Agenda Document Pack - Clinical and Care Governance Committee - 25/08/2022
Moray Council · 25 August 2022
Back to Clinical and Care Governance Committee — 25 August 2022 and its agenda
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Clinical and Care Governance Committee Thursday, 25 August 2022 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, 25 August 2022 at 09:30 to consider the business noted below. AGENDA 1. Welcome and Apologies 2. Declaration of Member's Interests 3. Minute of Meeting of 26 May 2022 5 - 8 4. Action Log - 26 May 2022 9 - 10 5. Complaints Report Quarter 1 11 - 26 6. Clinical and Care Governance Group Escalation Q1 Report 27 - 38 7. Out Of Hours Mental Health Service Provision for 16 to 18 year olds 39 - 42 8. Three Conversations Approach 43 - 54 9. Unmet Need Report 55 - 78 10. Strategic Risk Register Report 79 - 108 11. Items for Escalation to MIJB Page 1
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MORAY INTEGRATION JOINT BOARD SEDERUNT Mr Derick Murray (Chair) Professor Siladitya Bhattacharya (Voting Member) Councillor Peter Bloomfield (Voting Member) Councillor Scott Lawrence (Voting Member) Mr Ivan Augustus (Non-Voting Member) Ms Karen Donaldson (Non-Voting Member) Jane Ewen (Non-Voting Member) Ms Jane Mackie (Non-Voting Member) Mrs Val Thatcher (Non-Voting Member) Clerk Name: Tracey Sutherland Clerk Telephone: 07971 879268 Clerk Email: committee.services@moray.gov.uk Page 3
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MINUTE OF MEETING OF THE CLINICAL AND CARE GOVERNANCE COMMITTEE Thursday, 26 May 2022 Remote Locations via Video Conference, PRESENT Mr Ivan Augustus, Professor Siladitya Bhattacharya, Simon Bokor-Ingram, Mr Derick Murray, Jeanette Netherwood, Councillor Kathleen Robertson, Samantha Thomas APOLOGIES Mr Sean Coady, Ms Karen Donaldson, Jane Ewen, Dr Ann Hodges, Ms Jane Mackie, Ms Pauline Merchant, Mr Neil Strachan, Mrs Val Thatcher IN ATTENDANCE Also in attendance were Laura Stevenson, Dental Clinical Lead and Tracey Sutherland, Committee Services Officer. 1. Chair The meeting was chaired by Mr Derick Murray. 2. Welcome and Apologies The Chair welcomed everyone to the meeting and in particular Councillor Kathleen Robertson and Professor Bhattecharya to their first meeting of the Committee. Item 3. Page 5
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3. Declaration of Member's Interests There were no declarations of Members' Interests in respect of any item on the agenda. 4. Minute of Meeting of 24 February 2022 The minute of the meeting of 24 February 2022 was submitted and approved. 5. Action Log - 24 February 2022 The Action Log from the meeting of 24 February 2022 was discussed and updated. 6. Clinical and Care Governance Group Escalation Q4 Report A report by the Chief Nurse informed the Clinical and Care Governance Committee of progress and exceptions reported to the Clinical and Care Governance Group during quarter 4 of 2021/22 (1 January up to 31 March 2022). Following consideration the Clinical and Care Governance Group noted the contents of the report. 7. Complaints Report Quarter 4 A report by the Chief Nurse informed the Committee of complaints reported and closed during Quarter 4 (1 January 2022 - 31 March 2022). Following consideration the Committee agreed: i) to note the totals, lessons learned, response times and action taken for complaints submitted and completed within the last quarter; and ii) that no further info is required for future reports. 8. Dental Services in Moray Report A report by the Dental Clinical Lead informed the Committee of the current position in relation to provision of dental services in Moray. Following consideration the Committee noted the content of the report and the actions being taken forward to mitigate risks. 9. Out of Hours Primary Care GMED Report A report by the Out of Hours Primary Care (GMED) Service Manager informed the Clinical and Care Governance Committee of learning and education initiatives from adverse events and complaints in the GMED service. The Chair sought agreement to add an additional recommendation that the report should be circulated to Aberdeen City and Shire Integration Joint Board's for further scrutiny. This was unanimously agreed. Following further consideration the Committee agreed: Page 6
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i) to note the contents of the report; and ii) that the report should be circulated to Aberdeen City and Shire Integration Joint Board's for further scrutiny. 10. Unmet Need in Health and Social Care Moray A report by the Head of Service/Chief Social Work Officer updated the Committee of the current position on unmet need within Health and Social Care Moray. Following consideration the Committee agreed to note: i) the current situation within Health and Social Care Moray and the mitigation actions that have been introduced; ii) the continuing additional pressures placed upon Health and Social Care Moray staff; and iii) the recovery being achieved, but recognise the fragility of the improvement and the long-term impact on staff. 11. Items for Escalation to MIJB The Chief Officer, Health and Social Care suggested it would be useful to present a report to the Integration Joint Board on the Unmet Need in HSCM to raise awareness as the ongoing risks are significant and there is still an issue with recruiting staff. This was unanimously agreed by the Committee. Page 7
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MEETING OF MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE THURSDAY 26 MAY 2022 ACTION LOG ITEM NO. TITLE OF REPORT ACTION REQUIRED DUE DATE ACTION BY UPDATE AUGUST 2022 1. Progress Update for Clinical and Care Governance Developments A follow up workshop to be arranged in April/May 2022 on developments in relation to governance arrangements and assurance framework. 30 June 2022 Chief Social Worker and Lead Nurse 2. Out of Hours Primary Care GMED Report Report to be circulated to Aberdeen City and Shire Integration Joint Boards for further scrutiny Chief Officer 3. Items for Escalation to MIJB The Committee agreed to escalate the Unmet Need in Health and Social Care Moray to the MIJB June 2022 Chief Officer/Head of Service Item 4. Page 9
