Agenda Document Pack - Clinical and Care Governance Committee - 27/08/2026
Moray Council · 27 August 2026
Back to Clinical and Care Governance Committee — 27 August 2026 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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Clinical and Care Governance Committee Thursday, 27 August 2026 Council Chambers NOTICE IS HEREBY GIVEN that a Meeting of the Clinical and Care Governance Committee, Council Chambers, Council Office, High Street, Elgin, IV30 1BX on Thursday, 27 August 2026 at 10:00 to consider the business noted below. AGENDA 1. Welcome and Apologies 2. Declaration of Member's Interests 3. Minute of meeting of 28 May 2026 5 - 8 4. Action Log - 28 May 2026 9 - 10 Safe and Effective Practice 5. Moray Health and Social Care Partnership Clinical and Care Governance Group Escalation Report 11 - 26 Effective Communication and Information Page 1
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6. Complaints Report for Quarter 1 2026-2027 27 - 42 7. Moray Health and Social Care Partnership Annual Complaints Report 2025-26 43 - 70 8. Items for Escalation to MIJB Watching the Meeting You can watch the webcast live by going to: http://www.moray.gov.uk/moray_standard/page_43661.html Webcasts are available to view for 1 year following the meeting. You can also attend the meeting in person. If you wish to attend in person, please come to the High Street entrance door and a member of staff will let you into the Chamber. Page 2
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MORAY INTEGRATION JOINT BOARD SEDERUNT Mr Derick Murray (Chair) Councillor Peter Bloomfield (Voting Member) Councillor Scott Lawrence (Voting Member) Mr Alex Stephen (Voting Member) Professor Duff Bruce (Non-Voting Member) Mrs Sheila Brumby (Non-Voting Member) Ms Helen Chisholm (Non-Voting Member) Mr Sean Coady (Non-Voting Member) Ms Miriam Connor (Non-Voting Member) Dr Robert Lockhart (Non-Voting Member) Ms Aimee McIntosh (Non-Voting Member) Mr Stephen Morgan (Non-Voting Member) Ms Deborah O'Shea (Non-Voting Member) Ms Judith Proctor (Non-Voting Member) Ms Elizabeth Robinson (Non-Voting Member) Mrs Christine Stevens (Non-Voting Member) Clerk Name: Caroline O'Connor Clerk Telephone: 07779 999296 Clerk Email: committee.services@moray.gov.uk Page 3
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MINUTE OF MEETING OF THE CLINICAL AND CARE GOVERNANCE COMMITTEE Thursday, 28 May 2026 Council Chambers, Council Office, High Street, Elgin, IV30 1BX PRESENT Councillor Peter Bloomfield, Mrs Sheila Brumby, Ms Helen Chisholm, Ms Miriam Connor, Councillor Scott Lawrence, Dr Robert Lockhart, Ms Aimee McIntosh, Mr Derick Murray, Ms Deborah O'Shea, Ms Judith Proctor, Ms Elizabeth Robinson, Mrs Christine Stevens APOLOGIES Professor Duff Bruce, Mr Sean Coady, Mr Jim Lyon, Mr Alex Stephen IN ATTENDANCE Chief Nurse; Public Health Consultant, NHS Grampian and Caroline O'Connor, Committee Services Officer SUBSTITUTES Mr Sandy Riddell (for Mr Alex Stephen) 1. Chair The meeting was chaired by Mr Derick Murray. 2. Declaration of Member's Interests There were no declarations of Member's interests in respect of any item on the agenda. 3. Minute of meeting of 26 February 2026 The minute of the meeting of 26 February 2026 was submitted and approved. Item 3. Page 5
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4. Action Log - 26 February 2026 The Action Log of the meeting of 26 February 2026 was discussed and updated accordingly. 5. Health and Social Care Moray Clinical and Care Governance Group Escalation Report The meeting had before it a report by the Chief Nurse - Moray informing Committee of progress and exceptions reported to the Clinical and Care Governance Group since the last report to Committee in February 2026. Following consideration the Committee unanimously agreed to note the contents of the report. 6. Complaints Report for Quarter 4 2025-2026 The meeting had before it a report by the Chief Nurse - Moray informing the Committee of complaints and feedback reported and closed during Quarter 4 (1 January 2026 - 31 March 2026). Following consideration the Committee unanimously agreed to note the totals, lessons learned, response times and action taken for complaints completed within the last quarter of 2025/26. 7. Grampian Vaccination and Immunisation Annual Report 2025 The meeting had before it a report by the Vaccination Planning Manager and Public Health Consultant informing the Committee of the Annual Vaccination and Immunisation Report for NHS Grampian to provide an annual monitoring report of vaccine preventable disease surveillance data, along with uptake data for each vaccine delivered within NHS Grampian. Following consideration the Committee unanimously agreed to:- i) note the findings of the Vaccination and Immunisation Annual Report 2025 attached as Appendix 1; ii) acknowledge the importance of vaccination in primary prevention for the citizens of Moray; iii) acknowledge the requirement for a longer-term premises to ensure delivery and continued uptake of the vaccination programme in Moray; iv) acknowledge that a process will be established to review vaccination activity against vaccination staffing resource so that vaccination funding aligns with vaccination activity; v) acknowledge the Directions 2025 which once again confirm design and delivery of vaccination services is a responsibility of NHS Grampian; and vi) instruct the Chief Officer to provide an annual monitoring report to the Committee in 2027. Page 6
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8. Items for Escalation to MIJB The Committee noted that there were no items for escalation to the Moray Integration Joint Board. Page 7
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MEETING OF MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE THURSDAY 28 MAY 2026 ACTION LOG ITEM NO. TITLE OF REPORT ACTION REQUIRED DUE DATE ACTION BY UPDATE AUGUST 2026 1. HSCM Clinical and Care Governance Group Escalation Report 27/02/25 Work to be undertaken to refresh the Terms of Reference (TOR) in April 2025 following conclusion of national work relating to the practice governance elements and reported back to Committee in due course. February 2026 Chief Nurse Work underway and report scheduled for February 2027 Committee 2. HSCM Clinical and Care Governance Group Escalation Report 28/05/26 i) Adverse Events – Report to come back to Committee on outcomes/feedback from NHS short life working group to improve performance on Level 1 reviews with details on how improvements will be incorporated into business as usual and impact/effectiveness monitored. ii) All Adverse Events by Results per Quarter (App 1) – investigate reasons for upward trend shown on Graph 1 in no harm events and include update in next quarterly report. iii) Adverse Events by Category and Level of Review Reported on Datix (App 1): Abusive, Violent, disruptive or self- August 2026 August 2026 TBC Chief Nurse Chief Nurse Chief Nurse Update included in MHSCP CCGG Escalation Report on today’s agenda. As above As above Item 4. Page 9
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harming behaviour – annual report to include trend data and oversight on actions undertaken, particularly relating to violence towards staff. iv) Revised Terms of Reference (App 2) – report to Committee for approval once finalised. TBC Chief Nurse Scheduled for February 2027 Committee 3. Complaints Report for Quarter 4 2025/26 28/05/26 i) Elected Members Complaints – include details in future reports relating to the newly introduced the single point of access for EMs to direct complaints. ii) Average time in working days for a full response to complaints at each stage (Indicator 3, App 1) – more narrative to be added to future reports to give context for the difference between the resolution times for NHS and the Council. August 2026 August 2026 Interim Corporate Manager/SMT Chief Nurse SMT taking forward plan to address. Further update to be provided in due course. Complaints report on today’s agenda includes additional narrative. 4. Items for Escalation to MIJB 28/05/26 Regular briefing sessions to update Elected Members and IJB members on NHS Grampian’s new strategy, escalation issues and Dr Gray’s Hospital to be scheduled. TBC Chief Executive, Moray Council & Chief Officer, Acute Services, NHS Grampian Page 10
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REPORT TO: MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE ON 27 AUGUST 2026 SUBJECT: MORAY HEALTH AND SOCIAL CARE PARTNERSHIP CLINICAL AND CARE GOVERNANCE GROUP ESCALATION REPORT BY: CHIEF NURSE – MORAY 1. REASON FOR REPORT 1.1 To inform the Committee of progress and exceptions reported to the Clinical and Care Governance Group since the last report to Committee in May 2026. 2. RECOMMENDATION 2.1 It is recommended that the Committee consider and note the contents of the report. 3. BACKGROUND 3.1 The Clinical Governance Group was established as described in a report to this Committee on 28 February 2019 (para 7 of the minute refers). 3.2 The assurance framework for clinical governance was further developed with the establishment of the Clinical Risk Management Group (CRM) as described in a report to this Committee on 30 May 2019 (para 7 of the minute refers). 3.3 As reported to this Committee on 29 October 2020 (para 5 of the minute refers) Social Care representatives attend the Clinical Governance Group, so the group was renamed Clinical and Care Governance (CCG) Group. 3.4 A refresh of the Terms of Reference for the CCG Group was undertaken in 2023 and reported to this Committee on 30 November 2023 (para 6 of the minute refers). A further refresh of the Terms of Reference for the CCG Group is currently underway and will be presented to this Committee once finalised. 3.5 This report contains information reported to Moray Health and Social Care Partnership (MHSCP) CCG Group from clinical service groups / departments. This report also contains further information relating to incidents / adverse events Item 5. Page 11
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reported via Datix and areas of concern / risk and good practice shared during the reporting period. 3.6 The meeting schedule of the MIJB does not always align to quarterly reporting. It has been agreed that the Escalation Report should include the CCG Group meetings between committee scheduling to ensure committee is provided with the most up to date information; this may not always be quarterly. 3.7 The CCG Group have met 3 times during this reporting period. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 This section summarises the main governance matters considered by the MHSCP CCG Group during the reporting period, together with the key implications for assurance and any matters requiring onward attention by the Committee. MHSCP CCG Group Terms of Reference 4.2 As reported to Committee in May 2026 (para 5 of the minute refers) a structured review of the group’s effectiveness, purpose, objectives, reporting mechanisms and membership took place to ensure that its remit and structure remain fit for purpose. As reported, next steps were: • Trial the refreshed reporting template for 3–6 months, followed by evaluation • Finalise and confirm: o Membership and deputies o Chairing model o Social Work Practice Governance reporting arrangements 4.3 The final draft refreshed Terms of Reference will be submitted to Committee in February 2027, for approval. Committee will also be provided with detail on the impact of the refreshed approached. Social Work Training Team (Moray SVQ Centre) 4.4 Moray’s social work training team has been providing assessment and training opportunities to colleagues in social care roles for 10 years. Recent changes in the Scottish Social Services Council (SSSC) registration requirements have contributed to increased pressure on the capacity of the training team. Despite these challenges they continue to deliver a high standard of practice. The external verification procedures make three core assessments of an SVQ centre comprising Resources, Candidate Support, and Internal Verification of Assessments. The 2026 external verification reported high confidence in all these areas (this is the highest assessment rating the process can achieve). It was reassuring to hear that the verifier has confidence in Moray’s centre in these terms. GMED – strengthening clinical governance and learning 4.5 GMED has strengthened their operational process for tracking actions arising from Level 1 and Level 2 adverse event reviews. A dedicated action plan has been introduced, with progress routinely monitored at operational meetings. This provides greater assurance that learning arising from adverse events is translated Page 12
