Perth And Kinross Health & Social Care Partnership (HSCP) Clinical And Care Governance Assurance Report
Perth and Kinross Council · 26 April 2023
Back to Scrutiny and Performance Committee — 26 April 2023 and its agenda
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PERTH AND KINROSS COUNCIL Scrutiny and Performance Committee 26 April 2023 PERTH AND KINROSS HEALTH & SOCIAL CARE PARTNERSHIP (HSCP) CLINICAL AND CARE GOVERNANCE ASSURANCE REPORT Jacquie Pepper, Chief Officer, Perth and Kinross HSCP (Report No. 23/118) 1. PURPOSE OF REPORT This purpose of this report is to provide assurance to Perth & Kinross Council’s Scrutiny and Performance Committee on the Clinical Care and Professional Governance of the Perth and Kinross HSCP 2. REPORT SUMMARY 2.1 Situation This report is being brought to the meeting to provide assurance on the clinical and care governance activities and arrangements across the Partnership as outlined in the Getting It Right for Everyone (GIRFE) Framework in accordance with the Partnership integration scheme. Clinical Governance is a statutory requirement to report on, at Board level, from Scottish Government as per NHS MEL (1998) 75. The Scrutiny and Performance Committee is being asked to provide their view on the level of assurance this report provides and therefore the level of assurance regards clinical and care governance within the Partnership. The timescale for the data within this report is from 1st November 2022 to 28 February 2023. As Lead Officer for Perth and Kinross HSCP I would suggest that the level of assurance provided is: Reasonable Assurance. 2.2 Background The role of the Perth and Kinross HSCP Governance forum is to provide assurance to the Perth and Kinross HSCP Integration Joint Board (IJB), NHS Tayside Board (through the Care Governance Committee) and Perth and Kinross Council (through the Scrutiny and Performance Cttee), that there are effective and embedded systems for Clinical, Care and Professional Governance in all services within Perth and Kinross HSCP. The GIRFE Framework is an agreed tool used by all three HSCPs to ensure consistency of approach between Local Authorities, Tayside NHS Board and the IJBs for the three HSCPs; quality assurance is assessed against an
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agreed, prioritised common data set for each of the governance domains as detailed below. A GIRFE Steering Group continues to meet, with representatives from each of the three Partnerships and part of its remit is to support additional common assurance measures and this template. The six domains continue to evolve over time and must be adaptable and responsive to the changes in legislation and external support and monitoring. The domains reflect the principles set out in the Health and Social Care Standards, My support, My life; Scottish Government, 2018 and the Quality- of-Care Approach, HIS and Care Inspectorate, September 2018. The domains are: Information Governance Professional Regulation and Workforce Development Patient/Service user/Carer and Staff Safety Patient/Service user/Carer and Staff Experience Quality and effectiveness of care Promotion of Equality and Social Justice 2.3 Assessment 2.3.1 Clinical and Care Risk Management The risk registers for Health and for Adult Social Work and Social Care (appendices 2 & 3) are discussed monthly at the Perth and Kinross HSCP Care & Professional Governance Forum. Managers of red risks provide a written update at every meeting, and managers of amber risks are asked for update at every other meeting. This supports assurances that the relevant risks are being regularly monitored; what measures are in place to minimise the risk; what alternative mitigations plans and actions are in place to minimise the risk; that 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. The controls listed under each risk are the cumulative efforts being made to mitigate the risk. Perth and Kinross HSCP red risks as at 17th March 2023:
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Title of Risk Adequacy Inherent Risk Score (without controls) Current Risk Score (with current controls in place) (829 - Health) Challenges in relation to accommodation for clinical and non- clinical staff across Perth and Kinross Incomplete Consequence – 5 Likelihood - 4 20 (RED) Consequence – 5 Likelihood - 4 20 (RED) Controls: Risk last reviewed 17 March 2023 Perth and Kinross HSCP Chief Officer and key staff are participating in the one public estate discussions to identify appropriate accommodation for different health and social care teams. Head of Health has briefed NHS Director of Facilities re all options which have currently been explored in NHS and PKC family Interim Chief Exec of PKC has been briefed by Chief Officer re: accommodation needs for the HSCP. Premises requirements identified and summarised in a briefing paper for CCATS, IDART, CAMH's, potential relocation of GP premises in Perth City and a multi-disciplinary team supporting young people and adults with a learning disability and/or Autism with complex needs. Shared with NHS Procurement and Estates Accommodation walkrounds have been completed across Health & Social care sites with a view to mapping sites to accommodate future teams. Members of EMT to set up accommodation short life working group inclusive of partnership forum to support short, medium and long term moves for staff. Consultation paper to be completed in relation to engaging with staff re: accommodation moves.
