Agenda Document Pack - Clinical and Care Governance Committee - 28/08/2025
Moray Council · 28 August 2025
Back to Clinical and Care Governance Committee — 28 August 2025 and its agenda
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Clinical and Care Governance Committee Thursday, 28 August 2025 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, 28 August 2025 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 27 February 2025 5 - 8 4. Action Log - 27 February 2025 9 - 10 Safe and Effective Practice 5. Health and Social Care Moray Clinical and Care Governance Group Escalation Report 11 - 26 Leadership and Accountability 6. Health and Social Care Moray Clinical Risk Management Terms of Reference 27 - 34 Effective Communication and Information Page 1
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7. Draft Health and Social Care Moray Annual Complaints Report 2024-25 35 - 60 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) Mr Ivan Augustus (Non-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) Dr Robert Lockhart (Non-Voting Member) Mr Jim Lyon (Non-Voting Member) Ms Deborah O'Shea (Non-Voting Member) Ms Judith Proctor (Non-Voting Member) Ms Elizabeth Robinson (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, 27 February 2025 Council Chambers, Council Office, High Street, Elgin, IV30 1BX PRESENT Councillor Peter Bloomfield, Mrs Sheila Brumby, Mr Sean Coady, Councillor Scott Lawrence, Dr Robert Lockhart, Mr Jim Lyon, Mr Derick Murray, Ms Deborah O'Shea, Ms Judith Proctor, Ms Elizabeth Robinson APOLOGIES Mr Ivan Augustus, Professor Duff Bruce, Ms Helen Chisholm, Dr Malcolm Simmons, Mr Alex Stephen, Mr Kevin Todd IN ATTENDANCE Allied Health Professional, Sector Lead Moray; Corporate Manager; Lead Dietitian Moray; Interim Primary Care Development Manager 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 28 November 2024 The minute of the meeting of 28 November 2024 was submitted for approval. The Chair stated that Councillor Elaine Kirby was not included in those present at the meeting however noted the minute would be amended. Item 3. Page 5
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Subject to the amendment above, the Committee unanimously agreed the minute of the meeting. 4. Action Log - 28 November 2024 The Action Log of the meeting of 28 November 2024 was discussed and updated accordingly. 5. Complaints Report for Quarter 3 2024-25 The meeting had before it a report by the Chief Nurse - Moray informing the Committee of complaints reported and closed during Quarter 3 (1 October 2024 - 31 December 2024. Following consideration the Committee unanimously agreed to note the totals, lessons learned, response times and action taken for complaints completed within the last quarter. 6. 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 the Committee of progress and exceptions reported to the Clinical and Care Governance Group since the last report to Committee in November 2024. Councillors Lawrence and Warren entered the meeting during discussion of this item. Councillor Lawrence asked if there were figures for the uptake of the drop in sessions at the Aberlour Health Hub referenced at paragraph 4.2 and whether the hub model was specific to Speyside or if it could be replicated in other areas of Moray. In response, the Deputy Chief Officer agreed to share figures of uptake at the drop in sessions with the Committee following the meeting as he did not have the detail to hand. He further advised the model was not unique to Speyside and could be rolled out to other suitable areas in Moray. In response to a question from the Chair asking if there were plans to refresh the Terms of Reference of the Clinical and Care Governance Group referenced in paragraph 3.4, the Corporate Manager confirmed work would be undertaken to refresh the Terms of Reference in April following conclusion of national work relating to the practice governance elements and reported back to this Committee in due course. Following consideration the Committee unanimously agreed:- (i) to note the contents of the report; and (ii) that the Clinical and Care Governance Group will monitor progress of the Multi- Agency Adult Support and Protection Improvement Action Plan going forward, reporting only by exception to Committee. 7. Developing a digitally-enabled universal service model to reduce Type 2 diabetes related Risk Page 6
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The meeting had before it a report by the Lead Dietitian Moray informing the Committee of work undertaken by the Primary Care Team at Maryhiill and the Moray Dietetic Department in the testing of a digitally-enabled, low cost prevention and support model for reducing type 2 diabetes-related risk and improving readiness for lifestyle change in high priority patient groups. Following consideration the Committee unanimously agreed to:- (i) note the proposed model in the “Developing a Digitally-Enabled Universal Service Model to Reduce Type 2 Diabetes-Related Risk: Impact of the Prevent the Progress of Diabetes App and Brief Dietitian Call on Patient Readiness for Lifestyle Change” report attached as Appendix 1; and (ii) acknowledge this Test of Change may offer further transformation opportunities, with a focus on Prevention and Proactive Care. 8. Items for Escalation to MIJB The Committee noted there were no items for escalation to the Moray Integration Joint Board. 9. Primary Care Update [Para 6.2.5] The meeting had before it a report by the Primary Care Development Manager informing the Committee of issues identified within Moray Primary Care. Following consideration the Committee unanimously agreed to acknowledge the present position pending the completion of a review, which is currently being progressed. Page 7
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MEETING OF MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE THURSDAY 27 FEBRUARY 2025 ACTION LOG ITEM NO. TITLE OF REPORT ACTION REQUIRED DUE DATE ACTION BY UPDATE AUGUST 2025 1. Strategic Risk Register Update to be provided detailing the impacts of recruitment of dentists on dental services. Discussion to take place between Chief Officer and Unpaid Carer Officer on whether specific mention of Unpaid Carers Strategy should be included in controls section. November 2024 November 2024 Corporate Manager Chief Officer MIJB Development Session took place 31 October 2024 to review and update current Strategic Risk Register. Presented to MIJB May 2025. Action closed 2. HSCM Clinical and Care Governance Group Escalation Report Uptake figures for drop-in sessions at Aberlour Health Hub to be circulated to Committee. 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. TBC February 2026 Deputy Chief Officer Corporate Manager Included in HSCM CCG Group Escalation report. Practice Governance update being discussed at the August MIJB Development Session, this will be incorporated into the refreshed TOR along with a wider Item 4. Page 9
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refresh of the CCG Group Page 10