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into practice, improvement actions are implemented in a timely manner, and progress is monitored to completion. Aberdeen Walk-In Centre, Health Village 4.6 Through collaborative working this walk-in service, which launched in June 2026, provides same-day access to urgent primary care without the need for a booked appointment and forms part of a major national pilot programme funded by the Scottish Government. The service is delivered through the existing GMED infrastructure and operating model. The centre team are supported by GMED, who play a key role within the unscheduled care system. Overview of Incidents, Complaints and Risk Management Clinical Risk Management (CRM) 4.7 The CRM group continues to meet every 2 weeks to discuss issues highlighted on the CRM Datix dashboard. This includes Complaints, Level 1 and Level 2 Adverse Event Reviews, and Risks. 4.8 Membership includes Senior Managers, Clinical Leads, Chief Nurse and relevant Service Managers. The purpose is to enable oversight and assurance to senior leaders regarding the quality and standards of services. The group supports that adverse events and complaints are investigated appropriately, and learning is identified and shared appropriately, including cross sector learning where relevant. 4.9 Teams are encouraged to use the Healthcare Improvement Scotland (HIS) Shareable Learning Template to capture and disseminate learning arising from adverse events and complaints. The template provides a consistent national approach and focuses on what happened, contributing factors, what went well, what was learned, immediate actions taken and further improvements/ recommendations. This approach supports management’s oversight and provides assurance that learning is translated into improvements and risk reduction. 4.10 Adverse events that cross divisional boundaries require learning to be shared beyond MHSCP to support organisational improvement. For example, NHS Grampian hosts a Primary and Secondary Care Interface Meeting where learning relevant to both acute and community services is considered. Shared Learning Summaries from Moray have been shared with this group and are scheduled for discussion at a future meeting. 4.11 The group reviews all adverse events where there is potential for the Duty of Candour (DOC) procedure to apply. This has strengthened consistency and oversight in decision making, providing greater assurance that statutory requirements are considered and applied appropriately. In July 2026, MHSCP submitted the 2025/26 DOC Annual Report to the Associate Medical Director Clinical Assurance and Quality for inclusion within the NHS Grampian Annual report. This report confirms that MHSCP continues to meet its statutory obligations under the DOC legislation. During 2025/26, two incidents met the DOC threshold and were managed in line with national requirements. Learning from these reviews has informed improvements in clinical practice, Page 13
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documentation, communication, staff education and governance arrangements, with ongoing oversight provide through established clinical governance processes. Complaints and Feedback 4.12 The MHSCP Quarterly Complaints report for Quarter 1 of 2026/27 is a separate item on today’s agenda. Complaints continue to form an important part of the overall governance and assurance framework, alongside adverse events and risk management, by identifying themes, opportunities for learning and areas requiring improvement. Adverse Events (AE) 4.13 Information about AE reported on Datix during Quarter 1, 2026/27 is available at Appendix 1. 4.14 Graph 1 in Appendix 1 shows there are four peaks noted at Q3 2022/23, Q3 2023/24, Q2 2025/26 and Q1 2026/27 for adverse events that resulted in no harm. The peaks can be attributed to incidents in mental health inpatient areas. Some inpatients may present with higher levels of distress, violence or aggression, resulting in an increase in recorded incidents. In Q2 2025/26, reporting was also influenced by repeated absconding attempts by an individual in a Community Hospital, each of which was appropriately recorded on Datix. 4.15 The overall upward trend in no-harm adverse events is predominantly attributable to increased reporting within Adult Mental Health and Old Age Psychiatry services, particularly inpatient areas. These services support individuals with complex mental health needs, where incidents involving distress, violence, aggression, self-harm or absconding attempts may occur more frequently and appropriately require to be recorded through the Datix reporting system. The trend is considered to reflect continued compliance with adverse event reporting requirements and a positive reporting culture, rather than an increase in incidents resulting in harm. The majority of adverse events recorded during Quarter 1 (424 of 516) were assessed as negligible in severity. 4.16 Table 1 in Appendix 1 shows 244 adverse events recorded under the category abusive, violent, disruptive or self-harming behaviour, predominantly within Adult Mental Health and Old Age Psychiatry services. The increase in incidents compared to the previous quarter is largely attributable to reporting within mental health inpatient settings, where patients may present with complex needs and behaviours that challenge. Staff are encouraged to report all incidents of violence and aggression, and each incident is reviewed to identify learning, reduce future risk and ensure appropriate support and debrief arrangements are available for affected staff. At the time of reporting, 241 of the 244 incidents had undergone a Level 3 review. Findings and Lessons Learned from incidents and reviews 4.17 A Level 1 review consists of a full review team who have been commissioned to conduct a significant adverse event review (SAER), reporting findings and learning via the division/service governance structures. Page 14
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4.18 There are currently 11 Level 1 reviews in progress (at the time of reporting). 2 Level 1 reviews have concluded in this reporting period. 4.19 NHS Grampian has established a Short Life Working Group (SLWG) to improve the quality, consistency and timeliness of Level 1 Significant Adverse Event Reviews (SAERs), with a strong emphasis on Putting People First and trauma- informed approaches. The group has developed guidance and proposed governance arrangements for the commissioning and oversight of Level 1 reviews. Work is underway to determine how these requirements can best be incorporated within MHSCP’s existing governance structures. The Chief Nurse for Moray is contributing to this programme of work and will provide further updates through future reports. 4.20 This month saw an immediate interim change to the process for final sign-off of completed clinical Level 1 adverse event review reports. All clinical Level 1 reports will now require a clinical executive review by leads accountable for clinical quality and safety in NHS Grampian. MHSCP Risk Registers 4.21 Each Clinical service identifies and documents risks relevant to its area of responsibility. Service managers are invited to attend the Clinical Risk Management (CRM) group, which provides constructive challenge and support. These discussions facilitate the review of risks, consideration of mitigating actions and assurance that risk records remain accurate, proportionate, and up to date. 4.22 The risk register is routinely reviewed by Service leads with guidance and support provided through established governance arrangements. An updated Operational Risk Management Framework is currently under consideration by the Senior Management Team. Subject to approval, any changes arising from the revised framework will be implemented through the appropriate governance processes and reflected within local risk management arrangements. It is also anticipated that operational risk oversight will be strengthened through the new Corporate Assurance and Governance Group (CAG), with reporting and escalation through the MIJB Audit, Performance and Risk Committee, where appropriate. 4.23 At the time of reporting, there are 42 risks on the sector risk register. These are monitored and reviewed regularly, by Service Managers and escalated where appropriate. No risks met the threshold for escalation during the reporting period. The current risk level of each risk is displayed in the chart below: Page 15
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Items for escalation to the Clinical and Care Governance Committee 4.24 There are no items requiring escalation to Committee at this time. Current risks and governance matters continue to be managed through established operational and senior governance arrangements 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” As set out within Annex C of the Health and Social Care Integration Public Bodies (Joint Working) (Scotland) Act 2014 Clinical and Care Governance Framework. (b) Policy and Legal Clinical and Care Governance requirements are set out within the Moray Health and Social Care Integration Scheme. Appropriate arrangements must be in place to ensure and evidence good governance in meeting duties under the Public Bodies (Joint Working) (Scotland) Act 2014. (c) Financial implications None directly associated with this report. (d) Risk Implications and Mitigation Established systems and processes are in place across service areas to support clinical governance, providing assurance to the MHSCP Senior Management Team and to this Committee. These arrangements support the identification, review and management of risks arising from adverse events, complaints, scrutiny activity and wider governance concerns, while also enabling learning and sharing of good practice across Health and Social Care. Adverse events, complaints and risk information provide important intelligence on emerging themes, patterns and areas requiring Low 5% Medium 64% High 31% Risks by Risk level (current) Low Medium High Page 16