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REPORT TO: MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE ON 25 AUGUST 2022 SUBJECT: COMPLAINTS REPORT FOR QUARTER 1, 2022/2023 BY: CHIEF NURSE, MORAY 1. REASON FOR REPORT 1.1. To inform the Committee of complaints reported and closed during Quarter 1 (1 April 2022 – 30 June 2022). 2. RECOMMENDATION 2.1. It is recommended that the Committee: i) considers and notes the totals, lessons learned, response times and action taken for complaints completed within the last quarter; and ii) notes that a draft Health and Social Care Moray (HSCM) Annual Complaints Report for 2021/22 will be presented to the October meeting. 3. BACKGROUND 3.1. Within HSCM, 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. NHS and Local Authority Complaint Handling Procedure/Policy requires all staff to deal with feedback and complaints in a person/client-centred way. The procedure has been developed working closely with the Scottish Public Services Ombudsman (SPSO). 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 Item 5. Page 11
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the requirements of the Patient Rights (Scotland) Act 2011, and accords with the Healthcare Principles introduced by the Act. 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 should 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 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. 3.6. The first HSCM Annual Complaints Report (2020/21) was published at the end of September 2021 and can be found on the HSCM website https://hscmoray.co.uk/complaints.html 3.7. The annual report summarises and builds on the quarterly reports produced for Clinical and Care Governance Committee. It includes details of the numbers and types of complaints and information about the stage at which complaints were resolved, the time taken to do so, and about 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 CCG Committee is presented with quarterly complaints performance information using the draft mandatory Key Performance Indicators (KPIs), identified by SPSO. These are: Indicator One Learning from complaints A statement outlining changes or improvements to services or procedures as a result of consideration of complaints Indicator Two 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 Three 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 Page 12
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Indicator Four 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 Five 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 In March 2022 the agreed Complaints 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 4.3. The qualitative indicator on learning from complaints has 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. 4.4. The draft KPIs also included recommended indicators about raising awareness, staff training and customer satisfaction with the complaints process. Although Page 13
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these too have been removed from the refreshed guidance, organisations are encourage to continue collecting this data if they already do so to further support improvement in delivery of service. 4.5. These KPIs are applicable for data collected from 1 April 2022. The annual report publication deadline is the end of October. Therefore, the first annual report using these KPIs will be in October 2023. 4.6. 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 4.7. The NHSG Annual Complaints report provides information on all complaints, concerns, comments and feedback recorded on Datix, this includes any recorded under Health and Social Care Moray. The Annual Complaints Report produced by the Council includes all council related complaints recorded on lagan, this includes any Council related services under HSCM. 4.8. The SPSO have advised to ensure there is no double reporting of figures but it should be made clear where partnerships’ complaints performance information is published. 4.9. Given the importance HSCM places on receiving comments and feedback to use to continuously improve services it is suggested HSCM continues to publish annual complaints performance information to demonstrate HSCM’s commitment to valuing complaints. The annual report will provide links to the Council’s and NHSG’s Annual Complaints Performance Reports and provide supplementary information specific to Health and Social Care Moray. 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.” 4.10. HSCM Complaints performance data for Quarter 1 is attached at Appendix 1. 4.11. 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. Page 14
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4.12. 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. 4.13. Overall, a total of 26 complaints were received during Quarter 1. 4.14. The table below sets out HSCM complaints received and closed by Quarter: 4.15. There were 16 MP/MSP enquiries received and recorded on the Council system, Lagan, under HSCM. These were allocated as follows: Service Number of Enquiries Care at Home 8 Community Care Finance 3 TMC Specialist Unit 1 Occupational Therapy 2 Mental Health 1 Access Team 1 4.16. Correspondence has been received from MPs/MSPs and Councillors direct to managers in HSCM, at this stage it is not possible to accurately report on numbers received due to these enquiries not all being logged centrally. It can be noted enquiries were about a variety of matters with not one topic standing out more than others in terms of recurring themes. Processes for recording these appropriately are currently being defined to support effective feedback, prevent duplication and aid identification of trends and learning for all services. 21 18 15 23 32 18 17 2625 15 14 19 24 22 22 21 0 5 10 15 20 25 30 35 Q2 20/21 Q3 20/21 Q4 20/21 Q1 21/22 Q2 21/22 Q3 21/22 Q4 21/22 Q1 22/23 Received Closed Total Received in Quarter 1 Total Closed in Quarter 1 Local Authority 9 4 NHS 17 17 26 21 Page 15