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REPORT TO: MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE ON 28 AUGUST 2025 SUBJECT: HEALTH AND SOCIAL CARE MORAY 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 February 2025. 2. RECOMMENDATION 2.1 It is recommended that the Committee consider and note the contents of the report. 3. BACKGROUND 3.1 Health and Social Care Moray (HSCM) 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 HSCM Clinical and Care Governance (CCG) Group. 3.4 A refresh of the Terms of Reference for the HSCM CCG Group was undertaken in 2023 and reported to this Committee on 30 November 2023 (para 6 of the minute refers). 3.5 This report contains information reported to HSCM CCG Group from Clinical Service Groups / departments. This report also contains further information Item 5. Page 11
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relating to incidents / adverse events reported via Datix and areas of concern / risk and good practice shared during the reporting period. 3.6 The reporting schedule of the CCG Group does not always align to quarterly reporting to the committee. It has been agreed that the Escalation Report should include the CCG Group meetings between committee scheduling; this may not always be quarterly. 3.7 The CCG Group have met 5 times during this reporting period. 4. KEY MATTERS RELEVANT TO RECOMMENDATION Audit, Guidelines Reviews and Reports 4.1 Relevant Audits, Guidelines Reviews and Reports are presented and discussed at CCG Group. These include local and national information that is relevant to HSCM, for example, recommendations from Health Improvement Scotland (HIS) reports from other areas which require to be discussed, and assurance given that services in Moray are aware of these and have processes in place to meet / mitigate the report recommendations. Overview of items discussed during this reporting period are listed below: • CRM Minutes • External Reports • Service Updates • Adverse Events and Duty of Candour • HSCM Risk Register • Complaints / Feedback • Update from Practice Governance Group Areas of achievement / Good Practice Mental health Services 4.2 A number of staff have recently been supported to undertake the Leading an Empowered Organisation (LEO) training programme with the expectation that they will carry out a service improvement project within the service following completion of the training. Optometry 4.3 All overdue General Ophthalmic Services / Local Enhanced Service practice visits have now been undertaken. The recently appointed HSCM Optometry Clinical Lead is currently engaging with community optometrists across Moray to establish effective communication and partnership working. Pharmacy 4.4 Pharmacy 1st Plus in Community Pharmacy continues to expand, currently there are 11 community pharmacies offering this service. This is a vastly improved position compared to last year and includes having Independent Prescribers in more of the rural areas to offer enhanced medication access for minor conditions locally. Page 12
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4.5 A Care Home Pharmacist is now in post to support all care homes in Moray. Working with the GPs and Pharmacotherapy Teams to help reduce wastage, delivery cost efficient prescribing and to carry out Polypharmacy reviews. Planned Development Workshop – Clinical and Care Governance Group 4.6 As part of ongoing efforts to strengthen the effectiveness and clarity of the CCG Group, a development workshop is planned for late 2025. Part of the session will be for the group to consider the Terms of Reference (ToR) for the CCG Group and discuss whether any updating is required to reflect the ever changing governance landscape. The workshop will also explore the purpose and role of the group. It will also consider the quality and consistency of agenda items, professional attendance, and the alignment of escalated issues with the risk register. Practice Governance Board Framework – Governance and Development 4.7 The newly developed Practice Governance Board Framework has been subject to internal governance processes prior to its implementation. This ensures alignment with existing strategic and operational structures and provides an opportunity for feedback and refinement. The framework was a key focus of the MIJB development session held in August 2025, where members discussed its purpose, scope, and how it will support professional assurance and accountability across services. Aberlour Health Hub 4.8 Drop in sessions at the Health Hub are held on an ad hoc basis and typically consist of one off events focused on health promotion, prevention or awareness. Details of current service providers operating at the Health Hub are provided at Appendix 3. These services are available by appointment only and are not part of the drop-in offering. Clinical Risk Management (CRM) 4.9 The CRM group continues to meet every 2 weeks to discuss issues highlighted on the HSCM Datix dashboard. This includes Level 1 and Level 2 investigations, Complaints, Duty of Candour and new, Very High and High Operational Risks. 4.10 The group is attended by members of the Senior Management Team, Clinical Leads, Chief Nurse and relevant Service Managers. The purpose is to provide assurance to senior leaders regarding the quality and standards of services. The group ensures that adverse events and complaints are investigated appropriately, and learning is identified and shared across the organisation. 4.11 Any learning identified is presented and discussed at all relevant operational meetings. 4.12 The CRM group continue to review all High and Very High risks on the Moray Sector level Risk Register on a monthly basis and invite risk owners to join CRM meetings to offer constructive challenge and support. 4.13 The group recently undertook a refresh of the CRM Terms of Reference to reflect current governance structures, reporting lines and professional leadership Page 13
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arrangements. A separate report detailing the CRM group’s role is on today’s agenda. Complaints and Feedback 4.14 The draft HSCM Annual Complaints report for 2024/25 is a separate item on today’s agenda. 4.15 The table below shows complaints received and closed by Quarter received by HSCM. 4.16 Complaints received and closed are relatively stable across quarters. However when comparing Q1 2025/26 with Q1 2024/25 there is a significant increase in the number of complaints being managed. 4.17 A complaints performance report is now prepared and submitted to the Senior Management Team (SMT) each quarter to provide data-driven insights to monitor HSCM’s complaint handling performance. There have been two reports to date. The most recent focused on early resolution / frontline complaints. Following scrutiny by SMT the reports will be submitted CCG Group for information / any agreed actions. Adverse Events (AE) 4.18 Information about AE reported on Datix during Quarter 1, 2025/26 is available at Appendix 1. At the time of reporting 59 records, reported during Q1, have not yet been signed a level of review. The Head of Service and Chief Nurse are considering ways to manage this during the summer leave period. 4.19 The line graph in Appendix 1 shows that while figures remain relatively consistent there are two peaks noted at Q3 2022/23 and Q3 2023/24 for adverse events that resulted in no harm. The increases can be attributed to our mental health inpatient areas. Some inpatients can display higher levels of distress, violence and aggression, and this results in more recorded incidents. Findings and Lessons Learned from incidents and reviews 4.20 A Level 1 review consists of a full review team who have been commissioned to carry out a significant event analysis and review, reporting findings and learning via the division/service governance structures. 31 37 42 37 28 35 36 38 40 34 34 37 38 22 25 37 36 46 0 5 10 15 20 25 30 35 40 45 50 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 Received Closed Page 14