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Title of Risk Adequacy Inherent Risk Score (without controls) Current Risk Score (with current controls in place) (982 – Health) Mental Health Medical Workforce in Perth and Kinross HSCP Adequate Consequence – 4 Likelihood - 5 20 (RED) Consequence – 4 Likelihood - 5 20 (RED) Controls: Risk last reviewed 27 February 2023 Learning from staff exit interviews Operational Associate Medical Director for Mental Health is currently reviewing and arranging updated recruitment tools Begun the exploration of a model relating to General practitioner specialists in a collaboration with the AMD for Mental health Perth and Kinross service entered contingency, and Perth and Kinross Mental Health contingency meeting established. As of 26th Nov 21, the service will exit contingency. Liaison with Mental Health AMD, Nurse Director and Medical Director Medical contingency team to be based at Murray Royal Hospital commencing 21 June. The team was stood Down from 29th Nov 21 Pharmacy resource secured to support community teams from Oct 2022 Advanced Nurse Practitioner resource being secured to support contingency team Drafting patient pathways between CMHT and medical contingency team NHST are deploying medical resource from Dundee Secured adequate locum psychiatrist cover for the next six months.
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Title of Risk Adequacy Inherent Risk Score (without controls) Current Risk Score (with current controls in place) (1226 – Health) GP Cover for HMP Perth Inadequate Consequence – 3 Likelihood - 5 15 (AMBER) Consequence – 4 Likelihood - 5 20 (RED) * The current risk score is higher than the inherent score due to exacerbations of the risk by the last remaining GP giving notice to leave post Controls: Risk last reviewed 21 February 2023 The service is in communication with a practice who may be interested in a hybrid approach Authority given by Medical Director to utilise non-framework locum agency Escalate risk to red given short timescales and implications Clear process to attempt to secure additional cover using locum agency, local locum groups and regular locum session Documented escalation process should shifts remain unfilled Back up explored via GP practice who cover HMP Castle Huntly and GP OOH service Locum GP arranged to cover shifts over the coming months. 11 new GP’s now available
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Title of Risk Adequacy Inherent Risk Score (without controls) Current Risk Score (with current controls in place) (701 – Health) Mental Health Waiting Times within the Prison Healthcare Service Adequate Consequence – 3 Likelihood - 5 15 (AMBER) Consequence – 4 Likelihood - 5 20 (RED) * The current risk score is higher than the inherent score due to exacerbations of the risk by further staffing challenges. Controls: Risk last reviewed 16 January 2023 Review of workforce model to increase capacity of PHC teams to meet demand Seek agency nursing staff to reduce time spent by team administering medication Escalate to Chief Officer concern over recruitment delays by HR SBAR to extend agency cover authorised by Chief Officer Introduced telephone consultations Explore skill mix within the team Readvertise band 6 RN 3 x CN posts to support the workforce compliment /requirement SCN holding clinical caseload in Perth Consider Learning disability RN for team to enhance service and enhance overall compliment given recruitment challenges SCN increasing clinical caseload RAG status applied to all triaged referrals and current caseload Further recruitment - only two band 6 nurses in post, 1 sick and working notice, the other working notice - recruitment ongoing
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Title of Risk Adequacy Inherent Risk Score (without controls) Current Risk Score (with current controls in place) (1267 – Health) Capacity & Flow – Older Peoples Services) Inadequate Consequence – 4 Likelihood - 5 20 (RED) Consequence – 4 Likelihood - 5 20 (RED) Controls: Risk last reviewed 17 March 2023 Daily multiagency meetings within PRI regarding capacity and flow and prioritising of discharges Weekly Silver Command in place to monitor progress and actions Roll out of PDD implementation and training across sites now in place Frailty at Front Door Model in place Interim Bed usage across Perth and Kinross to facilitate flow TQUIP Improvement Work for Community Hospitals Improvement on Guardianship Processes across Perth and Kinross Focus on length of stay in Community Hospitals and improvement plans under development Care at Home Reviews to free up capacity Development of DD dashboard for Perth and Kinross Extension of Interim Process for further 12 months Review of integrated discharge team Development of discharge pathways using home first approach Further developments on integrated care model
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Title of Risk Adequacy Inherent Risk Score (without controls) Current Risk Score (with current controls in place) (5 – Social Work) Lack of Care at Home capacity, especially in rural P& K Consequence – 5 Likelihood - 4 20 (RED) Consequence – 5 Likelihood - 4 20 (RED) Controls: Risk last reviewed 17 February 2023 Active recruitment campaign has resulted in 52 applications to HART, 10 to HART+ and 14 to Living Well Care. 17 people have been recruited to HART and interviews still to be completed. 2.3.2 Clinical and Care Governance Arrangements Lead Partners Services Each HSCP is a Lead Partner for a number of services. These services report through to the Clinical Care and Professional Governance Forum for that HSCP. At the Clinical Care and Professional Governance Forum the Lead Partner Service reports receive the relevant level of scrutiny as other reports. Systems and processes are being established to ensure that all three HSCPs receive copies of reports from other Lead Partner Services to support integration, and effective whole system working. Full details of the Clinical & Care Governance Arrangements in Perth and Kinross HSCP are provided within appendix 4. Summary of key risks raised at recent CPGF meetings: Key risks identified within the exception reports from the CPGF meetings held in November 2022, December 2022, January 2023 and February 2023: • Prison Healthcare: o Insufficient leadership capacity to meet at the demands on the service. Senior posts have been recruited to with the full team in place by end March 2023. o GP medical cover for HMP Perth remains a risk. The service is currently being covered by locum GPs. The routine waiting time has reduced from 27-week s to 4 weeks. This model is unsustainable so an alternative model with Advanced Nurse