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5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Moray Partners in Care 2019 – 2029” 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. 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. (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. Page 16
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(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: • Chief Officer • Sean Coady, Head of Service, HSCM • Jane Mackie, Head of Service / Chief Social Work Officer • Corporate Manager • Tracey Sutherland, Committee Services Officer, Moray Council • Clinical and Care Governance Group 6. CONCLUSION 6.1. This report provides a summary of HSCM complaints received and closed during Quarter 1 (1 April – 30 June 2022). The governance and monitoring of complaints forms part of core business for teams and services and the provision of a good quality, effective and safe service is a key priority for all. Author of Report: Isla Whyte, Interim Support Manager Background Papers: with author Ref: Page 17
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APPENDIX 1 Complaints Data (by closed complaints) Quarter 1 (01/04/22 – 30/06/2022) Indicator 1 - Learning from complaints Teams and services actively review the outcomes of complaints to see where improvements can be made and learn from the feedback, with a view to reducing the number of complaints in future. The tables 1, 2, 3 and graph 1 below set out the stages the complaints were closed and what the complaint was about and what action taken. Table 1 Complaints Information Extracted from Datix – Action Taken/Outcome of complaints closed during Quarter 1, 2022/23 Fully upheld: Complaint is accepted Partially upheld: Complaint is partly accepted Not upheld: Complaint is not accepted Total Access - Improvements made to service access 1 1 0 2 Action plan(s) created and instigated 2 1 0 3 Communication - Improvements in communication staff-staff or staff-patient 4 3 0 7 Education/training of staff 2 0 0 2 No action required 0 0 2 2 System - Changes to systems 1 1 0 2 Share lessons with staff/patient/public 1 1 0 2 Waiting - Review of waiting times 0 1 0 1 Total 11 8 2 *21 *Figure more than total number of closed complaints as there could be multiple actions taken for each complaint Item 5. Page 19
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Table 2 Complaints Information Extracted from Lagan: 4 complaints were closed during Quarter 1, 2022/23. Directorate Department Service Upheld Partially Upheld Not Upheld Resolution Grand Total Health and Social Care Moray Health and Social Care Moray Access Team 0 0 1 0 1 Care at Home 0 2 0 0 2 Day Care 0 0 1 0 1 Graph 1 Due to the low numbers it is not possible to detail what the complaint was about as this could lead to patient identifiable information being reported. This information can be discussed in a closed session with committee members. 0 1 2 3 4 5 6 7 8 Allied Health Professionals Community Hospital Nursing Community Nursing GMED Mental Health - Adult Mental Health Public Dental Service Public Health Complaints Closed by Service Qtr1 (datix) Page 20
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Table 3 Complaints Information Extracted from Datix – Action Taken by Service (complaints closed during Quarter 1, 2022/23) Allied Health Professionals Community Nursing GMED Mental Health - Adult Mental Health Public Dental Service Total Access - Improvements made to service access 0 0 0 1 1 2 Action plan(s) created and instigated 1 1 1 0 0 3 Communication - Improvements in communication staff-staff or staff-patient 1 1 2 3 0 7 Education/training of staff 0 1 1 0 0 2 No action required 0 0 0 2 0 2 System - Changes to systems 0 0 1 1 0 2 Share lessons with staff/patient/public 0 0 0 2 0 2 Waiting - Review of waiting times 0 0 1 0 0 1 Total 2 3 6 9 1 *21 *this figure does not represent number of complaints closed 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 recent complaints. Actions and Lessons Learned (datix) Communication Development session focusing on effective communication between staff, patients, family members and other services Record Keeping – paper held records and electronic Learning for staff around dealing with sensitive documentation shared Additional training regarding contemporaneous paper held record keeping Community Modules issues have been escalated to senior management within the appropriate NHSG IT department. Infection, Prevention and Control Staff instructed to undertake further IPC training including donning and doffing System/Process change A post-operative discharge advice sheet for vasectomy is being developed. Education / training / share lessons learned Additional training and supports have been put in place for an administration team, and are implementing an additional layer of checks for all correspondence that is sent from the Minor Surgery department. GMED learning event held to assess sequence of events and how they may be managed differently. Training provided to give staff the skills to respond to people presenting or calling in a crisis. Decision Note / Learning Outcome (lagan) • Nationwide care crisis impacting on ability to provide care timeously – continue to look at all options • Acknowledge delay in installing equipment – process delay rectified Page 21
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Indicator 2 – 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 4 – Total number of complaints received in Quarter 1, 2022/23 System recorded Early Resolution / Frontline Investigation Not Marked Total NHS - Datix 4 closed at Early Resolution Stage 10 closed 3 currently under investigation 0 17 Moray Council - Lagan 4 marked frontline 2 marked investigative 3 not yet marked 9 Total 8 15 3 26 Table 5 – Allocation of complaints received in Quarter 1, 2022/23 NHS Service - Datix Public Dental Services 3 Community Hospital Nursing 1 Community Nursing 1 GMED 1 Mental Health – Adult Mental Health 7 Primary Care Contracts 1 AHP 3 Total 17 Table 6 – Allocation of complaints received in Quarter 1, 2022/23 MC Service - Lagan Moray East 1 Care at Home 5 Access Team 2 Day Care 1 Total 9 Page 22