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4.21 There are currently 7 Level 1 reviews in progress (at the time of reporting). HSCM Risk Register 4.22 Each Clinical Service Group/Department highlights risks associated with their service, which are then discussed at CRM. The risk register is routinely reviewed with leads with guidance and support provided regarding updates. A review of all internal processes associated with Risk Registers is about to commence and any relevant updates will be taken through the appropriate governance structures. 4.23 All new risks identified on Datix are discussed at CRM. There is an ongoing review of the operational risk registers. At the time of reporting, there are 38 risks on the risk register. These are monitored and reviewed as appropriate, by the service managers. Duty of Candour 4.24 Duty of Candour (DOC) incidents are unintended or unexpected incidents that result in death or harm as defined in the Act, and do no relate directly to the natural course of someone’s illness or underlying condition. 4.25 There were a total of 2 incidents where the DOC applied which occurred between 1 April 2022 and 31 March 2023. Both incidents resulted in an increase in the person’s treatment. 4.26 There were a total of 0 incidents where the duty applied which occurred between 1 April 2023 and 31 March 2024. 4.27 At the time of reporting there are 3 ongoing DOC incidents. 4.28 The annual report for 1 April 2024 and 31 March 2025 will be compiled later this year and submitted to NHS Grampian. 4.29 CRM requested a DOC incident reporting review to assess the accuracy, completeness, and systemic quality of incident documentation for the 2023/24 reporting period. Variations in incident reporting quality were found. These findings were reported to the CCG Group in February 2025 and a number of recommendations have been agreed. A local improvement plan around DOC understanding and reporting has been developed and is overseen by CRM. All services have now been requested to carry out a similar exercise and those findings are anticipated to be reviewed at CCG Group in September 2025. Items for escalation to the Clinical and Care Governance Committee General Practice Sustainability 4.30 Following presentation of a general practice update to CCG Group in May 2025, there was agreement to escalate the challenges faced by general practices in Moray. An overview of the key issues can be found at Appendix 2. A full report is scheduled to be presented to this Committee in February 2026. 5. SUMMARY OF IMPLICATIONS Page 15
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(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 There are systems and processes in place across service areas to support clinical governance, providing assurance to the HSCM 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. Moray Integration Joint Board (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. Adverse events and complaints provide significant information on trends relating to risk and an encouraging opportunity for learning across the system. Regular monitoring of this is critical to ensure continuous improvement and the ambition of achieving excellence in our delivery of high quality care and treatment. The local CRM group reviews all events logged on Datix, ensuring risk is identified and managed. (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. This report does not propose any changes to physical infrastructure. (g) Equalities/Socio Economic Impact Page 16
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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: • HSCM Clinical and Care Governance Group members • Sonya Duncan, Corporate Manager • Caroline O’Connor, Committee Services Officer, Moray Council • Lynne Clark, Interim Service Manager, Moray Mental Health Services • Robert Lockhart, GP Lead • Alistair Boyd-Orr, Lead Pharmacist, Primary Care • Cheryl St Hilaire, Locality Manager 6. CONCLUSION 6.1 The HSCM CCG Group are assured that issues and risks identified from complaints, clinical risk management, internal and external reporting, are identified and escalated appropriately. The group continues to develop lines of communication to support the dissemination of information for action and sharing of good practice throughout the whole clinical system in Moray. This report aims to provide assurance to this Committee that there are effective systems in place to reassure, challenge and share learning. Author of Report: Isla Whyte, Corporate Business Support Manager, HSCM Background Papers: with author Ref: Page 17
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APPENDIX 1 Adverse Events by Category and Level of Review Reported on Datix (Quarter 1, 2025/26) Table 1 Level 3 - local review by line manager in discussion with staff Level 2 - local management team review Level of Review not yet assigned Total Abusive, violent, disruptive or self-harming behaviour 103 1 6 110 Access, Appointment, Admission, Transfer, Discharge (Including Absconders) 12 1 3 16 Accident (Including Falls, Exposure to Blood/Body Fluids, Asbestos, Heat, Radiation, Needlesticks or other hazards) 85 0 24 109 Clinical Assessment (Investigations, Images and Lab Tests) 5 0 2 7 Consent, Confidentiality or Communication 15 0 1 16 Diagnosis, failed or delayed 5 0 0 5 Financial loss 2 0 0 2 Fire 3 0 2 5 Implementation of care or ongoing monitoring/review (inc. pressure ulcers) 14 2 7 23 Infrastructure or resources (Staffing, Facilities, Environment, Lifts) 10 1 1 12 Medical device/equipment 4 0 0 4 Medication 45 3 8 56 Other - please specify in description 31 0 5 36 Patient Information (Records, Documents, Test Results, Scans) 6 0 0 6 Total 340 8 59* 407 *At the time of reporting 59 Incidents did not have a level of review assigned Page 18
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Adverse Events by Type and Result Reported on Datix (Quarter 1, 2025/26) Graph 1 0 20 40 60 80 100 120 140 160 180 200 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 or ill-health Event resulted in injury, harm or ill-health Page 19
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Adverse Events by Service and Level of Review Reported on Datix (Quarter 1, 2025/26) Table 2 Level 3 - local review by line manager in discussion with staff Level 2 - local management team review Level of Review not yet assigned Total Allied Health Professionals 16 0 1 17 Community Hospital Nursing 32 4 32 68 Community Nursing 25 1 7 33 Community Pharmacy 9 0 1 10 General Practice 2 1 3 6 GMED 20 0 9 29 Grampian Diabetes & Heart Failure Nurses MCN 1 0 0 1 Grampian Vaccination and Immunisation Programme 24 0 0 24 Mental Health - Adult Mental Health 78 0 2 80 Mental Health - Learning Disabilities 4 0 0 4 Mental Health - Old Age Psychiatry 109 1 2 112 Mental Health - Specialisms 6 0 1 7 Primary Care 6 1 0 7 Public Dental Service 7 0 1 8 Public Health 1 0 0 1 Total 340 8 59 407 Page 20