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Practitioners supported by an aligned GP practice is under development. • North Locality: o Staffing difficulties within Community Nursing, Physiotherapy and CMHT (medical), and Social Work. These are recruitment issues relating to the rurality of the North locality and the lack of qualified staff living in northwest Perthshire in particular. The locality is exploring skill mix and competencies along with new ways of working to sustainably support these services. • Perth City: o Significant staff shortages within IDART resulting in staff not having time for CPD or supervision. As at Dec 2022, 9 of the 11 vacant posts have been recruited to, and a large part of the team are new in post and going through induction. o Also, within IDART, accommodation is a significant barrier to optimum service provision and has a negative impact on staff experience, wait times and the service’s ability to achieve MAT Standards. • Public Dental: o There remains a high risk regarding essential COVID ventilation modifications in HMP Perth and Springfield and Kings Cross dental clinics, and this continues to impact on the ability to treat patients safely and efficiently. • South Locality: o Increased use of bank and agency staff due to registered staff vacancy levels and recruitment difficulties. o Significant issues with private providers picking up care packages in the South Locality. 706 hours waiting across whole of the South. Key risks identified within the annual reports from the CPGF meetings held in November 2022, December 2022, January 2023 and February 2023: • Psychiatry of Old Age: o Recruitment and retention of staff and the service is very reliant on agency staff. To mitigate the risks with workforce we have brought in 3.8wte Assistant Practitioner roles at Band 4 to support the Multi- Disciplinary Team and feedback has been positive. o Ligature Risks – particularly within Leven Ward where we have OOH patients transferred to GAP inpatient services. This ward is not suitable for the nature of these patients. o Bed occupancy – Leven consistently on 100% occupancy (functional elderly ward) unable to discharge patients due to care at home packages. Garry and Tummel have been high but coming down slightly over the past few months.
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• South Locality: o Ongoing shortages of medical cover for GAP, continued delays around waiting times. o Care at Home presently challenged around shortage of social carers disproportionately affecting rural localities. o Covid 19 still having an effect on inpatient areas and capacity of staff teams. o Report highlighted new issues regarding fire evacuation of patients within Crieff Community Hospital and St Margaret’s Community Hospital which is being reported and shared through HSCP Health and Safety Meeting. • Mental Health Officer (MHO) and Wellbeing Support: o Referral rates and work rates remain high. Wellbeing Support Team have stabilised. MHO rates remaining unpredictable. o Biggest challenge is the ongoing issues with availability of general psychiatry cover. o Looking ahead there will be some challenges with staffing and nationally there is a shortage of MHOs. We have one candidate going through MHO training this year. • Access Team: o Throughout 2022, the main issues facing the team has been staff shortages (primarily through staff off on long term sickness). Pressure has more recently been reduced. • Public Dental Service: o There remains a high risk regarding essential COVID ventilation modifications in dental clinics in HMP Perth, Springfield Medical Centre Arbroath, Links Health Centre Montrose and Kings Park School and Kings Cross in Dundee. This continues to impact on the ability to treat patients safely and efficiently. This has now been on the minor works agenda for several months, and funding is in place. Necessary costings have now been obtained from the Property Department and a paper will be submitted to NHST Assets Management Group in March. o Essential non-ventilation building works and refurbishments to Kings Cross, Royal Victoria Hospital and Links Health Centre (totalling in the region of 400k) are similarly stalled. This funding has been earmarked for Primary Care Dentistry. o Increase in the number of unregistered patients trying to access the Public Dental Service for unregistered care. o Increase in volume of referrals from General Dental Practitioners o Access to General Anaesthetic (GA) lists for Special Needs Adults and Paediatric lists. o Misinterpretation of Theatre Utilisation figures and subsequent threat of withdrawal of access to GA lists.
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2.3.3 Adverse Event Management Systems are in place for services/localities to review DATIX incidents. The Nursing and AHP leads meet along with the Clinical Governance Coordinator on monthly basis to review the top 5 incident categories. This helps to identify any trends or any appropriate action and supports closing the loop. Regarding adverse events, the main themes reported during the months between November 2022 and February 2023 were: Highest frequency events: 1. Slips, Trips and Falls 2. Medication 3. Clinical Challenging Behaviour 4. Violence and Aggression 5. Pressure Ulcer Harm is defined as an outcome with a negative effect. Harm to a person or groups of people may result from worsening of a medical condition, the inherent risk of an investigation or treatment, system failure provider performance issues, service disruption, financial loss or adverse publicity. Slip, Trip & Fall During the months between November 2022 and February 2023, there were 199 incidents recorded, of which 37 involved harms. 89 occurred at MRH, 25 at PRI, 79 in Community Hospitals and the remaining 6 in other areas. The Psychiatry of Old Age inpatient wards at Murray Royal Hospital experienced a higher than usual number of falls at the end of 2021 due to several patients who had multiple falls (many of which were controlled). Ward staff were doing all they could to manage the falls, and they had support from the Falls Coordinator during this time.