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improvement. Regular monitoring through Datix, the Clinical Risk Management Group and wider governance structures supports timely action, proportionate mitigation and continuous improvement in the quality and safety of care. A number of operational risks remain high or very high, predominantly in relation to workforce pressures, but these are subject to active management and oversight through established governance arrangements. No new risk implications arise directly from this report, and no operational risks currently require escalation to Committee. (e) Staffing Implications This activity is core to all practitioners in the front line both in terms of their professional competence and assurances in care delivery. There are no direct implications arising from this report. (f) Property None directly arising from this report. This report does not propose any changes to physical infrastructure. (g) Equalities/Socio Economic Impact There is no requirement for an equality impact assessment because there is no change to policy required as a result of this report. (h) Climate Change and Biodiversity Impacts None directly arising from this report. This report focuses on clinical and care governance, specifically relating to service quality, safety, and learning from adverse events and complaints. (i) Directions None directly arising from this report. This report does not propose any changes to physical infrastructure, service delivery models, or resource allocation. (j) Consultations Consultations have been undertaken with the following staff who agree with the content of this report where it relates to their area of responsibility: • MHSCP Clinical and Care Governance Group members • Caroline O’Connor, Committee Services Officer, Moray Council • Bridget Coutts, Lead Nurse GMED • Lizette van Zyl, Social Work Service Manager 6. CONCLUSION 6.1 The MHSCP CCG Group is assured that issues and risks identified from complaints, adverse events, clinical risk management activity and internal and external reporting, are identified, reviewed, and escalated appropriately through established governance arrangements. This report provides Page 17
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assurance to the Committee that systems remain in place to support oversight, scrutiny, learning and improvement across MHSCP. Whilst some workforce related risks remain high, these continue to be actively managed, and there are no matters requiring escalation to the Committee at this time. Author of Report: Isla Whyte, Corporate Business Support Manager, MHSCP Background Papers: with author Ref: Page 18
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APPENDIX 1 Adverse Events by Category and Level of Review Reported on Datix (Quarter 1, 2026/27) Table 1 Level 3 - local review by line manager in discussion with staff Level 2 - local management team review No level of review assigned Total Abusive, violent, disruptive or self-harming behaviour 241 0 3 244 Access, Appointment, Admission, Transfer, Discharge (Including Absconders) 11 0 1 12 Accident (Including Falls, Exposure to Blood/Body Fluids, Asbestos, Heat, Radiation, Needlesticks or other hazards) 90 1 7 98 Anaesthesia 0 0 1 1 Clinical Assessment (Investigations, Images and Lab Tests) 4 0 3 7 Consent, Confidentiality or Communication 10 2 1 13 Diagnosis, failed or delayed 1 0 2 3 Financial loss 2 0 1 3 Fire 2 0 1 3 Implementation of care or ongoing monitoring/review (inc. pressure ulcers) 22 0 4 26 Infrastructure or resources (Staffing, Facilities, Environment, Lifts) 14 0 3 17 Medical device/equipment 1 0 0 1 Medication 30 1 4 35 Other - please specify in description 29 0 9 38 Patient Information (Records, Documents, Test Results, Scans) 4 1 2 7 Security (no longer contains fire) 4 0 0 4 Treatment, Procedure (Incl. Operations or Blood Transfusions etc.) 3 1 0 4 Total 468 6 42 516 Page 19
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Adverse Events by Type and Result Reported on Datix (Quarter 1, 2026/27) Graph 1 0 50 100 150 200 250 300 Breach of Information / IT Security Patient / Client / Resident Staff (including Volunteers) Student or Trainee Visitors, Relatives or member of the Public Provision of Service Property / Equipment Inadequate Discharge Adverse Events by Type and Result Near Miss (event prevented) Event resulted in NO injury, harm, ill-health, disruption or damage Event resulted in injury, harm, ill-health, disruption or damage Page 20
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Adverse Events by Service and Level of Review Reported on Datix (Quarter 1, 2026/27) Table 2 Level 3 - local review by line manager in discussion with staff Level 2 - local management team review No level of review assigned Total Allied Health Professionals 26 1 4 31 Community Hospital Nursing 85 1 8 94 Community Nursing 18 1 7 26 Community Pharmacy 0 1 0 1 Continence Service 0 0 1 1 General Ophthalmic Services 0 0 1 1 General Practice 0 0 1 1 GMED 20 1 9 30 Grampian Vaccination and Immunisation Programme 25 1 2 28 Mental Health - Adult Mental Health 111 0 2 113 Mental Health - Learning Disabilities 2 0 0 2 Mental Health - Old Age Psychiatry 168 0 3 171 Mental Health - Specialisms 2 0 3 5 Out of Hours Community Nursing 1 0 1 2 Primary Care (PCIP) 5 0 0 5 Public Dental Service 4 0 0 4 Administration 1 0 0 1 Total 468 6 42 516 Page 21
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Adverse Events by Type and Severity Reported on Datix (Quarter 1, 2026/27) Table 3 NEGLIGIBLE: Negligible/no injury or illness, negligible/no disruption to service, negligible/no financial loss MINOR: Minor injury or illness, short term disruption to service, minor financial loss MODERATE: Significant injury, externally reportable e.g. RIDDOR, some disruption to service, significant financial loss MAJOR: Major injury, sustained loss of services, major financial loss Total Breach of Information / IT Security 9 1 1 0 11 Patient / Client / Resident 324 72 3 1 400 Staff (including Volunteers) 13 10 0 0 23 Student or Trainee 2 0 0 0 2 Visitors, Relatives or member of the Public 4 1 0 0 5 Provision of Service 27 1 1 0 29 Property / Equipment 44 1 0 0 45 Inadequate Discharge 1 0 0 0 1 No value 0 0 0 0 0 Total 424 86 5 1 516 Page 22
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Table 4: All adverse events by result by Quarter (Qtr) on Datix 2023/24 Qtr 1 2023/24 Qtr 2 2023/24 Qtr 3 2023/24 Qtr 4 2024/25 Qtr 1 2024/25 Qtr 2 2024/25 Qtr 3 2024/25 Qtr 4 2025/26 Qtr 1 2025/26 Qtr 2 2025/26 Qtr 3 2025/26 Qtr 4 2026/27 Qtr 1 Occurrence with NO injury, harm or ill-health 210 270 327 235 217 225 252 275 272 340 270 250 349 Occurrence resulting in injury, harm or ill-health 73 76 71 70 69 59 70 79 99 96 78 90 107 Near Miss (occurrence prevented) 22 26 50 31 27 41 30 44 36 46 45 37 60 Property damage or loss 0 0 0 0 0 0 0 0 0 0 0 0 0 Death 0 0 0 0 0 0 0 0 0 0 0 0 0 Total 305 372 448 336 313 325 352 398 407 482 393 377 516 Page 23
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Table 5: Adverse Events by Severity Reported by Quarter (Qtr) on Datix 2023/24 Qtr 1 2023/24 Qtr 2 2023/24 Qtr 3 2023/24 Qtr 4 2024/25 Qtr 1 2024/25 Qtr 2 2024/25 Qtr 3 2024/25 Qtr 4 2025/26 Qtr 1 2025/26 Qtr 2 2025/26 Qtr 3 2025/26 Qtr 4 2026/27 Qtr 1 Negligible 240 305 388 274 256 278 294 329 325 400 319 299 424 Minor 58 61 52 53 50 43 56 66 79 74 70 68 86 Moderate 5 6 8 9 6 3 1 1 3 5 4 7 5 Major 1 0 0 0 1 1 0 0 0 0 0 2 1 Extreme 1 0 0 0 0 0 1 2 0 3 0 1 0 Total 305 372 448 336 313 325 352 398 407 482 393 377 516 Page 24
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Graph 1: All Adverse Events by Result per Quarter 0 50 100 150 200 250 300 350 400 Q4 21/22 Q1 22/23 Q2 22/23 Q3 22/23 Q4 22/23 Q1 23/24 Q2 23/24 Q3 23/24 Q4 23/24 Q1 24/25 Q2 24/25 Q3 24/25 Q4 24/25 Q1 25/26 Q2 25/26 Q3 25/26 Q4 25/26 Q1 26/27 All Adverse Events by Result per Quater No harm Harm Near Miss Page 25
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REPORT TO: MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE ON 27 AUGUST 2026 SUBJECT: COMPLAINTS REPORT FOR QUARTER 1, 2026/2027 BY: CHIEF NURSE - MORAY 1. REASON FOR REPORT 1.1 To inform the Committee of complaints and feedback reported and closed during Quarter 1 (1 April 2026 – 30 June 2026). 2. RECOMMENDATION 2.1 It is recommended that the Committee considers and notes the totals, lessons learned, response times and action taken for complaints completed within the first quarter of 2026/27. 3. BACKGROUND 3.1 Within Moray Health and Social Care Partnership (MHSCP), complaints received by NHS Grampian (NHSG) and Moray Council are recorded on 2 separate systems, in accordance with the appropriate policy and procedure of these organisations. 3.2 At the meeting on 27 February 2020 (para 7 of the minute refers), it was agreed that a combined report from NHSG and Council complaints systems be submitted to future meetings of the Committee. At the Committee meeting on 27 August 2020 (para 14 of the minute refers) it was requested that the procedures be explained to demonstrate the similarities and differences, if any. 3.3 The NHS and Local Authority (LA) Complaints Handling Procedure requires staff to receive, consider and respond to complaints and feedback in a person-centred and proportionate way, with an emphasis on early resolution, fairness and learning. The procedure has been developed in line with guidance issued by the Scottish Public Services Ombudsman (SPSO) and reflects the standardised, two-stage approach to complaints handling applied across NHS and Local Authority services. This ensures consistency of practice, compliance with SPSO expectations, fulfilment of statutory duties under the Patient Rights (Scotland) Act Item 6. Page 27
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2011, and alignment with the Healthcare Principles introduced by that Act. Complaints information is used as a source of assurance and service improvement, alongside other governance and performance intelligence. 3.4 The complaints process followed by both NHSG and Moray Council have the same target response timescales. Early resolution, or front line, complaints will be responded to within 5 working days and complaints handled at the investigation stage have a response time of 20 working days. Where it is not possible to complete the investigation within 20 working days an interim response should be provided with an indication of when the final response will be provided. 3.5 The decision as to whether the complaint is upheld or not will be made by the manager or Head of Service. If the person raising the complaint is not satisfied with the outcome, then they may contact the SPSO for an independent review and assessment, however prior to this, every effort is made to engage with the complainant to resolve the matter to their satisfaction. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 Committee is presented with quarterly complaints performance information using the mandatory Key Performance Indicators (KPIs), published by SPSO in March 2022. These are: Indicator One The total number of complaints received The sum of the number of complaints received at Stage 1 (this includes escalated complaints as they were first received at Stage 1), and the number of complaints received directly at Stage 2. Indicator Two The number and percentage of complaints at each stage which were closed in full within the set timescales of five and 20 working days The number of complaints closed in full at stage 1, stage 2 and after escalation within MCHP timescales as % of all stage 1, stage 2 and escalated complaints responded to in full Indicator Three The average time in working days for a full response to complaints at each stage The average time in working days to respond at stage 1, stage 2 and after escalation Indicator Four The outcome of complaints at each stage The number of complaints upheld, partially upheld, not upheld and resolved at stage 1, stage 2 and after escalation as % of all complaints closed at stage 1, stage 2 and after escalation 4.2 Part 4 of the SPSO Model Complaints Handling Procedure on Governance stresses the importance of learning from complaints, and the requirements to record and publicise learning. Qualitative analysis of learning and service improvement actions is a mandatory element of complaints reporting and is included within this report. Page 28