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Adverse Events by Type and Severity Reported on Datix (Quarter 1, 2025/26) 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 Total Breach of Information / IT Security 9 0 0 9 Patient / Client / Resident 213 67 3 283 Staff (including Volunteers) 29 7 0 36 Student or Trainee 1 0 0 1 Visitors, Relatives or member of the Public 3 1 0 4 Provision of Service 24 3 0 27 Property / Equipment 44 0 0 44 Inadequate Discharge 2 1 0 3 Total 325 79 3 407 Page 21
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Table 4: All adverse events by result by Quarter (Qtr) on Datix 2022/23 Qtr 2 2022/23 Qtr 3 2022/23 Qtr 4 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 Occurrence with NO injury, harm or ill- health 214 283 200 210 270 327 235 217 225 252 275 272 Occurrence resulting in injury, harm or ill- health 98 78 60 73 76 71 70 69 59 70 79 99 Near Miss (occurrence prevented) 40 38 20 22 26 50 31 27 41 30 44 36 Property damage or loss 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 Total 352 349 280 305 372 448 336 313 325 352 398 407 Table 5: Adverse Events by Severity Reported by Quarter (Qtr) on Datix 2022/23 Qtr 2 2022/23 Qtr 3 2022/23 Qtr 4 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 Negligible 264 283 226 240 305 388 274 256 278 294 329 325 Minor 78 60 48 58 61 52 53 50 43 56 66 79 Moderate 8 5 6 5 6 8 9 6 3 1 1 3 Major 2 0 0 1 0 0 0 1 1 0 0 0 Extreme 0 1 0 1 0 0 0 0 0 1 2 0 Total 352 349 280 305 372 448 336 313 325 352 398 407 Page 22
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Graph 1: All Adverse Events by Result per Quarter 0 50 100 150 200 250 300 350 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 All Adverse Events by Result per Quater No harm Harm Near Miss Page 23
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Overview General Practice in Moray continues to face significant and escalating pressures. A combination of demographic trends, increasing clinical complexity, and funding pressures is placing unsustainable strain on services. Key Issues 1. High Clinical Activity in Moray Analysis of direct clinical encounter data from January 2018 to May 2025 reveals that Moray recorded an average of 663.18 direct encounters per 1,000 patients per month—substantially higher than both Aberdeenshire (468.43) and Aberdeen City (427.66). A direct clinical encounter refers to any patient-facing consultation, either in person or by telephone. Moray currently has the highest rate of direct clinical encounters in Scotland, reflecting the exceptional demand placed on its General Practice teams. 2. Disease Prevalence Comparison Disease prevalence rates (per 100 patients) in 2025 show that Moray has consistently higher rates across several key conditions compared Aberdeen City and Aberdeenshire: Diabetes: 6.8 (vs 5.1 / 5.9), Heart Failure: 1.3 (vs 0.9 / 1.1), Dementia: 0.9 (vs 0.7 / 0.8), Depression: 16.8 (vs 14.4 / 14.6), Hypertension: 16.3 (vs 11.8 / 15.5). These elevated rates reflect a population with greater clinical complexity, requiring more intensive and sustained care from General Practice teams. Moreover, conditions such as dementia, heart failure, and diabetes are strongly associated with aging and are expected to increase further as Moray’s older population continues to grow. This trend will likely lead to even greater demand for long-term condition management, anticipatory care planning, and multidisciplinary support within primary care. These elevated rates reflect a population with greater clinical complexity, requiring more intensive and sustained care from General Practice teams. 3. Population Change The population aged 65–74 increased by over 40%, and those 75 and over grew by more than 60% between 2002 and 2022. In contrast, the working-age population (25–44) declined. These trends have been driven largely by net in-migration, especially from other parts of the UK, and place increasing demand on health and social care services. Looking ahead, the population aged 75 and over in Moray is projected to increase by around 80% by 2040. This will likely result in a sustained rise in age-related conditions such as dementia, frailty, and multimorbidity, further increasing the volume and complexity of care required from General Practice. Combined with a shrinking working-age base, this demographic trajectory poses a long-term challenge to service capacity and workforce sustainability in Moray. 4. Funding Pressures General Practice funding has declined to just 6.2% of total NHS spending, despite a 6% uplift in global sum payments and additional funding in late 2024. This sustained underfunding, combined with rising business costs and inflation, has left practices unable to expand services or recruit staff. The 2025 increase in National Insurance Contributions, from which GP practices are not exempt, adds further financial strain, with many practices facing unfunded five-figure costs. 5. Mental Health Service Gaps Access to consultant-led psychiatry services in Moray remains severely limited due to longstanding and unresolved staff shortages. Some areas of Moray have no consultant psychiatry coverage at all. As a result, GPs are left managing complex adult and child mental health cases—including ADHD, autism, and self-harm—without adequate specialist support, increasing clinical risk and pressure on primary care. 6. Systemic Pressures and Secondary Care Hospital waiting times remain long, particularly at Dr Gray’s Hospital, with delays in diagnostics and admissions. GPs are managing more complex cases that would previously have been referred, further increasing workload and clinical responsibility. Conclusion The evidence presented highlights the scale and complexity of the challenges facing General Practice in Moray. The region is delivering the highest rate of direct clinical encounters in Scotland, against a backdrop of rising disease prevalence, rapid population aging, and increasing clinical complexity. These pressures are compounded by sustained underinvestment in primary care, significant gaps in mental health provision, and growing systemic strain across secondary care services. Without targeted and coordinated action, the ability of General Practice in Moray to deliver safe, sustainable, and equitable care will continue to be at risk. APPENDIX 2 Page 24
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APPENDIX 3 Activity Frequency Average People accessing services Alzheimer’s Scotland Weekly Between 2- 6 Arrows Weekly Between 2- 6 Baby Immunisations Weekly Varies between 4-10 Care at Home Team Approx every 2 months Between 2- 12 Clan Cancer Support Fortnightly Between 2- 12 Community Learning Disability Team Between 2- 6 Community Physiotherapy Mon weekly Appointment based Dementia/Frailty Nurse Approx every 2 months Between 2- 6 Diabetic Retinal Screening Every 2 months Varies can be 20 Health Visitors - Antenatal PEEP (Parents as Early Education Partners) - Weekly Between 2- 6-8 HealthPoint Thur fortnightly Varies can be up to 8 HV - Baby & Children's Immunisations Tue weekly Varies can be c.12 HV - Baby & Toddler Group/Baby Massage - group session to support parents in bonding with baby Tue weekly Between 2- 6-8 parents and babies Moray Handy Person Service – Toe Nail Cutting Service Monthly Approx 4-5 Moray Rape Crisis 1:1 support As required 2 Page 25
