Perth and Kinross Health and Social Care Partnership (HSCP) Draft Care and Professional Governance Assurance Report
Perth and Kinross Council · 19 November 2025
Back to Scrutiny and Performance Committee — 19 November 2025 and its agenda
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Perth And Kinross Council Scrutiny and Performance Committee 19 November 2025 Perth and Kinross Health & Social Care Partnership (HSCP) Draft Care and Professional Governance Assurance Report Arun Singh, Chief Social Work Officer (CSWO) (Report No. 25/319) 1. Purpose Of Report This purpose of this report is to provide assurance on the Care and Professional Governance of the Perth and Kinross HSCP in respect to Social Work and Social Care services. 2. Situation 2.1 This report provides assurance on the Social Work and Social Care governance arrangements for services delegated within the Perth and Kinross Integration Scheme (approved June 2022) by the Council and delivered by the HSCP. Clinical Governance is a statutory reporting requirement at NHS Board level and our integrated approach enables Perth & Kinross Council to be assured about the standards and quality of social work and social care services 2.2 The Scrutiny and Performance Committee is asked to scrutinise this report and agree the level of assurance. The timescale for the data within this report are the two months between 1 August to 30 September 2025 2.3 The recommended level of assurance is: Reasonable Assurance; due to the following factors: • Recent annual reports received in line with the agreed reporting framework demonstrated reasonable levels of assurance to the Care and Professional Governance Forum. • Reporting and escalation of operational risks which have a bearing on clinical and care governance and associated mitigating actions and an established process for ensuring that the strategic risks to the Perth & Kinross Integration Joint Board take account of this where appropriate 3. Background 3.1 Perth & Kinross HSCP has an established Care and Professional Governance Forum (CPGF). The role of the CPGF is to ensure there are effective and embedded systems for Clinical, Care and Professional Governance and seek assurance from all services within.
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3.2 In April 2025, NHS Tayside launched the new Clinical Governance Strategy, which replaces the GIRFE Framework and provides the underpinning principles that support effective clinical governance and to emphasise how all staff contribute to the quality of care for people who access services in Tayside. 4. Assessment 4.1 Clinical & Care Risk Management The operational / team level risk registers for Adult Social Work and Social Care services are discussed monthly at the HSCP CPGF. 4.2 New risks and changes to existing risks are discussed at each meeting. Deeper dives of red and amber risks are undertaken on a quarterly and six monthly basis respectively outwith the CPGF for more detailed discussion with Service leads. 4.3 The reviewing of risks supports a proportionate approach to assurances, with relevant risks being regularly monitored. Scrutiny of risks ensures measures are put in place to minimise the risk(s) and assess the effectiveness of mitigations in place to minimise the risk. Where the risk affects, or is impacted by, other parts of the health or social care system, or indeed other agency, we are assured that they are fully informed and engaged in the process. 4.4 There is one red risk currently on the Risk Register for Social Work and Social Care: Risk 1 – Lack of OT capacity Because of increased demand for Single Handed Care and Moving & Handling (M&H) Risk Assessments, there is increased demand to support complex hospital discharges (including out of area hospitals) – environmental assessments and M&H equipment. I addition, there is increased demand for general assessments for long term conditions. There is consistently high intake of daily referrals by the OT Duty Service; an average of 40 referrals daily. At present, there are 3 OT's employed with a number of vacant posts. Mitigations are in place which include recruitment to vacant posts and each referral is prioritised according to presenting need and allocated on that basis. There is management oversight of the current challenges and collaborative working with Health colleagues. The CSWO has tabled the risk for a fuller discussion with the HSCP Senior Management Team.