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4.3 MHSCP Complaints performance data for Quarter 1 is attached at Appendix 1. 4.4 Information about complaints referred to the Ombudsman are also included along with any complaints relating to the actions and processes of Moray Integration Joint Board (MIJB). 4.5 Figures reported do not include complaints raised regarding the vaccination appointments or processes as these are being dealt with through a dedicated team covering the Grampian area. Any complaints or comments regarding the Moray Vaccination Centre in Elgin are included in reported figures. 4.6 Out of Hours Primary Care Service (known as GMED) is hosted by the MIJB for the whole of Grampian. GMED service cares for patients who have urgent care needs and cannot wait until their GP Practice is open. GMED operates 18:00 until 08:00 each weekday, all weekends and each public holiday including the festive period. Therefore, figures presented for GMED are for a Grampian wide service that on average sees around 90,000 contacts annually. Complaints 4.7 During Quarter 1, a total of 49 complaints were received across MHSCP, with 47 complaints closed during the period. The majority of complaints were not upheld. The data shows that GMED accounted for the highest volume of complaints closed during the quarter. This reflects the complexity of service delivery and the high levels of demand with these services. 4.8 The table below sets out total number of complaints received and closed, per quarter, for the last 12 months. Received Q2 25/26 Closed Q2 25/26 Received Q3 25/26 Closed Q3 25/26 Received Q4 25/26 Closed Q4 25/26 Received Q1 26/27 Closed Q1 26/27 NHS 18 22 22 23 19 19 21 24 Council 21 18 27 17 23 12 28 23 39 40 49 40 42 31 49 47 4.9 The chart below sets out MHSCP complaints received and closed by Quarter. 4.10 While headline figures suggest an increase in the number of complaints received, further analysis is required to provide an accurate interpretation of the data. For 31 37 42 37 28 35 36 38 39 39 49 42 49 34 34 37 38 22 25 37 36 41 40 40 31 47 0 10 20 30 40 50 60 Q1 23/24 Q2 23/24 Q3 23/24 Q4 23/24 Q1 24/25 Q2 24/25 Q3 24/25 Q4 24/25 Q1 25/26 Q2 25/26 Q3 25/26 Q4 25/26 Q1 26/27 Received Closed Linear (Received) Page 29
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example, Quarter 3 of 2025/26 shows a marginally higher volume of complaints compared with previous quarters; however, review of the records confirms that three cases were closed as duplicate submissions, one related to another service area within Moray Council, and one was withdrawn by the complainant. Quarter 1 2026/27 show 4 complaints were withdrawn, 2 were closed as a duplicate complaint, 1 was out of jurisdiction and 4 cases were cancelled. When these cases are excluded, the adjusted total for the quarter is 38 complaints, which is more consistent with numbers reported in previous quarters. Timescales 4.11 Whilst MHSCP aim to respond to complaints within timescales this is not always achievable. Complaints received are often complex and include more than one service and other sectors, which can impact on response times due to the level of investigation and coordination required. 4.12 The average closure times were significantly influenced by a small number of particularly complex complaints that required extended investigation and review, as detailed in Appendix 1. 4.13 Actions to improve response times is under ongoing Senior Management Team (SMT) oversight. SMT have commissioned the establishment of a new corporate oversight group called the Corporate Assurance and Governance Group (CAG). The group provides corporate assurance on governance, risk, internal control and organisational improvement, including oversight of complaints performance, emerging themes and evidence that learning from complaints is translated into service improvement. The introduction of CAG will enhance the quality of assurance available through quarterly complaints reporting. 4.14 Templates have been made available to staff to use when upon reviewing a complaint it is felt that the issues described are already, or should be, examined through an Adverse Event Review. The letter proposes pausing the complaint process to avoid duplication and to ensure the person receives a complete and accurate response. The individual complaining is advised they may resume or continue the complaint after the review is concluded. This change may result in variability in quarterly performance figures, where longer than average closure times are recorded. There may also be an increase in ‘complaints withdrawn / not taken forward’ being reported in future quarterly reports. 4.15 NHS Grampian held a complaints workshop on the 6 May 2026. The aim of the interactive session was to build a shared understanding of the end-to-end complaints process across services, and to agree practical, proportionate actions that will support timely, reliable and person-centred complaint management. An action plan has been drafted following the workshop, and staff members are being identified to join a Short Life Working Group, which will consider standardisation of processes and quality and consistency of responses, strengthening early resolution and workforce capability, improving ownership, governance and accountability as well as ensuring learning is shared systematically. Actions from Complaints Page 30
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4.16 Learning / actions from complaints closed during Q1 continues to focus primarily on communication, education / training of staff, adherence to agreed processes and clarity of next steps for people who access MHSCP services. In most cases, improvement actions were addressed at team level through staff reminders, reflective practice or targeted training. Progress against actions are monitored through local management structures and CRM. 4.17 Service Managers have been asked to give a particular focus on complaints, especially those relating to communication, when preparing service exception reports for the next meeting of the MHSCP Clinical and Care Governance Group in September 2026. The group is keen to understand the themes emerging from complaints, the specific actions taken in response, the impact of these actions and any further improvement measures planned to reduce the likelihood of similar issues arising in future. Scottish Public Services Ombudsman (SPSO) 4.18 During Q1, the SPSO upheld one complaint. In response, the team has provided additional training to staff, completed a sharable learning summary which was circulated widely and highlighted relevant guidance to staff. Learning Assurance Table 4.19 The table below provides some examples of actions that have been taken as a result of complaints received this quarter. Theme Complaint Action Taken Level of Learning Communication (staff-patient) Care, treatment and communication Ensuring clearer more proactive communication with patients when delays occur, including setting realistic expectations. Team Process / procedure Care, treatment and communication Strengthening processes. Team Communication (staff-patient) Care, treatment and communication Reinforcing expected standards. Team Communication (staff-patient) Support received and treatment Annual learning and refresher sessions. Individual and service MP/MSP Enquiries 4.20 There were 7 MP/MSP enquiries received (in this reporting period) regarding council services, under MHSCP and recorded on the Council system, Lagan. These were allocated as follows: Service Number of Enquiries HSCM – Access Team 2 HSCM – Care at Home 2 Children and Families and Justice Social Work – Access Team 1 Childres and Families Area Teams 2 Page 31
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4.21 As of 1 April 2024, all general MP/MSP enquiries received by NHS Grampian Chief Executive Office, regarding health services, and specific to Moray, are forwarded direct to a central mailbox in Moray to handle, in their entirety. To support this change MHSCP have streamlined their operational procedures for handling enquiries which has improved efficiency, management oversight, consistency in responses, time management and data collection. 4.22 There were 5 MP/MSP enquiries received regarding health services, under MHSCP, during this reporting period. These were in relation to four areas, as set out below: Service Number of Enquiries Walk in Centres 1 Delayed Discharges 1 Ward 4 2 Moray Huntington’s Support Group 1 4.23 Any patient specific MP/MSP enquiries continue to be logged on Datix, and processed by NHS Grampian, either as a complaint, concern or comment, and are captured in figures presented in Appendix 1. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” As set out within Annex C of the Health and Social Care Integration Public Bodies (Joint Working) (Scotland) Act 2014 Clinical and Care Governance Framework. Effective handling of complaints is used to ensure the efficient and sustainable delivery of services to meet priorities. (b) Policy and Legal Clinical and Care Governance requirements are set out within the Moray Health and Social Care Integration Scheme. Appropriate arrangements must be in place to ensure and evidence good governance in meeting duties under the Public Bodies (Joint Working) (Scotland) Act 2014. This report has been prepared in line with the SPSO Model Complaints Handling Procedures, using the four mandatory SPSO KPIs and associated qualitative learning analysis. (c) Financial implications None directly associated with this report. (d) Risk Implications and Mitigation There are systems and processes in place across service areas to support clinical governance, providing assurance to the MHSCP Senior Leadership Team and to the Clinical and Care Governance Committee. There are Page 32
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platforms within Health and Social Care to discuss and share good practice, learning and challenges. MIJB, Moray Council and NHS Grampian could find themselves exposed to significant risks if good governance is not in place. The purpose of this report is to oversee the processes to ensure that appropriate action is taken in response to adverse events, scrutiny reports/action plans, safety action notices, feedback, complaints and litigation, and those examples of good practice and lessons learned are disseminated widely. (e) Staffing Implications This activity is core to all practitioners in the front line both in terms of their professional competence and assurances in care delivery. (f) Property None directly arising from this report. (g) Equalities/Socio Economic Impact Not required as there are no changes to policy. (h) Climate Change and Biodiversity Impacts None directly arising from this report. (i) Directions None directly arising from this report. (j) Consultations Consultations have been undertaken with the following staff who agree with the content of this report where it relates to their area of responsibility: • Caroline O’Connor, Committee Services Officer, Moray Council • MHSCP Clinical and Care Governance Group 6. CONCLUSION 6.1 This report provides a summary of MHSCP complaints and enquiries received and closed during Quarter 1 of 2026/27 (1 April – 30 June 2026). Robust governance arrangements remain in place to monitor themes, oversee improvement actions and ensure learning from complaints contributes to service improvement and quality of care. Author of Report: Isla Whyte, Corporate Business Support Manager Background Papers: with author Ref: Page 33
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APPENDIX 1 Complaints Data, Quarter 1 (01/04/2026 – 30/06/2026) Actions from Complaints The tables 1, 2, 3 and 4 below set out the outcomes of closed complaints, what service received the complaint and any actions taken. Complaints Information Extracted from Datix – 24 complaints were closed during Quarter 1, 2026/27. Table 1 Actions Taken/Outcome of complaints closed during Quarter 1, 2026/27: Fully upheld: Complaint is accepted Partially upheld: Complaint is partly accepted Not upheld: Complaint is not accepted Irresolvable - funding: Complaint is irresolvable due to funding difficulties Complaint withdrawn: Complaint not taken forward Total Action plan(s) created and instigated 1 0 0 0 0 1 Communication - Improvements in communication staff-staff or staff- patient 5 8 0 0 0 13 Conduct issues addressed 1 0 0 0 0 1 Education/training of staff 4 3 0 0 0 7 Share lessons with staff/patient/public 2 2 0 0 0 4 Waiting - Review of waiting times 0 1 0 0 0 1 No action required 0 0 5 1 2 8 Total 13 14 5 1 2 *35 *this figure does not represent the number of complaints closed as complaints may have more than one action recorded against them. Page 34