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Moving & Handling Training (HSCM staff) As required 6 Occupational Therapy Wed weekly Appointments/Sessions Parkinson’s/Huntingdon’s Clinic Every 2 months Between 2- 8 Podiatry Weekly Between 2- 6 Proportionate Care Staff Training As required Between 2- 6 Quarriers Young Carers Group and Support Weekly Projected to be 20 Scotia Medical Group As required – first aid training Usually around 8 per session Speyside & Keith Community Response Team daily n/a Speyside & Keith District Nursing Team daily n/a Speyside Community & Inpatient Physiotherapy Team Fortnightly Between 4-7 Vaccination Team 2 days using 3 rooms twice yearly Approx 100 per day Versus Arthritis - led by Volunteer - Yoga/Tai Chi 2 x weekly Sept-March 12 people per session Volunteer Co-ordinators Mon/Tue/Thursday n/a Women’s Aid 1:1 support As required 2 Page 26
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REPORT TO: MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE ON 28 AUGUST 2025 SUBJECT: HEALTH AND SOCIAL CARE MORAY CLINICAL RISK MANAGEMENT TERMS OF REFERENCE BY: CHIEF NURSE, MORAY 1. REASON FOR REPORT 1.1 To inform the Committee of the updated Terms of Reference (ToR) for the Health and Social Care Moray (HSCM) Clinical Risk Management (CRM) Group and to outline its purpose, remit and reporting arrangements. 2. RECOMMENDATION 2.1 It is recommended that the Committee: i) Notes the updated ToR for the CRM Group (Version 3.0, August 2025) which reflect current governance structures and professional leadership within HSCM; and ii) Endorses the continued role of the CRM Group in providing assurance on clinical risk and governance matters, and its reporting relationship to the Clinical and Care Governance (CCG) Group and, where appropriate, to NHS Grampian. 3. BACKGROUND 3.1 HSCM CCG 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 CRM as described in a report to this Committee on 30 May 2019 (para 7 of the minute refers). This was to provide assurance on the identification, management, and escalation of clinical risks across delegated NHS functions and hosted services. Item 6. Page 27
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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 HSCM CCG Group. 3.4 A refresh of the ToR for the HSCM CCG Group was undertaken in 2023 and reported to this Committee on 30 November 2023 (para 6 of the minute refers). 3.5 The ToR for the CRM Group have now been reviewed and updated to reflect current governance structures, reporting lines, and professional leadership arrangements. The updated ToR (Version 3.0, August 2025) clarify the group’s remit, membership, and reporting responsibilities, including its role in providing assurance to the CCG Group and, where appropriate, to NHS Grampian. 3.6 The updated ToR (Appendix 1) were approved by the HSCM Senior Management Team (SMT) on 23 July 2025 and by the Clinical and Care Governance Group on 7 August 2025. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 The CRM Group continues to play an essential role in the governance framework of HSCM, providing oversight of clinical risks and assurance that appropriate systems are in place to manage these effectively. The group reviews incidents, complaints, adverse events, and feedback reported via Datix, and ensures that learning is identified and shared across services. 4.2 The updated ToR (Version 3.0) formalises the CRM Group’s remit, including its responsibility to escalate significant risks or concerns to the HSCM SMT or NHS Grampian Clinical Governance structures, as appropriate. This ensures timely and coordinated responses to emerging risks. 4.3 The CRM Group supports a culture of openness, professional curiosity, and continuous improvement. It provides a safe environment for multidisciplinary discussion of clinical governance concerns and good practice, and promotes leadership and engagement across services. 4.4 The CRM Group’s primary reporting lines are to the HSCM CCGG and, through it, to the MIJB Clinical and Care Governance Committee (CCGC). These structures provide the formal route for assurance on clinical risk and governance matters within the partnership. Where appropriate, and particularly where risks extend beyond local governance or require wider system input, the CRM Group may also escalate issues to NHS Grampian’s Clinical Governance structures. This ensures that local oversight remains robust while maintaining alignment with regional governance standards. 4.5 The revised ToR also clarify the group’s membership, meeting arrangements, and reporting responsibilities, including the use of dashboards, action logs, and structured agendas to support effective oversight and decision-making. 5. SUMMARY OF IMPLICATIONS Page 28
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(a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Partners in Care 2022 – 2032” The updated ToR for the CRM Group support the delivery of safe, effective, and person-centred care, aligning with the MIJB Strategic Plan “Partners in Care 2022–2032” and the LOIP priority of improving health and wellbeing outcomes for people in Moray. (b) Policy and Legal This report is consistent with the requirements of the Public Bodies (Joint Working) (Scotland) Act 2014 and the MIJB’s Standing Orders and Scheme of Delegation. It supports the Board’s duty to ensure robust clinical and care governance arrangements are in place across delegated services. (c) Financial implications There are no direct financial implications arising from this report. The CRM Group operates within existing governance and staffing structures. (d) Risk Implications and Mitigation Failure to maintain effective clinical risk management processes could expose the MIJB to reputational, legal, and service delivery risks. The CRM Group provides a structured mechanism for identifying, escalating, and mitigating clinical risks, thereby strengthening the Board’s assurance framework. (e) Staffing Implications There are no new staffing implications. The CRM Group is supported by existing professional leads and business support staff. Participation in the group is part of core governance responsibilities for relevant staff. (f) Property There are no property implications associated with this report. (g) Equalities/Socio Economic Impact There is no requirement for an Equality Impact Assessment as the report does not propose a change in policy or service delivery. The CRM Group supports equitable, safe, and inclusive care through its governance role. (h) Climate Change and Biodiversity Impacts There are no direct implications for climate change or biodiversity arising from this report. (i) Directions No new directions are required as a result of this report. The CRM Group operates under the existing governance framework approved by the MIJB. (j) Consultations The updated ToR have been developed in consultation with the Chief Nurse, Clinical Leads, Heads of Service, and members of the Clinical and Page 29