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Indicator 3 - 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 There were 17 Complaints closed on the NHS system Datix during Quarter 1, 2022/23 – breakdown as follows: Early Resolution – 4 (1 withdrawn by complainant and 1 was a duplicate) Investigation – 12 (1 consent was not received) Ombudsman – 1 There were 4 Complaint closed on the MC system Lagan during Quarter 1, 2022/23 – breakdown as follows: Frontline – 2 Investigation – 2 Table 7 – number and percentage of complaints at each stage closed within timescales (based on complaints closed during Quarter 1, 2022/23) Early Resolution with timescale Investigation within timescale NHS - Datix 2 out of 2 (100%) 2 out of 11 (18.18%) Moray Council - Lagan 2 out of 2 (100%) 2 out of 2 (100%) Whilst HSCM aim to respond to complaints within 20 working days this is not always achievable. Reasons for delay in response include: cross service complaints where coordinating responses from all parties and relevant staff being on annual leave have led to a delay. Page 23
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Indicator 4 - The average time in working days for a full response to complaints at each stage Table 8 – average time in working days to respond (based on complaints closed during Quarter 1, 2022/23) Frontline Investigative NHS - Datix 4 days 46 days Moray Council - Lagan 2.5 days 11.5 days HSCM have responded to all frontline/early resolution complaints within timescales for Quarter 1, 2022/23. Investigative complaints received into Lagan have been resolved well within the 20 working day timeframe. Complaints received into Datix are often multi-faceted and include more than one service across NHS Grampian and other sectors, which can impact on response times due to the level of investigation and coordination required. In most cases the HSCM response is uploaded within the timeframe, but due to the complexity and number of services involved the overall completion date does not meet timescales. Page 24
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Indicator 5 - 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 amount of complaints fully upheld, partially upheld and not upheld as recorded in Datix from the 17 closed complaints during Quarter 1, 2022/23. (Out of 17 closed complaints on the system 1 was withdrawn by complainant, 1 was a duplicate, 1 consent was not received and 1 was a misunderstanding (that was resolved by telephone) – these are recorded as ‘other’ below. From the remaining 13 complaints closed during Quarter 1 - approximately 38% of complaints closed during Quarter 1 were upheld, 46% were partially upheld and 15% were not upheld 0 1 2 3 4 5 6 Early Resolution Investigation Ombudsman Other Complaints Outcome (Datix) Fully Upheld: Complaint is accepted Partially Upheld: Complaint is partly accepted Not Upheld: Complaint is not accepted Page 25
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Complaints Information Extracted from Lagan: 4 complaints were closed during Quarter 1, 2022/23: 50% were partially upheld and 50% were not upheld. Graph 3 below shows the amount of complaints upheld, partially upheld and not upheld as recorded in Lagan from the 4 closed complaints during Quarter 1, 2022/23. 0 1 2 3 4 Early Resolution Investigation Ombudsman Complaints Outcome (Lagan) Fully Upheld: Complaint is accepted Partially Upheld: Complaint is partly accepted Not Upheld: Complaint is not accepted Page 26
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REPORT TO: MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE ON 25 AUGUST 2022 SUBJECT: HEALTH AND SOCIAL CARE MORAY (HSCM) CLINICAL AND CARE GOVERNANCE GROUP ESCALATION REPORT FOR QUARTER 1 (APRIL TO JUNE 2022) BY: CHIEF NURSE, MORAY 1. REASON FOR REPORT 1.1. To inform the Clinical and Care Governance Committee of progress and exceptions reported to the Clinical and Care Governance Group during quarter 1 of 2022/23 (1 April up to 30 June 2022). 2. RECOMMENDATION 2.1 It is recommended that the Committee consider and note the contents of the report. 3. BACKGROUND 3.1. 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 3.2 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 Group. The group is co- chaired by Samantha Thomas, Chief Nurse - Moray and Jane Mackie, Head of Service/Chief Social Work Officer. 3.4. The agenda for the Clinical and Care Governance Group follows a 2 monthly pattern with alternating agendas to allow for appropriate scrutiny of agenda items and reports. A reporting schedule for Quality Assurance Reports from Clinical Service Groups / departments is established. This report contains information from these reports and further information relating to complaints and incidents / adverse events reported via Datix; and areas of concern / risk and good practice shared during the reporting period. Exception reporting is Item 6. Page 27
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utilised as appropriate. Since April 2020, the 3 minute brief template has been used for services to share their updates; this approach has resulted in positive feedback from service managers and group members. 3.5. The Clinical and Care Governance Group have met 3 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 tabled and discussed. 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 process in place to meet/ mitigate these recommendations. Overview from quarter 1 2022/23 is listed below: • CRM Minutes • Suicide Assessment and Management Protocol • Moray Mental Health Admission, Transfer and discharge Policy • Service Updates • Learning Disability • GMED • Pharmacy • Public Dental Service • AHP • Moray GP/Primary Care • Buckie Locality • Public Health • Risk Management • Children and Families • Optometry • Adverse Events and DoC • Update from Practice Governance Committee • Adult Support and Protection • Self Directed Support (SDS) Guidance and My Life documentation • Update from Quality and Safety Forum, Grampian Area Areas of achievement / Good Practice 4.2 GMED reported working on improving the quality of the service that is provided to patients across NHS Grampian: • Working with various stakeholders, including Scottish Ambulance Service (SAS), NHS24, Emergency Department (ED) and Mental Health to identify how patient pathways can be streamlined to ensure quality of patient care is improved. • Regular Continuing Medical Education (CME) sessions are organised for the clinical team to ensure national clinical standards and guidelines are shared and reliably implemented within GMED for a specified condition. This ensures that patients receive evidence-based and consistent care. • Patient surveys were carried out in May 2022 to measure patient satisfaction with the quality of care provided by GMED service. • Professional to professional referrals audit to assess appropriateness of referral and priority given on receipt – a list of recommendations will be produced and changes implemented to improve current pathways. Page 28