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APPENDIX 1 Complaints Data, Quarter 1 (01/04/2026 – 30/06/2026) Table 2 Complaints Information Extracted from Lagan: 23 complaints were closed during Quarter 1, 2026/27 Directorate Department Service Upheld Partially Upheld Not Upheld Resolution Grand Total Health and Social Care Moray Children and Families and Justice Services Access Team 0 2 4 0 6 Cala 0 0 1 0 1 Children and Families Area Teams 1 2 3 1 7 Fostering and Adoption and Supported Lodgings 0 2 0 0 2 Health and Social Care Moray Access Team 0 0 2 0 2 Access Team Adult Care 0 0 4 0 4 Community Care Finance 0 1 0 0 1 Totals 1 7 14 1 23 Page 35
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APPENDIX 1 Complaints Data, Quarter 1 (01/04/2026 – 30/06/2026) Table 3 Complaints Information Extracted from Datix: 24 complaints were closed during Quarter 1, 2026/27: Fully upheld: Complaint is accepted Partially upheld: Complaint is partly accepted Not upheld: Complaint is not accepted Irresolvable - funding: Complaint is irresolvable due to funding difficulties Complaint withdrawn: Complaint not taken forward Total Allied Health Professionals 1 1 1 0 0 3 Community Hospital Nursing 2 1 0 0 1 4 GMED 2 4 4 0 1 11 Mental Health - Adult Mental Health 1 3 1 1 0 6 Total 6 9 6 1 2 24 Page 36
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APPENDIX 1 Complaints Data, Quarter 1 (01/04/2026 – 30/06/2026) Table 4 Complaints Information Extracted from Datix – Action Taken by Service (complaints closed during Quarter 1, 2026/27) Action plan(s) created and instigated Communication - Improvements in communication staff-staff or staff-patient Conduct issues addressed Education/training of staff Share lessons with staff/patient/public Waiting - Review of waiting times No action required Total Allied Health Professionals 0 2 0 0 0 1 1 4 Community Hospital Nursing 0 3 0 2 2 0 1 8 GMED 1 5 0 5 1 0 5 17 Mental Health - Adult Mental Health 0 3 1 0 1 0 1 6 Total 1 13 1 7 4 1 5 *35 *this figure does not represent number of complaints closed as complaints may have more than one action recorded. Page 37
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APPENDIX 1 Complaints Data, Quarter 1 (01/04/2026 – 30/06/2026) Indicator 1 – The total number of complaints received The sum of the number of complaints received at Stage 1 (this includes escalated complaints as they were first received at Stage 1), and the number of complaints received directly at Stage 2. Table 7 – Total number of complaints received in Quarter 1, 2026/27 System recorded Early Resolution / Frontline (Stage 1) Investigation (Stage 2) Not Marked Total NHS – Datix 10 11 0 21 Moray Council - Lagan 8 14 6 28 Total 18 25 6 49 Table 8 – Allocation of complaints received in Quarter 1, 2026/27 NHS Service - Datix Allied Health Professionals 2 Community Hospital Nursing 2 Community Nursing 3 General Practice 1 GMED 4 Grampian Vaccination and Immunisation Programme 1 Mental Health – Adult Mental Health 8 Total 21 Page 38
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APPENDIX 1 Complaints Data, Quarter 1 (01/04/2026 – 30/06/2026) Table 9 – Allocation of complaints received in Quarter 1, 2026/27 MC Service - Lagan Children and Families and Justice Access Team 8 Children and Family Area Teams 10 Fostering and Adoption and Supported Lodgings 1 Health and Social Care Moray Access Team 3 Access Team Adult Care 4 Community Care Finance 1 Learning Disability 1 Total 28 Indicator 2 - The number and percentage of complaints at each stage which were closed in full within the set timescales of 5 and 20 working days The number of complaints closed in full at stage 1, stage 2 and after escalation within MCHP timescales as % of all stage 1, stage 2 and escalated complaints responded to in full. There were 24 Complaints closed on the NHS system Datix during Quarter 1, 2026/27 – breakdown as follows: Early Resolution/Stage 1 2 Investigation/Stage 2 13 Escalated Stage 2 8 SPSO 1 There were 23 Complaints closed on the MC system Lagan during Quarter 1, 2026/27 – breakdown as follows: Early Resolution/Stage 1 9 Investigation/Stage 2 10 Escalated Stage 2 4 Page 39
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APPENDIX 1 Complaints Data, Quarter 1 (01/04/2026 – 30/06/2026) Table 10 – number and percentage of complaints at each stage closed within timescales (based on complaints closed during Quarter 1, 2026/27) Frontline/Early Resolution within timescale Investigation within timescale Escalated Investigation NHS - Datix 1 out of 2 (50%) 1 out of 13 (8%) 1 out of 8 (12.5%) Moray Council - Lagan 4 out of 9 (44%) 1 out of 10 (10%) 0 out of 4 (0%) Indicator 3 - The average time in working days for a full response to complaints at each stage Table 11 – average time in working days to respond at stage 1, stage 2 and after escalation (based on complaints closed during Quarter 1, 2026/27) A number of complex complaints were closed during Quarter 1. In 2 cases, complaint investigations recorded on Datix were paused while an adverse event review was undertaken. Under NHS Grampian Adverse Event Policy, a Level 1 Adverse Event Review should be commissioned within 10 working days of the event being reported and fully completed (including final report) within 90 working days of commissioning. Additionally, some complaints were initially resolved within, or close to, target timescales but were subsequently reopened following further correspondence from complainants. Indicators 2 and 3 do not distinguish between original and reopened investigations, as response times are calculated from the original date of receipt through to final closure. Excluding three particularly complex complaints, the average closure time for NHS Investigative complaints would reduce to 53 working days. Similarly, excluding three complex complaints from the NHS Escalated Investigative category would reduce the average closure time to 43 working days. Frontline Investigative Escalated Investigative NHS - Datix 4 days 99 days 116 days Moray Council - Lagan 13 days 53 days 37 days Page 40
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APPENDIX 1 Complaints Data, Quarter 1 (01/04/2026 – 30/06/2026) Indicator 4 - The outcome of complaints at each stage The number of complaints upheld, partially upheld, not upheld and resolved at stage 1, stage 2 and after escalation as % of all complaints closed at stage 1, stage 2 and after escalation. Graph 2 below shows the number of complaints fully upheld, partially upheld and not upheld as recorded in Datix during Quarter 1, 2026/27. 24 complaints were closed: 2 were withdrawn, 1 is irresolvable due to funding. From the remaining 21 complaints: 29% were upheld, 42% were partially upheld and 29% were not upheld. 0 1 2 3 4 5 6 Early Resolution Investigation Escalated Investigation SPSO Complaints Outcome (Datix) Fully Upheld Partially Upheld Not Upheld Page 41
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APPENDIX 1 Complaints Data, Quarter 1 (01/04/2026 – 30/06/2026) Complaints Information Extracted from Lagan: Graph 3 below shows the number of complaints upheld, partially upheld and not upheld as recorded in Lagan. 23 complaints were closed during Quarter 1, 2026/27: 4% were fully upheld, 31% partially upheld, 61% were not upheld and 4% reached resolution. 0 1 2 3 4 5 6 7 8 Frontline Investigation Escalated Investigative Complaints Outcome (lagan) Fully Upheld: Complaint is accepted Partially Upheld: Complaint is partly accepted Not Upheld: Complaint is not accepted Resolution Page 42
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REPORT TO: MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE ON 27 AUGUST 2026 SUBJECT: MORAY HEALTH AND SOCIAL CARE PARTNERSHIP ANNUAL COMPLAINTS REPORT 2025/26 BY: CHIEF NURSE, MORAY 1. REASON FOR REPORT 1.1 To provide the Committee with the Moray Health and Social Care Partnership (MHSCP) Annual Complaints Report for 2025/26. 2. RECOMMENDATION 2.1 It is recommended that the Committee:- i) consider and note the contents of the annual report; and ii) request the annual report is submitted to Moray Integration Joint Board in November 2026, for approval prior to publication. 3. BACKGROUND 3.1 A report to Clinical and Care Governance (CCG) Committee on 25 August 2022 (para 6 of minute refers) provided information on the agreed Complaints Key Performance Indicators (KPIs) for the Model Complaints Handling Procedures for Local Authorities (LA), which were published in March 2022 on the Scottish Public Services Ombudsman (SPSO) website (this includes Health and Social Work Partnerships, in relation to social work functions delegated from LAs). The Committee also received information detailing the 9 NHS performance indicators. 3.2 The NHS Grampian Annual Complaints report provides information on all complaints, concerns, comments, and feedback recorded on Datix; this includes any recorded under MHSCP. The Annual Complaints Report produced by the Council includes all council related complaints recorded on Lagan, this includes any Council related services under MHSCP. Item 7. Page 43
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3.3 The SPSO have advised ensuring there is no double reporting of figures, but it should be made clear where partnerships’ complaints performance information is published. 3.4 Given the importance MHSCP places on receiving comments and feedback to use to continuously improve services, the experience and satisfaction of people who receive services, along with their families and carers, the Committee agreed, at their meeting on 25 August 2022 (para 6 of minute refers) to continue to publish annual complaints performance information to demonstrate MHSCP’s commitment to valuing complaints. 3.5 The annual report pulls together and builds on the quarterly complaints’ reports produced for MIJB CCG Committee. It includes details about the number of complaints received and information about the stage at which complaints were resolved, the time taken to do so, and the actions that have been or will be taken to improve services as a result of complaints. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 The information from complaints from 1 April 2025 to 31 March 2026 has been collated and presented following the LA KPIs and NHS Performance Indicators. The MHSCP Annual Complaints Report for 2025/26 is attached at Appendix 1. 4.2 This will be the sixth published MHSCP Annual Complaints Report – all previous versions can be found on the MHSCP Website - https://hscmoray.co.uk/complaints.html 4.3 The annual report includes links to Moray Council’s and NHSG’s Annual Complaints Performance Reports and provides supplementary information specific to MHSCP. 4.4 There have been no complaints received relating to the dissatisfaction with the MIJB’s policies, decisions or administrative or decision-making processes followed by the MIJB. The MIJB’s definition of a complaint is: “An expression of dissatisfaction by one or more members of the public about the MIJB’s action or lack of action, or about the standard of service the MIJB has provided in fulfilling its statutory responsibilities.” 4.5 Figures reported do not include any complaints that might have been raised regarding the vaccination appointments or processes as these are being dealt with through a dedicated team covering the Grampian area. Any complaints or comments specific to the Moray Vaccination Centre in Elgin are included in reported figures. 4.6 All figures presented in Appendix 1 are correct at the time of reporting. There may be some small variations when data is reviewed and systems updated to ensure accuracy. 4.7 A total of 156 complaints were received by MHSCP in 2025/26, an increase of 18 compared with the previous year. Further analysis identified that 13 complaints Page 44