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Care Governance Group. Feedback has been incorporated to ensure alignment with current governance structures and professional leadership. 6. CONCLUSION 6.1 The updated ToR for the CRM Group reflect the evolving governance landscape within HSCM and reaffirm the group’s critical role in providing assurance on clinical risk and safety across delegated NHS functions and hosted services. 6.2 By strengthening the group’s remit, reporting lines, and professional leadership, the revised ToR support the MIJB’s commitment to safe, effective, and person-centred care, and ensure that clinical risks are identified, managed, and escalated appropriately within a robust governance framework. Author of Report: Sonya Duncan Background Papers: Ref: Page 30
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APPENDIX 1 Health and Social Care Moray Clinical Risk Management Group Terms of Reference Date of Issue: August 2025 Date of Review: July 2026 UNCONTROLLED WHEN PRINTED Version 3.2 Page 31
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Purpose The Clinical Risk Management (CRM) group provides oversight and assurance of clinical risk related to NHS delegated functions across Health and Social Care Moray (HSCM) and hosted services. It reports to the Clinical and Care Governance Group (CCGG), ensuring that robust systems are in place to manage clinical risk and governance with clear escalation routes to the HSCM Senior Management Team (SMT) and NHS Grampian Whole System Clinical Governance Group, as appropriate. The group promotes a culture of openness, accountability, integrity in decision- making, and continuous improvement to support the delivery of high quality, safe and effective person-centred clinical care across HSCM. It is responsible for establishing, implementing, and monitoring governance arrangements that provide professional assurance to HSCM and the Moray Integration Joint Board Clinical and Care Governance Committee (MIJB CCGC) on matters relating to clinical risk and clinical governance in Moray. Please note: Services that fall under the remit of the local authority services (e.g. social care complaints or non-clinical risks) are managed through separate governance structures and are not within the scope of this group. The CRM group maintains strong links with NHS Grampian to ensure alignment with clinical governance standards and practices. Remit and Objectives • Provide professional assurance to HSCM Clinical and Care Governance Group, and NHS Grampian, that clinical risk and governance systems are embedded and effective. • Ensure clear lines of accountability for clinical care, quality, and safety. • Promote leadership and engagement to support a consistent and robust approach to quality, safety, and governance. • Support learning from health related adverse events, complaints and feedback. • Use data to identify areas for improvement and drive continuous improvement of care, quality, and safety. • Provide a safe environment where concerns or risks can be shared in confidence. • Promote a culture of professional curiosity, self-reflection, and constructive challenge to drive continuous improvement of care, quality, and safety. • Provide a monthly report to CCGG. Any issues for escalation would be shared at the next SMT meeting or sooner if required. Core Agenda The CRM group will seek assurance and provide approval for the following core items: • Review of o Complaints and Feedback Page 32
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o Major and Extreme incidents o Duty of Candour events o Level 1 and 2 investigations o RIDDOR reports o High and Very High Risks o New Risks • Items for escalation to SMT • CRM may immediately escalate an identified increasing or unmanageable issue or risk to the appropriate person within the partnership or NHS Grampian. Membership The meeting will be Chaired by a Professional Lead; the Chief Nurse, Clinical Lead or Allied Health Professional (AHP) Professional Lead, as they hold senior Professional Clinical roles in HSCM and are members of SMT. This ensures consistency, stability, and a well-coordinated approach to how the meeting is run. The core membership of the HSCM CRM group is as follows (all representatives should hold the position of Lead or Manager within the service they are representing unless agreed by exception): 1. Chief Nurse (Chair) 2. AHP Professional Lead 3. Head of Service 4. GP Clinical Lead 5. Mental Health Lead Nurse 6. GMED Clinical and Professional Leads 7. Community Nursing Lead 8. Lead Operational Nurse 9. Corporate Manager Other attendees by invitation e.g. Childrens Health Services Lead, Integrated Learning Disability Service Manager, Clinical Governance Advisor, Locality Manager(s). Meeting Arrangements • Meetings will be held fortnightly. • A quorum of 4 Professional members is required. • Papers will be circulated at least two working days before the meeting. • The HSCM CRM group will review the dashboard at each meeting. • An action log will be kept for each meeting and will be stored in the MS Teams space. The meeting is currently supported by the Corporate Business Support Manager on a temporary basis. Page 33
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Health and Social Care Moray Governance Reporting Structure * Falls group, HAI Group, Quality Groups etc. ** HSCM representative to NHSG CGC is the Chief Nurse Review of Terms of Reference These Terms of Reference will be reviewed annually or sooner if required, to ensure they remain aligned with the strategic priorities and governance framework of HSCM and NHS Grampian. 2025 V3.2 Final approved for issue 07 August 2025 2025 V3.1 SMT discussed and approved with some minor amendments 23 July 2025 2019 Version Released April 2019 Page 34
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REPORT TO: MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE ON 28 AUGUST 2025 SUBJECT: DRAFT HEALTH AND SOCIAL CARE MORAY ANNUAL COMPLAINTS REPORT 2024/25 BY: CHIEF NURSE, MORAY 1. REASON FOR REPORT 1.1 To provide the Committee with the Draft Health and Social Care Moray (HSCM) Annual Complaints Report for 2024/25. 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 September for approval prior to publication. 3. BACKGROUND 3.1 A report to this 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 In March 2022, the SPSO confirmed the annual report publication deadline is the end of October each year, with the KPIs applicable for data collected from 1 April 2022. 3.3 The NHS Grampian Annual Complaints report provides information on all complaints, concerns, comments, and feedback recorded on Datix; this includes any recorded under HSCM. The Annual Complaints Report produced by the Item 7. Page 35