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• Clinical note audit was undertaken in April 2022. 4.3 Pharmacotherapy team now an integral part of all GP practices with daily input. Recent successful recruitment of pharmacists. Pharmacy technicians continue to support care homes with medicines issues and homely and palliative medication supply with the recommencement of monthly presence within care homes. 4.4 An update from the Buckie Locality Manager advised the East Community Care Team commenced as an innovation site for the Three Conversations model in April 2022. The team are positive about the approach and it has given them a new focus and enthusiasm. 4.5 Development of the Buckie Community Response Team commenced in May with 5 WTE staff recruited. 4.6 Quality Improvement work ongoing for all aspects of the discharge process in Seafield Community Hospital – look to hold shared learning sessions across all Community Hospitals to support consistency across the sites. 4.7 With community Optometry returning to routine practice, with increased hygiene standards and use of PPE, practices are open once again for inspections. Inspections are underway with both General Ophthalmic Services (GOS) and Locally Enhanced Services (LES) inspections being undertaken together at each practice visit to minimise time spent in each practice. Clinical Risk Management (CRM) 4.8 The Clinical Risk Management (CRM) group 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 Risks. 4.9 The group is attended by members of the senior management team, clinical leads, chief nurse and relevant service managers / consultants. The purpose is to ensure that senior managers are assured of the standards of services and that where necessary investigations are carried out appropriately and learning opportunities identified. An action log is produced following each meeting and is administered and monitored. Individual services can be invited to attend to offer further scrutiny and assurance. 4.10 The CRM group did not meet during July 2022, this was due to annual leave and a change in personnel. Service Managers and Heads of Service continued to monitor risks relevant to patient safety during this time. Interviews for the Clinical Governance (CG) Coordinator role have taken place and the successful candidate is expected to be in post by end of August. The CG Coordinator will coordinate CG intelligence to inform the partnership of local risks relevant to patient safety, providing information to Clinical Leads, Service Managers and local governance groups and committees. A schedule of meetings for the CRM group are now in place. Complaints and Feedback 4.11 HSCM complaints information for Quarter 1, 2022/23 is included in a separate report on today’s agenda. Page 29
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Adverse Events 4.12 Adverse Events by Category and Level of Review Reported on Datix (Quarter 1, 2022/23) Level 3 - local review by line manager in discussion with staff Level 2 - local management team review Level 1 - significant adverse event analysis and review Total Abusive, violent, disruptive or self-harming behaviour 76 2 0 78 Access, Appointment, Admission, Transfer, Discharge (Including Absconders) 25 0 0 25 Accident (Including Falls, Exposure to Blood/Body Fluids, Asbestos, Heat, Radiation, Needlesticks or other hazards) 117 1 0 118 Clinical Assessment (Investigations, Images and Lab Tests) 3 0 0 3 Consent, Confidentiality or Communication 8 0 0 8 Diagnosis, failed or delayed 1 1 1 3 Fire 4 0 0 4 Implementation of care or ongoing monitoring/review (inc. pressure ulcers) 8 1 0 9 Infrastructure or resources (Staffing, Facilities, Environment, Lifts) 7 0 0 7 Medical device/equipment 4 0 0 4 Medication 21 0 0 21 Other - please specify in description 23 0 1 24 Patient Information (Records, Documents, Test Results, Scans) 7 0 0 7 Security (no longer contains fire) 1 0 0 1 Treatment, Procedure (Incl. Operations or Blood Transfusions etc.) 2 0 0 2 Total 307 5 2 *314 * At time of reporting 22 AE had not yet been allocated a Level of Review Page 30
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0 20 40 60 80 100 120 140 160 180 Breach of Information / IT Security Patient / Client / Resident Staff (including Volunteers) Visitors, Relatives or member of the Public Provision of Service Contractor/s 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 31
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4.13 Adverse Events by Service and Level of Review Level 3 - local review by line manager in discussion with staff Level 2 - local management team review Level 1 - significant adverse event analysis and review Allied Health Professionals 8 0 0 Community Hospital Nursing 76 1 0 Community Nursing 16 3 0 Community Pharmacy 1 0 0 General Practice 8 0 0 GMED 22 0 1 Mental Health - Adult Mental Health 76 2 0 Mental Health - Old Age Psychiatry 79 0 0 Mental Health - Specialisms 7 0 0 Phlebotomy Service 1 0 0 Primary Care 2 0 0 Public Dental Service 9 0 1 Public Health 1 0 0 Total 306 6 2 *314 * At time of reporting 22 AE had not yet been allocated a Level of Review Page 32