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were withdrawn, recorded as duplicates, fell out with authority, or could not be progressed because consent was not received. Taking these cases into account, the overall level of complaints is broadly consistent with recent years and should be considered in the context of ongoing service activity, complexity and demand. 4.8 It should be noted the figures reported for 2023/24 onwards include Children and Families and Justice Social Work Services, as these services were delegated to the Moray Integration Joint Board on 16 March 2023. This accounts for the increase in complaints recorded on Lagan from 2023/24. 4.9 The number of complaints recorded in DATIX includes the Out of Hours Primary Care Service (known as GMED) for the whole of Grampian, not just Moray. This is because the Moray Integration Joint Board hosts this service for the whole Grampian. The GMED service cares for patients who have urgent care needs and cannot wait until their GP Practice is open. GMED operates 18:00 until 08:00 each weekday, all weekends and each public holiday including the festive period. The service has, on average, 90,000 contacts annually. 4.10 In 2025/26, 12% (18) complaints were upheld fully with the remainder being partially upheld and not upheld. Most complaints were resolved without concerns about safety or care quality. 4.11 When a complaint is straightforward and does not require investigation, the target response time is 5 working days, often referred to as frontline or early resolution. Where an investigation is required, the target response time is 20 working days. Performance during 2025/26 did not consistently achieve these targets. For social work and social care services, the average response time was 11 working days for frontline complaints and 39 working days for investigative complaints. For health related services, there was an average time of 5 working days for early resolution complaints and 58 working days for investigative complaints. 4.12 Most complaints do not appear to indicate concerns about unsafe or poor-quality care, but they do show areas where people’s experience could be improved. The data shows that some people experience delays, communication issues or dissatisfaction with processes. Year Number recorded in DATIX Number recorded in LAGAN Total complaints 2018/19 62 31 93 2019/20 62 25 87 2020/21 33 32 65 2021/22 68 24 92 2022/23 78 30 108 2023/24 67 80 147 2024/25 71 65 138 2025/26 73 83 156 Page 45
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4.13 GMED, adult mental health services, access teams and children and families area teams accounted for the highest proportion of complaints, reflecting complexity of service delivery and the high levels of demand across these services. This is consistent with previous years. Communication remained the most consistent theme for learning this year and this feedback has been used to improve how services listen and respond. SPSO involvement and outcome 4.14 During 2025/26, three complaints relating to MHSCP services were referred to the SPSO through the local authority complaints process. Following review by SPSO case reviewers, none were taken forward for formal investigation. 4.15 Three complaints relating to MHSCP services were also referred to the SPSO through the NHS complaints process. Of these, one complaint was fully upheld and two were not taken forward for further investigation by the SPSO. 4.16 The upheld complaint resulted in targeted improvement activity, including the completion and dissemination of a shared learning brief across primary and secondary care services, together with the development of supporting guidance and a policy to address the issues identified through the investigation. Similar examples of learning and shared learning activity are reported within the annual report. 4.17 The low number of complaints progressing to formal SPSO investigation provides assurance that, in most cases, concerns are being appropriately addressed through local complaint handling processes. Where opportunities for improvement are identified, learning is shared and acted upon at individual, team and organisational level to support continuous improvement, strengthen governance arrangements and improve the experience of people receiving services. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” As set out within Annex C of the Health and Social Care Integration Public Bodies (Joint Working) (Scotland) Act 2014 CCG Framework. Effective handling of complaints is used to ensure the efficient and sustainable delivery of services to meet priorities. (b) Policy and Legal Clinical and Care Governance requirements are set out within the Moray Health and Social Care Integration Scheme. Appropriate arrangements must be in place to ensure and evidence good governance in meeting duties under the Public Bodies (Joint Working) (Scotland) Act 2014. (c) Financial implications None directly associated with this report. Page 46
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(d) Risk Implications and Mitigation There are systems and processes in place across service areas to support clinical governance, providing assurance to the MHSCP Senior Leadership Team and to the CCG Committee. There are platforms within Health and Social Care to discuss and share good practice, learning and challenges. MIJB, Moray Council and NHS Grampian could find themselves exposed to significant risks if good governance is not in place. The purpose of this report is to oversee the processes to ensure that appropriate action is taken in response to adverse events, scrutiny reports/action plans, safety action notices, feedback, complaints and litigation, and those examples of good practice and lessons learned are disseminated widely. (e) Staffing Implications This activity is core to all practitioners in the front line both in terms of their professional competence and assurances in care delivery. (f) Property None directly arising from this report. (g) Equalities/Socio Economic Impact The complaints process supports an accessible, fair and person-centred approach by ensuring that feedback is received, reviewed and responded to in a consistent way. Complaints provide an important opportunity to understand people’s experiences, identify areas for improvement and ensure that learning is used to strengthen service quality, safety and responsiveness. (h) Climate Change and Biodiversity Impacts None directly arising from this report. (i) Directions None directly arising from this report. (j) Consultations Consultations have been undertaken with the following staff who agree with the content of this report where it relates to their area of responsibility: • Caroline O’Connor, Committee Services Officer, Moray Council • MHSCP Clinical and Care Governance Group 6. CONCLUSION 6.1 The governance and monitoring of complaints forms part of core business for teams and services and provision of a good quality, effective and safe service is a key priority for all staff. Monitoring and learning from all feedback is an ongoing process. Page 47
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Author of Report: Isla Whyte, Corporate Business Support Manager Background Papers: with author Ref: Page 48
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APPENDIX 1 Annual Report on Complaints and Feedback 2025 – 2026 01/04/25 – 31/03/26 Page 49
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2 Table of Contents MORAY HEALTH AND SOCIAL CARE PARTNERSHIP ............................................................................................................................................ 3 INTRODUCTION TO THE REPORT ....................................................................................................................................................................... 3 THE MODEL COMPLAINTS HANDLING PROCEDURE ........................................................................................................................................... 4 COMPLAINTS HANDLING TIMESCALES .............................................................................................................................................................. 5 KEY PERFORMANCE INDICATORS ..................................................................................................................................................................... 6 WHAT IS INCLUDED .......................................................................................................................................................................................... 8 SUMMARY ........................................................................................................................................................................................................ 9 LEARNING FROM COMPLAINTS ....................................................................................................................................................................... 10 COMPLAINT PROCESS AND EXPERIENCE ........................................................................................................................................................ 14 COMPLIMENTS ............................................................................................................................................................................................... 14 INDICATOR 1 .................................................................................................................................................................................................. 16 INDICATOR 2 .................................................................................................................................................................................................. 19 INDICATOR 3 .................................................................................................................................................................................................. 19 INDICATOR 4 .................................................................................................................................................................................................. 20 Page 50
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3 Moray Health and Social Care Partnership Health and Social Care Moray (MHSCP) brings together the NHS and Council to provide a wide range of social work, social care, community health and primary care services. In Moray, the partnership includes: • Adult Services, including older people • Children and Families Services • Justice Services The work of MHSCP is governed by the Moray Integration Joint Board – a public body formed in 2014 through Scottish Government legislation. Introduction to the Report This Complaints Handling Annual Report provides a summary of people who use services’ feedback and complaints recorded by Moray Health and Social Care Partnership (MHSCP) in the period from 1 April 2025 to 31 March 2026. Within MHSCP, complaints received by NHS Grampian (NHSG) and Moray Council (the Council) are recorded on 2 separate systems, in accordance with the appropriate policy and procedure of these organisations. The NHSG Annual Complaints report provides information on all complaints, concerns, comments and feedback recorded on Datix (electronic risk management information system); this includes any recorded under MHSCP. The Annual Complaints Report produced by the Council includes all council related complaints recorded on Lagan (communication management system); this includes any Council related services under MHSCP. Links to these annual reports can be found here: (TO BE ADDED WHEN AVAILABLE) Page 51