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0 1 2 3 4 5 6 7 8 9 April May June July Aug Sept Oct Nov Dec Jan Feb March Complaints Closed 2025-2026 Stage 1 Stage 2 4.5 Clinical & Care Governance arrangements: All services/localities report exceptions on a two monthly basis, and all service localities reported to the CPGF during this time period. There were no issues highlighted in respect of social work or social care for escalation to Scrutiny and Performance Committee. The following services in relation to Council oversight, provided annual reports during the reporting period, and were given assurance levels as follows: MHO Team Report (Sept 2025) • A Short Life Working Group had been set up to review the pathways for arranging transport to hospital of acutely ill patients when Mental Health Act compulsory measures are required. A revised protocol is in the process of being finalised, and it is hoped that this will address some of the identified concerns. • Ongoing engagement specifically in relation to interface with Police Scotland and reciprocal expectations of both agencies in relation to mental health crisis work. • The PKC MHO Team continues to perform very well in relation to the national picture in the completion of Social Circumstances Reports (SCRs), a key performance indicator reported on by the Mental Welfare Commission for Scotland. In their 2023/24 annual monitoring report, the Commission reported that Perth and Kinross’s completion rate for SCRs was 92.3% (the national rate was 47.4%). This has a positive impact for our mental health services in P&K Level of Assurance: Reasonable 4.6 Complaint summary:
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*Reference to 4 or fewer, is to avoid potential identification due to the small numbers involved. • Total number of complaints received during August and September 2025 = 5 • Stage 1 = 12 • 4 or fewer Stage 1 complaints progressed to Stage 2 in August and September. • Total number of complaints closed in August and September 2025 = 12 • % Stage 2 responded to within timescales = 75% • Stage 2 not responded to within timescales = 25% • Services the complaints relate to as below • Community Alarm/Telecare - 4 or fewer • North Locality Social Work Highland - 4 or fewer • Care Homes - 4 or fewer • Care at Home – 4 or fewer • HART - 4 or fewer • Perth Locality Social Work South - 4 or fewer Total - 12 • Top themes ▪ Overall (more than one theme can be applicable per complaint) • Service Provision - 7 • Employees – 4 or fewer • Communication - 4 or fewer • Policy and Procedure - 4 or fewer Upheld or Partially Upheld complaints (more than one theme can be applicable per complaint) 4 or fewer Stage 1 complaints were partially upheld during August and September. Actions taken from upheld/partially upheld stage 1 complaints following fact finding: Supervisory oversight given with learning identified and supported directly with the team member in relation to communication Scottish Public Services Ombudsman Reports There have been no complaints referred to the SPSO during the time period.
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4.7 External Reports & Inspections There were no external inspections during the time period. 4.8 Adult Support & Protection (ASP) During the reporting time period, there were two active Large Scale Investigations (LSIs). These were both in relation to Care Homes in P&K HSCP (one involving low staffing, and one involving medication administration concerns). LSIs are overseen by the Care Home Operational Group (CHOG) The Adult Protection Committee (APC) received formal intimation to consider an APC led learning review on 10 Feb 2025, in respect to a supported accommodation provider where an individual died suddenly. A learning review group was established and has met and found that there are no obvious missed opportunities in respect to other similar incidents, other than an opportunity for providers to be reminded about training opportunities. The plan is to bring the learning review group back again to coordinate the findings and learning from other reviews. A report into the coordinated findings and learning opportunities will be shared. Local actions to mitigate risks of Drug related deaths in Perth and Kinross include: Implementation and embedding of the Medication Assisted Treatment (MAT) Standards. Current RAG scores as at Sept 2025 are green apart from MAT Standard 7, which is being progressed in line with national recommendations. • National Mission to reduce drug deaths funding utilised to increase IDART staff compliment to reduce waiting times and enhance service provision e.g. – provision of an OT service and the creation of a new psychology assistant post to provide low level psychological interventions. • Creation of a multiagency referral pathway for all new substance use referrals. • Creation of a near fatal overdose pathway and multiagency group to review all reported near fatal overdoses. During the reporting period there were 16 incidents reviewed. • Funding provided to third sector partners to employ assertive outreach workers to actively engage with service users.
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• Creation of a residential rehabilitation pathway and funding panel to facilitate access to rehabilitation services for service users, with 6 requests approved and none declined during the reporting period. 4.9 Workforce There is one red risk in relation to workforce capacity which is detailed above and the mitigations in place 4.10 Financial The composition of the Senior Management Team allows for a discussion of any financial issues from the perspective of Care & Professional Governance. 4.11 Risk Assessment/Management Key risks and assurance processes are detailed in earlier sections of this report 4.12 Equality and Diversity, including health inequalities Details regarding any Equality, diversity and health inequalities are included, if required within each service exception report. There are no exceptions requiring to be escalated to CGC. 4.13 Communication, involvement, engagement and consultation All HSCP Staff have been invited to complete the latest iMatter survey, and teams will meet to discuss the results of these and create actions to take forward 5. Recommendation This report is being presented for: • Reasonable Assurance As Chief Social Work Officer for Perth & Kinross Council, I would suggest that the level of assurance provided is: Reasonable Assurance Level of Assurance System Adequacy Controls ✓ Substantial Assurance A sound system of governance, risk management and control exists, with internal controls operating effectively and being consistently applied to support the achievement of objectives in the area audited Controls are applied continuously or with only minor lapses. Reasonable Assurance There is a generally sound system of governance, risk management and control in place. Some issues, non-compliance or scope for improvement were identified which may put Controls are applied frequently but with evidence of non-compliance. ✓
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at risk the achievement of objectives in the area audited. Limited Assurance Significant gaps, weaknesses or non- compliance were identified. Improvement is required to the system of governance, risk management and control to effectively manage risks to the achievement of objectives in the area audited. Controls are applied but with some significant lapses. No Assurance Immediate action is required to address fundamental gaps, weaknesses or non- compliance identified. The system of governance, risk management and control is inadequate to effectively manage risks to the achievement of objectives in the area audited. Significant breakdown in the application of controls.