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Appendix 2 - Clinical and Care Governance Arrangements

Perth and Kinross Council · 31 January 2024
Back to Scrutiny and Performance Committee — 31 January 2024 and its agenda

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Page 1

Appendix 2
Clinical & Care Governance Arrangements 
The P&K Care & Professional Governance Forum (CPGF) has responsibility to ensure
that there are effective and embedded systems for Clinical, Care & Professional
Governance in all services within the partnership.  This includes seeking assurances
from all partnership localities and hosted services within the context of the six domains
of Clinical, Care & Professional governance.  Localities and Hosted Services have
regular Governance Forums within their own services attended where appropriate by
HSCP professional leads.  
The HSCP remain committed to improving Care & Professional Governance.  Work is
progressing to develop governance and performance dashboards to support Care
Assurance across agreed professional standards.  Although delayed due to the Covid
response, work to progress this has now resumed and is being tested in one of the
localities.  Additionally, work is underway to improve availability of locality performance
data. 
The HSCP has also commenced a Mental Health Clinical Care & Professional
Governance Group, which reports directly to P&K CPGF and the Tayside Mental
Health Quality & Performance Review.  This will allow targeted improvement to
improve Mental Health performance data, mitigation of Mental Health risks and to
support scrutiny on progress made in respect of HIS Improvement Plan and Listen,
Learn, Change work streams. 
Exception reporting is a mechanism for services to quickly and easily flag up where
work or events vary significantly from that which would be expected. 
Exception reports were provided by all HSCP service grouping and localities
(including hosted services) at each meeting of the previous bi-monthly Care &
Professional Governance Forum (CPGF). Now that these meetings are occurring
monthly such exception reports are now expected from half the services at each
meeting, thus continuing the service reporting every 2-months. 
Exception reports received during the previous year have been: 
SEP
2022
OCT
2022
NOV
2022
DEC
2022
JAN
2023
FEB
2023
MAR
2022
APR
2022
MAY
2023
JUN
2023
ACCESS TEAM &
MHO ✓
NOT
REQUIRED ✓
NOT
REQUIRED ✓
NOT
REQUIRED ✓
NOT
REQUIRED ✓
NOT
REQUIRED
COMMISSIONED
SERVICES ✓
NOT
REQUIRED ✓
NOT
REQUIRED
NOT
RECEIVED
NOT
REQUIRED ✓
NOT
REQUIRED ✓
NOT
REQUIRED
EQUIPMENT & TEC
NOT
REQUIRED NOT
RECEIVED
NOT
REQUIRED
✓
NOT
REQUIRED
✓
NOT
REQUIRED
✓
NOT
REQUIRED
✓
NORTH LOCALITY
NOT
REQUIRED
✓
NOT
REQUIRED
✓
NOT
REQUIRED
✓
NOT
REQUIRED
✓
NOT
REQUIRED
✓
PERTH CITY
LOCALITY
NOT
REQUIRED
✓
NOT
REQUIRED
✓
NOT
REQUIRED NOT
REQUIRED
NOT
REQUIRED
✓
NOT
REQUIRED NOT
REQUIRED

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MFTE/POA IN-
PATIENTS & 
INTERMEDIATE
CARE
NOT
REQUIRED
NOT
RECEIVED
✓
NOT
REQUIRED
✓
NOT
REQUIRED
✓
NOT
REQUIRED
✓
NOT
REQUIRED
PODIATRY
NOT
REQUIRED
✓
NOT
REQUIRED
✓
NOT
REQUIRED
✓
NOT
REQUIRED
✓
NOT
REQUIRED
✓
PRISON
HEALTHCARE ✓
NOT
REQUIRED ✓
NOT
REQUIRED ✓
NOT
REQUIRED ✓
NOT
REQUIRED ✓
NOT
REQUIRED
PUBLIC DENTAL
SERVICES ✓
NOT
REQUIRED ✓
NOT
REQUIRED ✓
NOT
REQUIRED ✓
NOT
REQUIRED ✓
NOT
REQUIRED
REGISTERED
SERVICES
NOT
REQUIRED
NOT
RECEIVED
NOT
REQUIRED ✓
NOT
REQUIRED ✓
NOT
REQUIRED ✓
NOT
REQUIRED ✓
SOUTH LOCALITY NOT
REQUIRED
NOT
RECEIVED
NOT
REQUIRED
NOT
REQUIRED
NOT
REQUIRED ✓
NOT
REQUIRED
NOT
REQUIRED
NOT
REQUIRED ✓
* non submission of reports highlighted to manager for action 
Annual reports are provided by all HSCP services and localities (including hosted
services). 
The structured annual reporting template brings together the six domains of Clinical,
Care & Professional Governance outlined in the Getting it Right Framework, and
also seeks to incorporate the new Health & Social Care Standards. Managers submit
report and attend Care Governance Forum to present report, give assurance and
answer questions.  The HSCP have begun cycle four and has now received all annual
reports from the 3rd cycle. 
2nd Cycle 3rd Cycle 4TH Cycle
ACCESS TEAM & MHO November 2020 April 2022 
COMMISSIONED SERVICES July 2021 July 2022 
EQUIPMENT & TEC June 2021 May 2022 Jun 2023
NORTH LOCALITY July 2021 June 2022 May 2023
PERTH CITY LOCALITY April 2021 February 2022 Apr 2023
MFTE/POA IN-PATIENTS &
INTERMEDIATE CARE May 2021 April 2022 Jun 2023
PODIATRY September 2021 September 2022 
PRISON HEALTHCARE March 2021 March 2022 Mar 2023
PUBLIC DENTAL SERVICES November 2020 January 2022 
REGISTERED SERVICES August 2021 August 2022 
SOUTH LOCALITY September 2020 November 2021 
POA Inpatients (added in cycle 3)  November 2021

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Wider governance arrangements: 
• Integrated Locality Care Governance Groups (bi monthly)
• Prison Healthcare Medicines Management Governance Group (monthly)
• Prison Healthcare Business & Governance Group (monthly)
• Nursing and Allied Health Profession Forum (bi-monthly) to explore pertinent
professional issues with CPTMs and other relevant colleagues.
• Senior Nurses, AHP Professional Leads, and the Clinical & Professional Team
Managers meet regularly on an individual 1:1 basis with the Lead Nurse and also
the AHP Lead to discuss relevant professional and governance issues.
• Mental Health Portfolio Lead contributes to the Mental Health QPR Forum
• Partnership Short Life Working Group commenced to improve care governance
for mental health services 
• Health Senior Management Team Huddle weekly to review Datix risks and red
adverse events 
• Clinical Governance Coordinator supports locality groups to undertake Local
Adverse Event Reviews (LAER’s) where required.  All LAER’s are signed off by a
senior manager.
• Care Home Oversight Group meeting at times daily to monitor and provide
support to Care Home resident and staff safety wellbeing.
• The P&K CPGF co-chairs contribute to the NHST Getting It Right For Everyone
(GIRFE) group.
• Adult Social Work and Social Care Forum (monthly)