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Council includes all council related complaints recorded on Lagan, this includes any Council related services under HSCM. 3.4 The SPSO have directed to ensure there is no double reporting of figures, but it should be made clear where partnerships’ complaints performance information is published. 3.5 Given the importance HSCM places on receiving comments and feedback to use to continuously improve services, the experience and satisfaction of service users, 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 HSCM’s commitment to valuing complaints. 3.6 The annual report pulls together and builds on the quarterly complaints’ reports produced for Clinical and Care Governance 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 2024 to 31 March 2025 has been collated and presented following the LA KPIs and NHS Performance Indicators. The draft HSCM Annual Complaints Report for 2024/25 is attached at Appendix 1. 4.2 This will be the fifth published HSCM Annual Complaints Report – all previous versions can be found on the HSCM 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 Health and Social Care Moray. 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 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. Page 36
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4.7 A total of 136 complaints were received by HSCM during 2024/25. 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 explains the increase in complaints recorded on Lagan from 2023/24 onwards. 4.9 The number of complaints recorded in DATIX include 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 (MIJB) host the service for Grampian. The GMED service cares for patients who have urgent primary care needs and cannot wait until their GP Practice is open. GMED operates from 18:00 until 08:00 each weekday, weekends and public holidays including the festive period. The services has on average 90,000 contacts annually (this equates to 1/6th of the population of Grampian). 4.10 In 2024/25, 23% (27) complaints were upheld fully, with the remainder being partially or not upheld. 4.11 Complaints often arose from unclear or inconsistently followed processes, communication issues where messages or guidance were not sufficiently clear, and situations where people were not informed in a timely manner. 4.12 HSCM governance structures allow ongoing review of complaints and incidents to identify areas for improvement and learning opportunities, to drive positive change. 4.13 It is positive to note that complaints regarding provision of care are small in number and that very positive feedback is regularly received from people receiving support from services. 4.14 When a complaint is straightforward and does not require investigation, HSCM aim to respond within 5 working days (referred to as frontline or early resolution complaints). For complaints requiring investigation, the target response time is 20 working days. During 2024/25, HSCM did not consistently meet these targets. For social work and social care services, the average response time was 18 working days for early resolution complaints and 51 working days for investigative complaints. For health related services, the average was 3 working days for early resolution and 45 working days for investigative complaints. Improving response times remains a priority. Internal processes continue to be reviewed to ensure they are as streamlined and efficient as possible. 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” Page 37
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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. (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 HSCM Senior Leadership Team and to the Clinical and Care Governance 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 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 are in agreement with the content of this report where it relates to their area of responsibility: Page 38
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• Corporate Manager, Health and Social Care Moray • Caroline O’Connor, Committee Services Officer, Moray Council • 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 a continuous improvement process. Author of Report: Isla Whyte, Corporate Business Support Manager Background Papers: with author Ref: Page 39
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APPENDIX 1 Annual Report on Complaints and Feedback 2024 – 2025 01/04/24 – 31/03/25 Page 40
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2 Table of Contents HEALTH AND SOCIAL CARE MORAY 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 15 INDICATOR 2 18 INDICATOR 3 18 INDICATOR 4 19 Page 41
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3 Health and Social Care Moray Health and Social Care Moray (HSCM) 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 HSCM 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 Health and Social Moray (HSCM) in the period from 1 April 2024 to 31 March 2025. Within HSCM, 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 HSCM. 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 HSCM. Links to these annual reports can be found here: (TO BE ADDED WHEN AVAILABLE) Page 42
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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 43
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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 44
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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 45
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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 service user’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 HSCM 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 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. Page 46
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8 There is a challenge for reporting of complaints for HSCM 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 HSCM’s fifth published annual complaints performance report. It includes performance statistics, in line with the complaints 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 us 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 47
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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 guide improvements, reveals 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 48
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Complaints Data 2024/25 – Annual Report (01/04/24 – 31/03/2025) 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 19 4 2 29 Education/training of staff 0 6 5 1 12 Access - Improvements made to service access 1 3 0 0 4 Action plan(s) created and instigated 1 0 2 0 3 No action required 2 12 10 0 24 System - Changes to systems 0 1 1 0 2 Conduct issues addressed 0 1 1 0 2 Share lessons with staff/patient/public 0 4 1 0 5 Waiting - Review of waiting times 0 4 2 0 6 No value 1 0 1 0 2** Total 9 50 27 3 89* *figures do not directly correlate with number of closed complaints as there may be more than one action selected per complaint. There were 65 complaints closed on Datix during 2024/25. **one record relates to a complaint that was closed as an adverse event investigation will take place instead and one has been incorrectly recorded as a complaint when it was a concern. Page 49