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4 The Model Complaints Handling Procedure The original Model Complaints Handling Procedures (MCHPs) were first developed by the SPSO in collaboration with complaints handlers and key stakeholders from each sector and were published in 2012. The MCHPs were produced taking account of the Crerar and Sinclair reports that sought to improve the way complaints are handled in the public sector, and within the framework of the SPSO’s Guidance on a MCHP. The MCHPs also reflect the SPSO Statement of Complaint Handling Principles approved by the Scottish Parliament in January 2011. Following recommendations from the Scottish Government’s social work complaints working group in 2013, a separate MCHP for social work was developed. The ‘Public Services Reform (Social Work Complaints Procedure) (Scotland) Order 2016’ (the Order) brought social work complaint handling under the remit of the SPSO Act and subsequently the separate documents for Local Authorities (LA) and Social Work sectors were combined into a single document, the LA MCHP. The SPSO revised and reissued all the MCHPs (except the NHS) in 2020 under section 16B(5) of the Scottish Public Services Ombudsman Act 2002 on 31 January 2020 to give public sector organisations time to implement any changes by April 2021. The revised Local Authority MCHP, published 2020, applies to social work complaints, whether they are handled by local authority or health and social care partnership (HSCP) staff. The NHS was the last public sector to adopt the MCHP on 1 April 2017 and it has not yet been revised since it was first published. Page 52
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5 Complaints Handling Timescales There is a standard approach to handling complaints across the NHS and Local Authority, which complies with the SPSO's guidance on a model complaints handling procedure and meets all of the requirements of the Patient Rights (Scotland) Act 2011, and accords with the Healthcare Principles introduced by the Act. The complaints process followed by both NHSG and the Council have the same target response timescales. Early resolution, or front line, complaints will be responded to within 5 working days and complaints handled at the investigation stage have a response time of 20 working days. Where it is not possible to complete the investigation within 20 working days an interim response should be provided with an indication of when the final response should be provided. The decision as to whether the complaint is upheld or not will be made by the manager or Head of Service. If the person raising the complaint is not satisfied with the outcome then they many contact the Scottish Public Services Ombudsman (SPSO) for an independent review and assessment, however prior to this, every effort is made to engage with the complainant to resolve the matter to their satisfaction. Page 53
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6 Effective governance and monitoring of complaints forms part of core business for health and social care teams; ensuring services are safe, high- quality, and responsive to the needs of the people they support. Key Performance Indicators Performance Indicators are measures and targets that help assess and demonstrate how functions are carried out. In March 2022 the agreed Complaints Key Performance Indicators (KPIs) for the Model Complaints Handling Procedures for Local Authorities (LA) were published on the SPSO website. There are four mandatory KPIs for LAs (this includes Health and Social Work Partnerships, in relation to social work functions delegated from LAs). These are: Indicator One The total number of complaints received The sum of the number of complaints received at Stage 1 (this includes escalated complaints as they were first received at Stage 1), and the number of complaints received directly at Stage 2. Indicator Two The number and percentage of complaints at each stage which were closed in full within the set timescales of five and 20 working days The number of complaints closed in full at stage 1, stage 2 and after escalation within MCHP timescales as % of all stage 1, stage 2 and escalated complaints responded to in full Indicator Three The average time in working days for a full response to complaints at each stage The average time in working days to respond at stage 1, stage 2 and after escalation Indicator Four The outcome of complaints at each stage The number of complaints upheld, partially upheld, not upheld and resolved at stage 1, stage 2 and after escalation as % of all complaints closed at stage 1, stage 2 and after escalation The qualitative indicator on learning from complaints was part of the published draft indicators but has now been removed. However, Part 4 of the SPSO Model Complaints Handling Procedure on Governance stresses the importance of learning from complaints, and the requirements to record and publicise learning. Page 54
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7 With regard to Indicator Four, the updated MCHP has provided a definition of “resolving” a complaint. “A complaint is resolved when both the organisation and the customer agree what action (if any) will be taken to provide full and final resolution for the customer, without making a decision about whether the complaint is upheld or not”. This focusses efforts to, wherever possible and appropriate, resolving complaints to the complainant’s satisfaction. To do this it is necessary to identify and clarify what outcome the service user wants at the start of the process which maybe a change in process for some people currently involved with complaints. It will also change the number of categories of outcomes for complaints to:- • Upheld • Not upheld • Partially upheld and • Resolved The above KPIs are applicable for data collected from 1 April 2022. Complaints about a service that is provided by MHSCP on behalf of the NHS, require to be captured using the 9 NHS performance indicators. These are: • Learning from complaints • Complaint process experience • Staff awareness and training • The total number of complaints received • Complaints closed at each stage • Complaints upheld, partially upheld and not upheld • Average time to close complaints at each stage • Complaints closed in full within the timescales • Number of cases where an extension is authorised Page 55
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8 The data detailed in this report is based on the four KPIs detailed above and also includes information pertaining to some of 9 NHS performance indicators. For detail on staff awareness and training and the number of cases where an extension is authorised, please refer to the NHS Grampian Annual Complaints report. There is a challenge for reporting of complaints for MHSCP due to the fact that there is a need to use two recording systems which then requires collation and as the systems hold data in slightly different ways. This means that there are differences in how the information is reported for some of the indicators. What is Included This is MHSCP’s sixth published annual complaints performance report. It includes performance statistics, in line with the complaint’s performance indicators detailed for complaints received about community health and social care services under the direction of the Moray Integration Joint Board. Any complaints received relating to the dissatisfaction with the MIJB’s policies, decisions or administrative or decision-making processes followed by the MIJB will be reported, even if the number is nil. The MIJB’s definition of a complaint is: “An expression of dissatisfaction by one or more members of the public about the MIJB’s action or lack of action, or about the standard of service the MIJB has provided in fulfilling its statutory responsibilities.” Information about complaints referred to the Ombudsman are also included. Figures reported do not include complaints raised regarding the vaccination appointments or processes as these are being managed through a dedicated team covering the Grampian area. Positive feedback enables MHSCP to understand what services and behaviours people value. Capturing compliments data across the partnership, which has a wide range of services and two different recording systems, can be challenging. Our staff and services receive compliments in a range of ways and there is no mandatory reporting requirements. Data that has been recorded centrally is captured in this report. Page 56
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9 Summary Our Model Complaints Handling Procedure reflects the partnership’s commitment to serving the public by valuing complaints. It seeks to resolve issues through local, early resolution and, where necessary, to conduct thorough, impartial and fair investigations of complaints. All feedback helps to guide improvements, reveal training needs and supports performance monitoring. Our website Feedback - Health and Social Care Moray provides information about how people can provide feedback or raise formal concerns. Complaints can be submitted in person, by phone, by email or by post. There are also Feedback Cards throughout NHS sites that can be completed and submitted using the business reply paid envelopes. Page 57
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Complaints Data 2025/26 Annual Report (01/04/25 – 31/03/2026) Learning from Complaints Teams and services actively review the outcomes of complaints to see where improvements can be made and learn from the feedback. Complaints provide valuable information which can be used to continuously improve services, the experience and satisfaction of people along with their families and carers. The tables 1a, 1b and 2 below set out the stages the complaints were closed and what the complaint was about and what action taken. Table 1a - Complaints Information Extracted from Datix – Actions Taken/Stage (closed complaints) Stage 1 - Early Resolution Stage 2 - Escalated Stage 2 - Non Escalated Ombudsman Total Communication - Improvements in communication staff-staff or staff-patient 4 9 15 2 30 Share lessons with staff/patient/public 0 3 3 1 7 Waiting - Review of waiting times 0 0 0 1 1 No action required 1 13 21 1 36 Access - Improvements made to service access 1 0 4 0 5 Education/training of staff 1 2 2 0 5 Policy reviewed 1 0 0 0 1 Action plan(s) created and instigated 1 1 0 0 2 Conduct issues addressed 0 1 1 0 2 Risk issues identified and passed on 0 1 2 0 3 Total 9 30 48 5 92* *figures do not directly correlate with number of closed complaints as there may be more than one action selected per complaint. There were 74 complaints closed on Datix during 2025/26. Page 58
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11 Table 1b Complaints Information Extracted from Lagan – reason for complaint (closed complaints) Early resolution Investigation Total Complaint against service – assessment 3 5 8 Complaint against service – equipment 1 1 2 Complaint against staff 15 7 22 Other 2 7 9 Policy and Procedure 3 1 4 Process / Procedure 9 20 29 Total 33 41 74 Noted below are some actions arising from the review of complaints received during the last financial year (data extracted from Lagan). Decision Note / Learning Outcome (lagan) Process / Procedure Supports put in place to avoid similar delays in future Reinforced process Department to devise a process to ensure better management of meeting minutes Team training around communication Discussion with team around importance of following process Reflective practice undertaken regarding language used in professional context Brief circulated to staff regarding the importance adhering to communication requests Attention to detail in documentation – reminder to staff Other Investigating telephony system to ensure unanswered calls can be diverted Communication Brief circulated to team to share the importance to meet communication request Page 59