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4.14 Adverse Events by Harm Reported on Datix (Quarter 4, 2021/22) NEGLIGIBLE MINOR MODERATE MAJOR/EXTREME Total Breach of Information / IT Security 4 0 0 0 4 Patient / Client / Resident 195 54 4 3 256 Staff (including Volunteers) 21 15 0 0 36 Visitors, Relatives or member of the Public 2 0 0 0 2 Provision of Service 14 0 0 0 14 Contractor/s 1 0 0 0 1 Property / Equipment 20 1 0 0 21 Inadequate Discharge 2 0 0 0 2 Total 259 70 4 3 336 4.15 All adverse events by Quarter 2020/21 Quarter 1 2021/22 Quarter 2 2021/22 Quarter 3 2021/22 Quarter 4 2022.23 Quarter 1 Occurrence with no injury, harm or ill-health 193 239 271 189 218 Occurent resulting in injury, harm or ill-health 80 61 87 79 89 Near Miss (occurrence prevented) 34 37 25 31 29 Property damage or loss 0 0 0 0 0 Death 0 0 1 0 0 Total 307 337 383 299 336 Page 33
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4.16 Adverse Events by Severity Reported on Datix by Quarter 2020/21 Quarter 1 2021/22 Quarter 2 2021/22 Quarter 3 2021/22 Quarter 4 2022.23 Quarter 1 Negligible 234 281 308 231 259 Minor 66 48 72 64 70 Moderate 6 8 2 2 4 Major 1 0 0 2 1 Extreme 0 0 1 0 2 Total 307 337 383 299 336 All adverse events have the appropriate level of investigation implemented. At the time of reporting some events had yet to be allocated a Level of Review on datix. Outcomes and learning from extreme events will be subject of a confidential report to the committee following due process. Page 34
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4.17 Findings and Lessons Learned from incidents and reviews: • Staff reminded of the importance of accurate record keeping with monthly audits of patient notes to ensure record keeping is maintained to a high standard with clear and concise documentation. • Review of the policy and procedure for blood glucose monitoring and ketone monitoring. Ensured all staff are aware of and know how to access policy. • Reminder to all dentists and clinicians to ensure they follow sharps protocol. 4.18 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. 4.19 There are currently 2 Level 1 reviews in progress (at the time of reporting). HSCM Risk Register 4.20 New risks identified on Datix are discussed at each Clinical and Care Governance Group and CRM. There have been no new risks identified as ‘Very High’ during this reporting period. There is 1 new ‘High’ risk and 2 new ‘Medium’ risks identified in Quarter 1. 4.21 Each Clinical Service Group/Department highlights risks associated with their service, which are then discussed at HSCM Clinical and Care Governance Group. The risk register is routinely reviewed with leads with guidance and support provided regarding updates. There are 3 “Very High” risks currently on the register. These are being closely monitored by the CRM and senior leadership team. Duty of Candour 4.22 Three events were considered for Duty of Candour (DoC) during Quarter 1, which have all completed a Level 3 investigation process. Learning identified includes: staff reminded of the importance of accurate record keeping with monthly audits of patient notes to ensure record keeping is maintained to a high standard with clear and concise documentation. Items for escalation to the Clinical and Care Governance Committee 4.23 Trauma Informed Practice – with every Local Authority receiving £100,000 funding from Scottish Government to see trauma-informed policy developed across services, a local proposal is currently being developed to take this forward in Moray. A multi- agency working group will be established to implement throughout the partnership. The CCG Group welcome this significant development. 4.24 Adult Support and Protection – at the time of reporting the Multi-Agency Improvement Action Plan is in final draft stage. The plan is scheduled to be submitted to the Care Inspectorate on 17 August 2022. The plan will be discussed at the next Clinical and Care Governance Group. It was noted the Scottish Government launched Adult Support and Protection Code of Practice and Guidance for Adult Protection Committees on 28 July 2022. Page 35
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4.25 Closure of pharmacies – community pharmacy closures during pharmacist absences continues. This is a known national issue and has been raised at Pharmacy Performance and Governance Group. 4.26 Increased workload demand post Covid-19 pandemic on the Moray Health Visiting and School Nurse service – some teams are experiencing up to 45-48% increase in families identified as needing support. Service delivery in Moray was reviewed through Priority of Care guidance with escalation of service delivery pressures and concerns through NHS Grampian. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Moray Partners in Care 2019 – 2029” 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 Clinical and Care Governance 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 Clinical Risk Management (CRM) group reviews all events logged on Datix, ensuring risk is identified and managed. (e) Staffing Implications Page 36
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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 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. (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: • Jane Mackie, Head of Service / Clinical and Care Governance Group Joint Chair • Clinical and Care Governance Group members • Sonya Duncan, Corporate Manager • Tracey Sutherland, Committee Services Officer, Moray Council 6. CONCLUSION 6.1 The HSCM Clinical and Care Governance 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 the Moray Integration Joint Board Clinical and Care Governance Committee that there are effective systems in place to reassure, challenge and share learning. Author of Report: Isla Whyte, Interim Support Manager, HSCM Background Papers: with author Ref: Page 37