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In addition, the Falls Coordinator continues to: • Review all the wards in-patient falls Datix reports and provide feedback to the ward with a breakdown of their falls, outlining any trends, highlighting patients who fall repeatedly and enquiring if further information is required. • Supports all the HSCP wards to have strength and balance exercise panels fitted on their walls and suitable patients also receive a set of strength and balance cue cards which they can take home with them. Along with that they receive a Care About Walking booklet and record charts for recording activity/steps. Medication During the months between November 2022 and February 2023, there were 67 incidents recorded, of which 1 involved harm. 4 occurred at MRH, 6 at PRI, 14 in Community Hospitals, 31 within a Prison Establishment and the remaining 12 in other areas. Most medication adverse events occurred with the Prison Healthcare service. The prison healthcare service manages and administers a high volume of medication across three sites across Tayside - HMP Perth, HMP Castle Huntly and HMP & YOI Bella. The service has ongoing challenges with regards to the Lloyds pharmacy contract and issues with medication deliveries. This has an impact on the patient population and, as such, has been added to DATIX as a service risk. The Clinical Pharmacist is in discussion with Lloyds and the national prison pharmacy team at National Services Scotland with a view to improve the situation. The service is also carrying vacancies across all teams. The medication adverse events are varied, ranging from medication being delivered late due to the Lloyds delivery, to rarer Controlled Drugs incidents which are fully investigated and reported through the Primary Health Care Medicines Management Group then on to Perth and Kinross CCPG. Any thefts or losses of controlled drugs are reported to the Home Office.
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Violence and Aggression During the months between November 2022 and February 2023 there were 41 incidents recorded, of which 6 involved harm. 20 occurred at MRH, 7 at PRI, 5 in Community Hospitals, and the remaining 9 in other areas. The 20 incidents within Murray Royal Hospital were within the Psychiatry of Old Age wards. The 6 incidents which involved harm were across a variety of different services and locations, and all but one was regarding aggression against a member of staff. The remaining incident was violence from a patient towards a family member. Clinical Challenging Behaviour (such as patient unable to understand risks, sexual disinhibition, general agitation) During the months between November 2022 and February 2023, there were 43 incidents recorded, of which 9 involved harm. 30 occurred at MRH, 6 in PRI, 7 in Community Hospitals. Most of these incidents were within the Psychiatry of Old Age wards at Murray Royal Hospital. The wards have sought input from the NHST PMVA team regarding the ongoing management of Violence and Aggression, and Clinical Challenging Behaviour.
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Pressure Ulcers During the months between November 2022 and February 2023, there were 41 incidents recorded, of which 29 involved harm. 14 were within the patients home, 14 within Care Homes, 10 within Community Hospitals, and the remaining 3 in other areas. Red & Amber events: Overdue red and amber events within Perth and Kinross HSCP are discussed monthly at the CPGF meeting, and there has been a focus on reducing outstanding reviews: • September 2020 – 24 outstanding events • January 2021- 19 outstanding events • May 2021 - 13 outstanding events • July 2021 – 13 outstanding events • November 2021 – 11 outstanding events • March 2022 - 8 outstanding events • July 2022 - 5 outstanding events • Oct 2022 – 2 outstanding events • March 2023 - 1 outstanding event Progress has been made throughout the year regarding the outstanding red events, and as of March 2023, there is 1 outstanding which is overdue. The reason for these being outstanding relates to complexity of events; delays due in part to the COVID pandemic response; co-ordination across multiple agencies and services etc. Reviews will continue until a further sustained improvement is evident. Further details regarding these incidents are provided within Appendix 5. Each geographical locality in Perth and Kinross is provided with a summary of adverse events specific to their locality to enable them to identify trends and any learning.