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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 1 0 1 Complaint against service – self-directed care 1 0 1 Complaint against staff 5 7 12 Other 3 3 6 Policy and Procedure 3 2 5 Process / Procedure 10 20 30 Total 23 32 55 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 Enhance communication between professionals involved in care package Relook at all components of the planning for the care and support offered Increased oversight of the care package to be provided Continue to explore alternative options with family Reminder to staff about the importance of timely communication with people who use our services Ensure all information provided is clear and transparent Procedure to be put in place to facilitate timely decision making Policy Communicate policy around sharing of minutes with attendees Communication Communication clearly role and purpose of panel and how attendees participate Reflect on language used Staff training to be undertaken Page 50
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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 Community Pharmacy General Practice GMED Grampian Vaccination and Immunisation Programme Mental Health - Adult Mental Health Mental Health - Old Age Psychiatry Mental Health - Specialisms Primary Care Total Access - Improvements made to service access 1 0 1 0 1 0 1 0 0 0 0 4 Action plan(s) created and instigated 1 0 0 0 0 1 0 0 0 0 1 3 Communication - Improvements in communication staff- staff or staff-patient 5 1 2 0 5 7 2 6 0 0 1 29 No action required 1 0 2 1 1 3 4 10 1 1 0 24 Waiting - Review of waiting times 1 0 0 0 0 3 0 2 0 0 0 6 Education/training of staff 0 1 2 0 2 5 1 0 0 0 1 12 Share lessons with staff/patient/public 0 1 1 0 1 0 0 1 0 0 1 5 Conduct issues addressed 0 0 0 0 0 1 0 0 0 0 1 2 System - Changes to systems 0 0 0 0 2 0 0 0 0 0 0 2 Total 9 3 8 1 12 20 8 19 1 1 5 87* *Figure more than total number of closed complaints as there could be multiple actions taken for each complaint Page 51
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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 01/04/2024 and 31/03/2025 (data extracted from Datix). Communication Ensure patients have a clear understanding of procedure Improved communication with patient Continue to ensure all contacts are recorded in case notes Reminder sent to all clinicians to ensure they communicate clearly with patients Staff to signpost to website as opposed to having printed materials which can become outdated Call centre staff to be made fully aware of eligibility criteria Improvements to communication between primary and secondary care Clear and respectful language to be used at all times System/Process change Reintroduce safety calling to ensure patients are aware of delays Education / training / share lessons learned Always expand on differentials and consider other possibilities even when symptoms are vague Reminder medication to be dispensed from centre only if it cannot wait to be collected from the pharmacy the following day Training on signs and symptoms of pertussis Reminder about appropriate PPE Further learning about meningitis presentation Values based reflective practice Training and education on caring for people with a brain injury Reminder all telephone consults to start with identifying caller Training / education around clinical history note taking 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 52
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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 2024 to 31 March 2025, is detailed below. 18% 23% 47% 6% 6% Compliments (datix) Community Nursing GMED Moray Vaccination Centre Phlebotomy Service Community Hospital Nursing 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 53
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15 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 46 25 0 71 Moray Council - Lagan 26 38 1 65 Total 72 63 1 136 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 Year Total 2018/19 62 2019/20 62 2020/21 33 2021/22 68 2022/23 78 2023/24 67 2024/25 71 Page 54
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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 2018/19 2019/20 2020/21 2021/22 2022/23 2023/24 2024/25 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 A total of 138 complaints were received by Health and Social Care Moray in 2024/25. A breakdown of complaints received is detailed on the next page. Page 55
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17 Table 5 – combined data from Datix and Lagan (complaints received) for 2024/25 Health and Social Care Moray (Datix) Allied Health Professionals 8 4Community Hospital Nursing 4 Community Nursing 4 Community Pharmacy 1 General Practice 7 GMED 18 Moray Vaccination Centre 7 Mental Health - Adult Mental Health 19 Mental Health - Old Age Psychiatry 2 Mental Health - Specialisms 1 Health and Social Care Moray (Lagan) Access Team 19 Care at Home 7 Community Care Finance 2 Drug and Alcohol 1 Learning Disability 1 Moray East 1 TMC Specialist Unit 1 Children and Families and Justice Social Work Access Team 19 Children and Families Area Teams 8 Criminal Justice 2 Fostering and Adoption and Supported Lodgings 4 136 Page 56
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18 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 6 out of 6 (100%) 9 out of 17 (53%) 8 out of 35 (23%) Moray Council - Lagan 7 out of 23 (30%) 3 out of 25 (12%) 2 out of 7 (29%) 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 3 days 45 days 75 days Moray Council - Lagan 18 days 51 days 27 days During 2024/25, HSCM 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. Improving the timeliness and quality of complaints responses remains a priority. Work is ongoing to identify barriers, streamline processes, and promote early resolutions that meets the needs of complainants. 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 57
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19 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 2024/25. Out of 65 closed complaints on the system 1 complaint was incorrectly recorded as a complaint (should be a concern),1 was closed due to an adverse event review taking place and 3 were closed as consent was not received. From the remaining 60 complaints closed during 2024/25 - approximately 33.3% were fully upheld, 33.3% were partially upheld and 33.3% were not upheld 0 2 4 6 8 10 12 14 16 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 closed 33.3% were upheld, 33.3% partially upheld and 33.3% not upheld. From all investigative complaints closed 18% were upheld, 41% were partially upheld and 41% were not upheld. From all escalated investigative complaints 40% were upheld, 29% were partially upheld and 31% were not upheld. Page 58
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20 Complaints Information Extracted from Lagan: 55 complaints were closed during 2024/25: 15% were upheld, 33% were partially upheld, 43% were not upheld and 9% were resolved. Graph 3 below shows the number of complaints upheld, partially upheld and not upheld as recorded in Lagan. 0 2 4 6 8 10 12 14 Upheld Partially Upheld Not upheld Resolution Lagan - Outcome of Closed Complaints Frontline Investigative Escalated Investigative SPSO From all frontline complaints closed 17% were upheld, 13% partially upheld and 48% not upheld. 22% were resolved. From all investigative complaints closed 12% were upheld, 52% were partially upheld and 36% were not upheld. From all escalated investigative complaints 14% were upheld, 29% were partially upheld and 57% were not upheld. Page 59
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