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REPORT TO: MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE ON 25 AUGUST 2022 SUBJECT: OUT OF HOURS MENTAL HEALTH SERVICE PROVISION FOR 16-18 YEAR OLDS BY: SERVICE MANAGER, CHILD AND ADOLESCENT MENTAL HEALTH SERVICE (CAMHS) 1. REASON FOR REPORT 1.1. To update the Committee on progress towards addressing the previous gaps in out-of-hours mental health service provision for young people aged 16-18 years in Moray, the current risk mitigation plan and longer term plans. 2. RECOMMENDATION 2.1. It is recommended that the Committee: i) Note the contents of this update report; and ii) Agree whether a further update report is required at the next meeting 3. BACKGROUND 3.1. A previous report to this Committee on 28 October 2021 (para 8 of the minute refers) informed the Committee about the previous gap in out of hours mental health service provision for young people aged 16-18 years in Moray and actions that were being taken to address this. 3.2. There were a number of issues to be addressed including the change in staff profile and the way in which services are being delivered. A short life working group, chaired by the Clinical Director for Child and Adolescent Mental Health Services (CAMHS), was convened with key stakeholders from across the system in Moray to develop a sustainable plan to address this gap. 3.3. The risk has been recorded on the risk register for Health and Social Care Moray and an immediate risk mitigation plan and short-term solution was put in place whereby all Consultant Psychiatrists on the on-call rota for Health and Social Care Moray have been requested to supervise nursing staff who are undertaking a mental health assessment on a young person aged 16-17 who Item 7. Page 39
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presents out of hours with a mental health problem. If the Consultant Psychiatrist feels unable to do so, they must escalate that decision to the Clinical Director for Mental Health and Substance Misuse Services (Health and Social Care Moray) for managerial support out of hours. 3.4. The Short Life Working Group have met on four occasions to-date. Progress was slow over the summer months due to group members being on annual leave at various points. A Terms of Reference for the group was drafted and agreed. Baseline data and case studies were gathered to show more specifically the current gaps in demand and capacity and inform the work plan for the group. This included gaps in the multi-disciplinary system for young people’s disposal when they are in crisis and simply need a “safe space” out of hours rather than an inpatient admission. 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 The key focus was to start a trial of a 7-day decision support rota between the hours of 9am till 5pm to cover both Dr Gray’s and Aberdeen hospital sites on weekends and public holidays with CAMHS Consultant Psychiatrists. The start date for this was February 2022 and has now been rolled out as a permanent service from August 2022 following a successful pilot period. We would look to extend the decision support over a 24 hour day 7 days per week as a Regional on-call role for North of Scotland (see below 4.4). 4.2. The Emergency Psychiatric Page Holder (EPPH) nursing staff undertake assessments for those 14 years and over and are supported by the decision support rota above. In alignment with integration of the mental health workforce within the Moray site we are looking to recruit to a nursing EPPH post to support an all age range service out of hours within Moray. 4.3. CAMHS has committed to supporting the Continuous Professional Development (CPD) of colleagues working in Mental Health and Substance Misuse Services in Health and Social Care Moray to help them feel more confident and skilled with regards to the mental health assessment and decision making for 16 and 17 year olds who may present out of hours. This is working well with good attendance by both medical and nursing colleagues and positive discussion to inform improvements. 4.4. The current CAMHS Psychiatry establishment in Scotland is 88.5 WTE, with approximately 20 WTE vacancies and there is a national shortage of Psychiatrists. Therefore, a regional CAMHS Consultant on-call rota for the North of Scotland, including the island boards, is considered to be a longer- term and more sustainable solution for CAMHS out of hours decision support. In order to generate support for regional working, including a long-term regional solution to CAMHS out of hours provision, at an Executive level from all Boards in the North of Scotland (Oct 2021 meeting). Dr June Brown, Executive Nurse Director for NHS Grampian has agreed to take on the role of Executive Champion for regional CAMHS provision. Dr Brown is being supported by Dr Kandarp Joshi, the CAMHS Clinical Director and CAMHS Clinical Lead for the North of Scotland, and Professor Steve Turner, Regional Clinical Lead for North of Scotland Children and Young People’s Health Services. There has been agreement to recruit a jointly funded Regional Programme Manager to help progress this and other regional pathways for the North of Scotland. Page 40
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5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Moray Partners in Care 2019 – 2029” This report links to delivery of Outcome 7 of the Strategic Plan to ensure people using health and social care services are safe from harm. (b) Policy and Legal The content of this report relates to services provided in relation to The Mental Health (Care and Treatment) (Scotland) Act 2003 (updated in 2015) (c) Financial implications The financial implications of these recommendations would be in relation to workforce costs for CAMHS Consultants to be able to facilitate the out of hours rota working over a seven day period. And also the workforce costs in relation to a funding Emergency Psychiatric Page Holder staff. (d) Risk Implications and Mitigation This report outlines the risks that currently exist and the measures that are in place to mitigate them in the short term, and outlines the plan for developing a sustainable service for the longer term. (e) Staffing Implications None arising directly from this report (f) Property There are no property implications arising from this report. (g) Equalities/Socio Economic Impact An Equalities Impact Assessment is not required as there is no change to policy and procedures resulting from this report. (h) Climate Change and Biodiversity Impacts None arising directly from this report. (i) Directions None arising directly from this report. (j) Consultations Consultation on this report has taken place with the Chief Officer, Chief Social Work Officer, Head of Service, Corporate Manager, HSCM and Tracey Sutherland, Committee Services Officer, Moray Council; who are in agreement with the content of this report as regards their respective responsibilities. 6. CONCLUSION Page 41