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Adverse events are regularly reviewed and form a standing agenda item at the locality governance groups to identify learning, improvements, training needs or themes. It has been identified and acknowledged by the CPGF that further performance improvement is required regarding the timescales for reporting and verifying DATIX incidents. This continues to be monitored at CPGF meetings. 2.3.4 Significant Adverse Event Reviews There is one ongoing SAER within Perth and Kinross HSCP relating to a patient who died by suicide. A draft report has been completed, and comments received back from the family and those involved in the review. An action plan based on the recommendations has been created, and both the report and action plan have been signed off at first and second stage. 2.3.5 Pressure Ulcers Falls Details regarding both types of Adverse events has been provided above in section 2.3.3. Pressure ulcers are reviewed on an individual basis to ensure that all mitigating actions are in place and any themes in relation to learning are identified. 2.3.6 Complaints (Health) Current Health Complaints as at 23 February 2023 - Stage 1 Service Area 0-5 Days 6-10 Days Total Perth and Kinross HSCP 4 3 7 Current Health Complaints as at 23 February 2023 - Stage 2 Service Area 0 - 5 d a 6- 10 da ys 11- 15 da ys 16- 20 da ys >2 0 da ys >4 0 da ys >6 0 da ys To tal 0 10 20 30 40 50 60 Mar-21 Apr-21 May-21 Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 Dec-21 Jan-22 Feb-22 Mar-22 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Stage 1 Stage 2
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y s Perth and Kinross HSCP 1 0 1 1 1 0 0 4 • Total number of complaints received in February 2023 = 24 • Total number of complaints closed in February 2023 = 24 • Stage 1 = 18 (6 upheld or partially upheld) • Stage 2 = 6 (6 upheld or partially upheld) • % Stage 2 completed within timescales = 50 • % Stage 2 not completed within timescales = 50% Services • Prison Healthcare – 19 • Perth City – 1 • Mental Health – 3 • South Locality – 1 Top themes (Prison Healthcare): Overall • Disagreement with treatment plan. • Wait times/delay. • Medication. Upheld or Partially Upheld complaints • Wait times/delay. • Disagreement with treatment plan. • Communication. Top themes (other HSCP services): Overall • Appointment Wait times. • Communication. • Treatment received. Upheld or Partially Upheld complaints • Appointment Wait times. • Communication • Treatment received. Complaints (Adult Social Work & Social Care)
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A summary of recent closed health and social care complaints is presented and discussed at each monthly meeting of the CPGF. This includes the breakdown of complaints by service, Stage 1 or 2, the number upheld or partially upheld, and the percentage responded to within timescales. It also includes the main complaint themes (both overall and for those complaints fully or partially upheld). Complaints are also discussed in more detail within the locality/service Care Governance meetings, with any key learning included within the exception reports to the CPGF. 2.3.7 Scottish Public Services Ombudsman Reports There have been no complaints referred to the SPSO during the time.
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The last complaint which was referred to the SPSO was from October 2020, and further information has recently been provided to the SPSO regarding this complaint. 2.3.8 External Reports & Inspections There have been no external inspections to our NHS services during the time period. 2.3.9 Adult Support & Protection This above shows a significant increase in both AP concerns and VPRs. This is, at least partly, a result of increased awareness due to ongoing information campaigns and improved multi-agency working. Extra social worker posts have been recruited to respond to this increased demand. Responding to concerns about adults at risk of harm is prioritised and, despite this increase in referrals, 97% of all concerns are screened within 24-hours. This indicator, together with the wider performance framework, is monitored at locality governance meetings, the Public Protection Group, Chief Officers Group and the Adult Protection Committee. MAT Standards Progress against implementation of the MAT standards is on track in Perth and Kinross, with current focus on standards one to five that have a fixed deadline date of 14th April for the submission of evidence. This falls into three categories, with the main aspect being evidence of processes and operating procedures; supported by data around service users receiving same day
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prescribing and key themes identified from responses to experiential interviews conducted with service users, staff and families. Regular update meetings are held with the national support team to discuss and update on progress with our current expectation that we are on ‘green’ RAG status for the delivery of our implementation plans. We do not have any significant concerns about delivery. Work is ongoing around standards six to ten that have an implementation date of April 2024. 2.3.10 Mental Health Community Mental Health Service Activity (NORTH)
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Community Mental Health Service Activity (SOUTH)
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Community Mental Health Service Activity (PERTH CITY)
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2.4 Quality/Patient Care There are several ongoing risks (summarised within Appendices 2 & 3) which, if not mitigated, pose a risk to the provision of safe care which is of high quality. The HSCP continues to manage these risks proactively. Services across Perth and Kinross HSCP have and continue to see pressure due to the ongoing impact of Covid-19 on whole system capacity and flow, as well as the further impacts due to a sustained increase in living and fuel costs. This is leading to increased recruitment and retention difficulties and in some cases, providers handing back packages of care they deem unaffordable to maintain and staff moving to more centralised posts to save fuel costs. Particular capacity and flow pressure is being felt across inpatient services, care homes, care at home, community hospitals and more generally, across all health and care community teams and services This has been further impacted by multiple factors including staff exhaustion, sickness and absence, increased demand and complexity of patients presenting in hospital and to community teams, causing significant impact on length of stay, larger packages of care being required on discharge, rise in people delayed in their discharge and impacts on system wide service capacity. Due to this increase and complexity in referrals there has been an increase in unmet need. This situation is adding to our current delayed discharge position where we are seeing us averaging above our normal delays, increasing diverts to Ninewells, causing poor journeys for Perth and Kinross patients and capacity and flow issues across the Psychiatry of Old Age and community hospital sites. Due to the ongoing impact the inpatient services are running consistently above agreed bed numbers across acute and HSCP services but also impacting on our AHP resources and ability to respond to patient rehabilitation needs. Within Perth and Kinross HSCP, the current substantive staffing resource (in post) in all areas is unable to fulfil or sustain safe daily staffing levels with
