: 17.07.2023