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12 Table 2 Complaints Information Extracted from Datix – Actions Taken by Service (closed complaints) Allied Health Professionals Community Hospital Nursing Community Nursing General Practice GMED Grampian Vaccination and Immunisation Programme Hospital Dental Services Mental Health - Adult Mental Health Mental Health – Learning Disabilities Mental Health - Old Age Psychiatry Mental Health - Specialisms Total Access - Improvements made to service access 1 0 0 0 2 0 1 1 0 0 0 5 Communication - Improvements in communication staff- staff or staff-patient 3 3 1 1 9 1 0 10 0 0 0 28 Conduct issues addressed 1 1 0 0 0 0 0 0 0 0 0 2 Education/training of staff 1 0 0 0 4 0 0 0 0 0 0 5 No action required 1 2 0 0 7 4 0 16 1 1 1 35 Action plan(s) created and instigated 0 1 1 0 0 0 0 0 0 0 0 2 Policy Reviewed 0 0 0 0 1 0 0 0 0 0 0 1 Share lessons with staff/patient/public 0 1 0 0 1 1 0 4 0 0 0 7 Waiting - Review of waiting times 0 0 0 0 0 0 0 1 0 0 0 1 Risk issues identified and passed on 0 0 0 0 0 0 0 1 0 1 1 3 Total 7 8 2 1 24 6 1 33 1 2 2 87* *Figure more than total number of closed complaints as there could be multiple actions taken for each complaint Page 60
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13 Active review of complaints through reporting and investigation is a useful tool to identify learning and improve services. Below are some of the actions and learning from complaints closed between 01/04/2025 and 31/03/2026 (data extracted from Datix). Communication Improvement in Communication Skills – individual learning undertaken Reminder to team about ensuring communication is clear Team discussed ways to communicate with patients and reminded of importance of ensuring patient has clear understanding of next steps Individual learning regarding communication and ward procedures Communication – team training to take place Feedback shared with team and example will support learning and improve communication going forward Action Plan Team currently reviewing and strengthening Safety Calling Protocol All learning points will be added to trainee doctor e-portfolio, which is a mandatory requirement during training Education / training / share lessons learned New process implemented regarding rejected referrals. Shared Learning Summary completed and shared appropriately Shared Learning Template completed for vaccination team Staff members undertake additional training and reflective piece of work. Training on documentation / record keeping and language used. Reminder to staff about protocols Process / procedure Shared learning brief completed and shared with primary and secondary care services. Adverse events are defined as incidents that result in or could have resulted in harm, and reviews are triggered based on severity and nature of the event, and not on whether a complaint was made. However some adverse event reviews are triggered by a complaint, or a complaint may help inform an adverse event review that is already underway. In such cases complainants can be invited to participate in the adverse event review, and pause or close the formal complaint procedure to support a more integrated and person-centre approach to learning and improvement. Page 61
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14 Complaint Process and Experience NHS Grampian issue an experience survey to participants 2 months after their complaint was closed. Information is available from complainants whose complaint was closed during the last financial year in NHS Grampian’s Annual Complaints Report. NHS Grampian are also signed up to Care Opinion. Through this website patients and carers can share their stories, experiences and thoughts online. To find out more about Care Opinion and to see stories shared about NHS Grampian, please visit https://www.careopinion.org.uk/opinions Moray Council issue a customer satisfaction survey to all complainants once their complaint is closed. Many of the customer satisfaction surveys are completed as anonymous. Unless the customer chooses to insert their complaint reference, there is no way of knowing who the return survey is from or which service it was about. More information on this can be found in the Moray Council Complaints Performance Report (see page 3 for link). Compliments Compliments can be provided verbally to staff, via emails or letters. When compliments are received, they are shared with staff and teams. Whilst there is no mandatory requirement to report compliments in the same way as complaints some compliments are recorded on our electronic systems. Data recorded for our health related services, for the period 1 April 2025 to 31 March 2026, is detailed overleaf. Page 62
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15 12% 62% 13% 13% Compliments (datix) Community Nursing GMED Moray Vaccination Centre Allied Health Professionals Positive feedback was received about staff and about the care and treatment received. Staff receive compliments verbally and many of these do not get formally recorded but are shared with teams. Page 63
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16 Indicator 1 - The total number of complaints received The sum of the number of complaints received at Stage 1 (this includes escalated complaints as they were first received at Stage 1), and the number of complaints received directly at Stage 2. Table 3 – total number of complaints (received) System recorded Early Resolution / Frontline Investigation Not marked (at time of reporting) Total NHS - Datix 30 43 0 73 Moray Council - Lagan 33 35 15 83 Total 63 78 15 156 Datix – Complaints Received by Year: Lagan - Complaints Received by Year: Year Total 2018/19 31 2019/20 25 2020/21 32 2021/22 24 2022/23 30 2023/24 80 2024/25 65 2025/26 83 Year Total 2018/19 62 2019/20 62 2020/21 33 2021/22 68 2022/23 78 2023/24 67 2024/25 71 2025/26 73 Page 64
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Graph 1 - Complaints Received by Year There was a drop in the number of complaints NHS received during 2020/21, for health services, which is likely due to the Covid-19 pandemic; in 2020 there were many services that were suspended and many others where service delivery was altered in some way to accommodate the requirements for social distancing. It should be noted the figures reported for 2023/24 onwards include Children & Families and Justice Social Work Services, as these services were delegated to the Moray Integration Joint Board on 16 March 2023. This accounts for the increase in complaints recorded on Lagan from 2023/24 onwards. 0 20 40 60 80 100 120 140 160 180 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 2025/26 Complaints Received by Year Datix Lagan Combined Combined (Datix and Lagan) Complaints received by year: 2018/19 93 2019/20 87 2020/21 65 2021/22 92 2022/23 108 2023/24 147 2024/25 136 2025/26 156 A total of 156 complaints were received by MHSCP in 2025/26. A breakdown of complaints received is detailed on the next page. Page 65
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18 Table 4 – combined data from Datix and Lagan (complaints received) for 2025/26 Health and Social Care Moray (Datix) Allied Health Professionals 4 Community Hospital Nursing 3 Community Nursing 3 General Practice 2 GMED 21 Moray Vaccination Centre 5 Hospital Dental Services 1 Mental Health - Adult Mental Health 30 Mental Health – Learning Disabilities 1 Mental Health - Old Age Psychiatry 1 Mental Health - Specialisms 2 TOTAL 73 Health and Social Care Moray (Lagan) Children and Families and Justice Social Work (Lagan) Access Team 13 Access Team 23 Access Team Adult Care 2 Cala 1 Care at Home 4 Children and Families Area Teams 21 Community Care Finance 4 Fostering and Adoption and Supported Lodgings 1 Learning Disability 3 Throughcare 1 Mental Health 3 Youth Justice 1 Moray East 2 Moray West 3 Occupational Therapy 1 TOTAL 35 48 Page 66
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19 Indicator 2 - The number and percentage of complaints at each stage which were closed in full within the set timescales of five and 20 working days The number of complaints closed in full at stage 1, stage 2 and after escalation within MCHP timescales as % of all stage 1, stage 2 and escalated complaints responded to in full Table 5 – number and percentage of complaints at each stage closed within timescales Early Resolution/Frontline with timescale Investigation within timescale Escalated Investigation within timescale NHS - Datix 3 out of 6 (50%) 18 out of 40 (45%) 6 out of 28 (21%) Moray Council - Lagan 10 out of 33 (30%) 12 out of 37 (32%) 1 out of 4 (25%) Indicator 3 - The average time in working days for a full response to complaints at each stage Table 6 – average time in working days to respond Early Resolution/ Frontline Investigative Escalated Investigation NHS - Datix 5 days 58 days 62 days Moray Council - Lagan 11 days 39 days 70 days During 2025/26, MHSCP did not meet the target timescales for responding in all cases. Many complaints received are complex and involve more than one service, which can impact on response times due to the level of investigation and coordination required. In some cases, complaints cannot be closed until other processes, such as adverse event reviews, HR processes or information governance checks are completed. These dependencies can significantly extend response times. Additionally, some complaints are initially resolved within target timescales but are later reopened following further correspondence from the complainant, sometimes months after closure. Indicators 2 and 3 do not account for these reopened phases, as response times are calculated from the original date of receipt through final closure. Page 67
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20 Indicator 4 - The outcome of complaints at each stage The number of complaints upheld, partially upheld, not upheld and resolved at stage 1, stage 2 and after escalation as % of all complaints closed at stage 1, stage 2 and after escalation Graph 2 below shows the number of complaints fully upheld, partially upheld and not upheld as recorded in Datix during 2025/26. Out of 74 closed complaints on the system 4 were withdrawn / not taken forward, 2 were closed as consent was not received and 4 were recorded irresolvable due to funding difficulties. Only 1 complaint was investigated and upheld by the SPSO – the partially upheld figure noted below refers to the investigation and outcome undertaken by MHSCP. From the remaining 64 complaints closed during 2025/26 - approximately 16% were fully upheld, 39% were partially upheld and 45% were not upheld 0 2 4 6 8 10 12 14 16 18 Fully Upheld: Complaint is accepted Partially Upheld: Complaint is partly accepted Not upheld: Complaint is not accepted Datix - Outcome of Closed Complaints Early Resolution Investigative Escalated Investigative SPSO From all early resolution complaints completed and closed 20% were upheld, 80% partially upheld and 0% not upheld. From all investigative complaints completed and closed 15% were upheld, 36.5% were partially upheld and 48.5% were not upheld. From all escalated investigative complaints completed and closed 13% were upheld, 35% were partially upheld and 52% were not upheld. Page 68
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21 Complaints Information Extracted from Lagan: 74 complaints were closed during 2025/26: 11% were upheld, 24% were partially upheld, 57% were not upheld and 8% were resolved. Graph 3 below shows the number of complaints upheld, partially upheld and not upheld as recorded in Lagan. 0 5 10 15 20 25 Upheld Partially Upheld Not upheld Resolution Lagan - Outcome of Closed Complaints Frontline Investigative Escalated Investigative SPSO From all frontline complaints closed 12% were upheld, 16% partially upheld and 63% not upheld. 9% were resolved. From all investigative complaints closed 11% were upheld, 34% were partially upheld and 49% were not upheld. 6% were resolved. From all escalated investigative complaints 0% were upheld, 25% were partially upheld and 50% were not upheld. 25% were resolved. Page 69
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