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current increased bed capacity in some areas to maintain capacity and flow. Therefore, we have had to resort to block booking agency staff to ensure safe staffing levels. Advertising and engagement with Newly Qualified Graduate recruitment processes have has been consistent since pre 2020 but staffing gaps have persisted. Within the Community, teams are seeing increasing referrals, increasing complexity, frailty, increased deaths due to substance use, poor mental health and wellbeing and increased acuity of mental illness all within increasing pressure to maintain individuals at home with resource that does not meet escalating clinical demand. Temporary COVID monies are no longer available so posts that were recruited to manage the direct outcomes of COVID have no further funding. There is a risk to patient safety and staff wellbeing if a decision is made to stop agency usage across our services as part of The Scottish Government Supplementary Staffing Agency Controls, and this has been escalated to our executive team and through professional structures. The HSCP has used other options to create capacity and flow and Interim funding has been used to ensure delivery of a whole system approach to flow and safe and timely discharge. Nine care homes were commissioned, with 2 beds identified in each, including one Perth and Kinross owned care home, 18 in total. Located in all three localities allowing individuals to remain close to their family/friends and within their own community. It was recognised that for care homes the acceptance of individuals, on an interim placement basis, was an additional workload pressure, in recognition it was agreed that the 2 beds in each of the 8 commissioned care homes would be block booked and paid for the duration of the contract. To support in addressing this demand and risk to service delivery, several actions have been progressed (many of which funded from the Winter Resilience reserve): • Continuation of agency staffing within Care at Home until March 2023. • Continuation of 18 x Interim beds, currently approved until 30th September 2022, proposed to be extended to 31st March 2023. • Additional hours within community teams (incl. AHP and Community Nursing). • Extend sustainability cost support to providers in exceptional circumstances, until 30th September 2022. In the first instance, approval should be sought from Scottish Government to continue to fund this from locally held COVID Reserves. • Increase the recruitment to HART from 10 Social Care Officers above budgeted establishment to 25, therefore an additional 15 posts. The turnover of Social Care Officers across all Social Care is 4-5 FTE per month. • Earmark funding to support an increase in mileage rates for internal social care staff and providers, matching that offered to NHS employees.
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• AHP Resilience. • Peripatetic team for MFE and Community hospital to support Senior Leadership Team Capacity to ensure safe care. • Use of hire cars across the health and social work teams to add additional capacity where required to ease pressure on community staff/fuel costs. • Increased resource through joint initiatives with Alzheimer’s Scotland for Post Diagnostic Support for people with dementia. • Increased resource to Primary Care Mental Health and Wellbeing Nursing with enhanced delivery of core mental health learning packages across communities such as anxiety management, confidence, safety and stabilisation. • Increased resource to MindSpace counselling and joint working with a range of partners to enhance the local response to people with mental health crisis. • Development of the Health Hub at Murray Royal Hospital, including discharge pack work with GAP inpatients, increased use of self-help resources and peer support. • Increased staffing within iDART from ADP monies has resulted in the Team meeting national wait times, testing community detoxification models, implementing same day prescribing, providing an assertive engagement model. • Transformation programme progressing for Adult CMHTs and Primary Care Mental Health to ensure a no wrong door approach to mental ill health. • Variation of the contracts for supported accommodation to include people over the age of 65 years with major mental illness whose discharge for POA Inpatients is currently determined as delayed. Drug related deaths: Numbers of suspected drug related deaths are recorded across the three HSCP’s and is used to inform learning and context within and across the HSCP’s. The following shows data regarding confirmed drug deaths in Perth and Kinross as compared to across Scotland (please note the two y-axes):
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The following shows data regarding confirmed drug deaths in Perth and Kinross as compared to across Scotland (please note the two y-axes): Local actions to mitigate risks in Perth and Kinross include: • Implementation of Medication Assistant Treatment (MAT) Standards 1- 5 by April 2023. • Implementation of MAT Standards 6-10 by April 2024. • 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 with funding provided to third sector partners to employ assertive outreach workers to actively engage with service users. • Creation of a residential rehabilitation pathway and funding panel to facilitate access to rehabilitation services for service users. 2.5 Workforce There are ongoing risks regarding workforce challenges (summarised within Appendices 2 &3) which, if not mitigated, pose a risk to the provision of safe care which is of high quality. The HSCP continues to manage these risks proactively. Perth and Kinross HSCP ensure alignment with NHS Tayside’s approved 3- year workforce strategy and Perth and Kinross Council Workforce Plan. Workload tools are in use within the Community Nursing service, and workload tools have also been used in the past within services such as POA, and these requires to be conducted again. There are several workload tools which can be used, and the purpose of each tool is to provide information and recommendations on staffing levels based on patient workload. AHP staff have also been engaging in testing Workforce Templates in some services in conjunction with Healthcare Improvement Scotland (HIS) colleagues, as part of the Common Staffing Method approach. A Workforce Steering Group has been established to oversee the implementation of the Perth and Kinross HSCP Workforce Plan. 2.6 Financial The composition of the Executive Management Team allows for a discussion of any financial issues from the perspective of Care & Professional Governance. 2.7 Risk Assessment/Management Key risks and risk assurance process is detailed under section 2.3a.
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2.8 Equality and Diversity, including health inequalities Equality, diversity and health inequalities are core to the Getting it Right Framework and the domains within. Each service provides exception reports which include this aspect. Currently there are no exceptions requiring to be escalated to CGC. 2.9 Other impacts N/A 2.10 Communication, involvement, engagement and consultation All HSCP Staff have been invited to complete the latest iMatter survey, and teams have met to discuss the results of these and actions to take forward. The HSCP is working with the Strategic Planning and Communication and Engagement Groups to support more effective communication, engagement and involvement, and exploring the most appropriate way to respond to the feedback we have received. The North Locality is also trialling a ‘you said, we did’ approach to a recent community consultation. The HSCP took out a subscription to Care Opinion in May 2022, following a Test period. We continue to receive feedback from people who use our services from this public platform. To date we have had over 60 feedback stories submitted with 89% of the feedback received being positive. We are rolling Care Opinion out across all services in a cumulative approach and teams are now using its performance generated reporting data within their business activities. We are currently one of the best performing HSCPs in Scotland with regards to utilisation of Care Opinion. 2.11 Route to the Meeting This has been previously considered by the following groups as part of its development. The groups have either supported the content, or their feedback has informed the development of the content presented in this report. • Perth and Kinross HSCP Care & Professional Governance Forum member • Perth and Kinross HSCP Professional Leads and Heads of Service • Perth and Kinross HSCP Executive Management Team (final draft) 3 CONCLUSION AND RECOMMENDATION(S) This report is being presented for: Assurance – Reasonable Assurance As Lead Officer for Perth and Kinross HSCP I would suggest that the level of assurance provided is: Reasonable Assurance; due to the following factors: • The ongoing development of Clinical & Care Governance structures for Mental Health services in Perth and Kinross HSCP.
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Please the level of assurance you are providing: Level of Assurance System Adequacy Controls ✓ Substantial Assurance A sound system of governance, risk management and control exist, 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 at risk the achievement of objectives in the area audited. Controls are applied frequently but with evidence of non-compliance. 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.
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Author(s) Name Designation Contact Details Kenny Ogilvy Dr Hamish Dougall Interim Head of Service ASWSC Operations Associate Medical Director KOgilvy@pkc.gov.uk Hamish.Dougall@nhs.scot Approved Name Designation Date
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ANNEX 1. IMPLICATIONS, ASSESSMENTS, CONSULTATION AND COMMUNICATION The undernoted table should be completed for all reports. Where the answer is ‘yes’, the relevant section(s) should also be completed. Where the answer is ‘no’, the relevant section(s) should be marked ‘not available (n/a)’. Strategic Implications Yes / None Community Plan / Single Outcome Agreement Yes Corporate Plan Yes Resource Implications Financial Yes Workforce Yes Asset Management (land, property, IST) Yes Assessments Equality Impact Assessment Yes Strategic Environmental Assessment Yes Sustainability (community, economic, environmental) Yes Legal and Governance Yes Risk Yes Consultation Internal Yes External Yes Communication Communications Plan Yes 1. Strategic Implications Community Plan/Single Outcome Agreement 1.1 This report covers Clinical Care and Professional Governance across the HSCP. The HSCP contributes to all of the following: (i) Giving every child the best start in life (ii) Developing educated, responsible and informed citizens (iii) Promoting a prosperous, inclusive and sustainable economy (iv) Supporting people to lead independent, healthy and active lives (v) Creating a safe and sustainable place for future generations Corporate Plan 1.2 This report covers Clinical Care and Professional Governance across the HSCP. The HSCP contributes to all the following: (i) Giving every child the best start in life. (ii) Developing educated, responsible and informed citizens. (iii) Promoting a prosperous, inclusive and sustainable economy.
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(iv) Supporting people to lead independent, healthy and active lives; and (v) Creating a safe and sustainable place for future generations. 2. Resource Implications Financial 2.1 This report covers Clinical Care and Professional Governance across the HSCP. Any financial issues identified are escalated to the Chief Officer, Chief Finance Officer and HSCP EMT as required. Workforce 2.2 This report covers Clinical Care and Professional Governance across the HSCP. Any workforce issues identified are escalated to the Chief Officer, Chief Finance Officer and HSCP EMT as required. Asset Management (land, property, IT) 2.3 This report covers Clinical Care and Professional Governance across the HSCP. Any workforce issues identified are escalated to the Chief Officer, Chief Finance Officer, PKC and HSCP EMT as required 3. Assessments The following 3 sections should report on the assessments which have been undertaken and should set out how the results of the assessments can be accessed, which could be appended to the report as supporting documents. An Integrated Appraisal Toolkit (IAT) is now available across the Council for policy makers to carry out their assessment requirements on a single system. The IAT combines the functions and requirements of Equality Impact Assessment (EqIA), Sustainability Assessment and pre-screening/screening for Strategic Environmental Assessment (SEA). The IAT ‘final report’ produced on completing the integrated appraisal should be used as supporting evidence that the assessments listed below have been undertaken. Equality Impact Assessment This report covers Clinical Care and Professional Governance across the HSCP. Any Equality Impact Assessments are completed as required. 3.1 Under the Equality Act 2010, the Council is required to eliminate discrimination, advance equality of opportunity, and foster good relations between equality groups. Carrying out Equality Impact Assessments for plans and policies allows the Council to demonstrate that it is meeting these duties.
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The Equality Impact Assessment undertaken in relation to this report can be viewed clicking here. This section should reflect that the proposals have been considered under the Corporate Equalities Impact Assessment process (EqIA) with the following outcome: (i) Assessed as not relevant for the purposes of EqIA (ii) Assessed as relevant and actions taken to reduce or remove the following negative impacts: (add summary points only here) (iii) Assessed as relevant and the following positive outcomes expected following implementation: (add summary points only here). Strategic Environmental Assessment This report covers Clinical Care and Professional Governance across the HSCP. Any Strategic Environmental Assessments are completed as required. 3.2 The Environmental Assessment (Scotland) Act 2005 places a duty on the Council to identify and assess the environmental consequences of its proposals. This section should reflect that the proposals have been considered under the Act and [choose appropriate statement]: Option 1 However, no action is required as the Act does not apply to the matters presented in this report. This is because the Committee are requested to note the contents of the report only and the Committee are not being requested to approve, adopt or agree to an action or to set the framework for future decisions. Option 2 no further action is required as it does not qualify as a PPS as defined by the Act and is therefore exempt. Option 3 pre-screening has identified that the PPS will have no or minimal environmental effects, it is therefore exempt, and the SEA Gateway has been notified. The reason(s) for concluding that the PPS will have no or minimal environmental effects is that [add reasons]. Option 4a screening has determined that there is unlikely to be significant environmental effects and is therefore exempt and the Consultation Authorities have been notified. The reason(s) for concluding that the PPS is unlikely to have significant environmental effects is that [add reasons]. Option 4b screening has determined that there are likely to be significant environmental effects and as a consequence an environmental assessment is necessary. The likely significant environmental effects have been identified as being [add effects]. At the
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present time a scoping report, which will determine the scope of the environmental assessment, is being prepared for submission to the Consultation Authorities. Option 4c the determination was made that there were likely to be significant environmental effects and as a consequence an environmental assessment was necessary. The environmental report has been completed and will be submitted to the Consultation Authorities together with the draft PPS for their consideration. The key findings of the Environmental Report were that [add key findings]. And the PPS has been modified by [demonstrate how plan modified] Sustainability This report covers Clinical Care and Professional Governance across the HSCP. Any assessments regarding sustainability are completed as required. 3.3 Under the provisions of the Local Government in Scotland Act 2003 the Council has to discharge its duties in a way which contributes to the achievement of sustainable development. Under the Climate Change (Scotland) Act 2009 the Council also has a duty relating to climate change and, in exercising its functions must act: • in the way best calculated to delivery of the Act’s emissions reduction targets. • in the way best calculated to deliver any statutory adaptation programmes; and • in a way that it considers most sustainable. This section should reflect the steps that have been taken to assess the proposals against the Council’s Principles for Sustainable Development. Click here for further guidance. Legal and Governance 3.4 This report covers Clinical Care and Professional Governance across the HSCP. Any legal and governance issues identified are escalated to the Chief Officer, Chief Finance Officer and HSCP EMT as required Risk This report covers Clinical Care and Professional Governance across the HSCP. The purpose of the report is to identify, and risks relating to Clinical Care and Professional Governance, mitigating actions and escalate to HSCP EMT as required. 3.6 This section should set out the key risks associated with the proposals which have not been addressed elsewhere in the report, including any implications
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for the corporate risk management process, and also the controls required to mitigate those risks. 4. Consultation Internal 4.1 This report covers Clinical Care and Professional Governance across the HSCP. Any consultation is progressed by the relevant strategy or locality groups. External 4.2 This report covers Clinical Care and Professional Governance across the HSCP. Any consultation is progressed by the relevant strategy or locality groups. 5. Communication 5.1 This report covers Clinical Care and Professional Governance across the HSCP. Any communication is progressed by the relevant strategy or locality groups. 2. BACKGROUND PAPERS This section should list the documents that have been relied on in preparing the report, other than those committee reports already referenced within the main body of the report. All documents must be kept available by the author for inspection by the public for four years from the date of the meeting at which the report is presented. 3. APPENDICES Appendix 1 – List of Services Within Perth and Kinross HSCP Appendix 2 – DATIX Service Risks Within Perth and Kinross HSCP Health Services (as at 17 March 2023) Appendix 3 – Service risks within Perth and Kinross HSCP Adult Social Work & Social Care Appendix 4 – Clinical & Care Governance Arrangements Appendix 5 - Glossary