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6.1 This report sets out the current position in relation to the service provided for 16 and 17 year olds in Moray, the mitigation in place and the steps that are being taken to establish longer term provision. 6.2. It is proposed that if there are any further update or changes to what has been outlined in this report that this is brought to the next available committee group. Author of Report: Amanda Farquharson, Service Manager, CAMHS Background Papers: Ref: Page 42
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REPORT TO: MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE ON 25 AUGUST 2022 SUBJECT: THREE CONVERSATIONS APPROACH BY: HEAD OF SERVICE / CHIEF SOCIAL WORK OFFICER 1. REASON FOR REPORT 1.1. To inform the Committee of progress made regarding the initial implementation of the Three Conversation Model within Health and Social Care in Moray (HSCM). 2. RECOMMENDATION 2.1. It is recommended that the Clinical Care and Governance Committee considers and notes: i) the impact of the implementation of the Three Conversations Approach thus far; and ii) the future plans and next steps for this approach in Moray. 3. BACKGROUND 3.1. In 2021 HSCM commissioned Partners 4 Change to support the implementation of the Three Conversations Approach; the rationale was to facilitate the change management required to deliver health and social care in an increasingly competing and demanding environment. This relationship- based approach uses three distinct conversations to understand what really matters to people and families, to work intensively and effectively with people in crisis and to support people to build a good life. Appendix 1 provides a 3 Conversations visual. 3.2. The approach is underpinned by a set of values and principles which includes: • Recognising that people and families are the experts in their own lives and that practitioners need to listen hard and use the resources and skills available to build on people’s wishes and strengths, connecting them to the right people, networks and supports to help them live as independently as possible. Item 8. Page 43
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• Stop passing people around like parcels for someone else to deal with somewhere else in the system. Practitioners will start working with people as quickly as possible until they are safe and their plan for a good life is working. • Response in a crisis is critical. Rather than ‘assessing people for services’ in a time of crisis, workers will ‘stick like glue’; eligibility and longer-term supports will not be considered until the crisis is over. • Our current health and social care system is process-heavy. This bureaucracy can be complicated and time-consuming and can actually be a barrier to the person getting the support they need when they need it. The 3 Conversations Approach focuses on reducing bureaucracy and streamlining processes so that practitioners can use their time and skills more effectively working directly with people and families. 3.3. To implement this approach, three innovation sites have been established; these are in the Hospital Discharge Team, the East Community Care Team and the Learning Disability Team. Practitioners within these innovation sites have been allowed to work differently using this approach to change and modify practice and the processes which support this. Each innovation site went through a process of co-design and presented a site proposal to the ‘Making It Happen’ Group (MIH), which is the governance body for this approach in Moray. All of the proposals were discussed and agreed by this group. Practitioners from the innovation sites attend a fortnightly MIH meeting to update the group on their work and to seek help with any barriers or challenges to the implementation of the approach. 3.4. Innovation sites are supported throughout the co-design process and the innovation period by consultants from Partners 4 Change. This includes weekly reflective meetings where practice and progress can be discussed and learning shared. Innovation periods generally last for around 13 weeks. 3.5. Throughout the innovation period, data and evidence has been gathered to allow evaluation of the impact of the approach. The raw data suggests that, across the three innovation sites since 18 April 2022, 371 people either referred into or already known to services have been seen and 403 conversations have been held and recorded. The innovation sites have not reached the evaluation stage as yet; formal evaluation will provide clearer data around this and will allow some comparison with the previous way of working. 3.6. As part of the innovation site, both the East Team and the Hospital Discharge Team have taken work directly from the Access Team waiting list – i.e. people who were unallocated and awaiting a Social Worker. In April 2022, the East Team took a total of 33 people, with a postcode within the east of Moray, from the low/medium waiting list. All 33 people have now been seen; one had been on the Access Team waiting list since May 2020. Of the 33 people, 12 needed no further input from Social Work following a conversation. At the start of the innovation period, the East Team had over 100 people waiting a review of their support. This number reduced by around 20 under the new way of working. The number of overdue reviews has remained static for some weeks now, mainly due to staff absence/holidays/other work pressures but it has not increased, and prior to the innovation sites, the number was increasing steadily. 3.7. The Hospital Discharge Team now have a process whereby if someone is admitted to hospital and they are on the Access Team waiting list (awaiting Page 44
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allocation of a worker), they are seen by a worker from the hospital team and removed from the Access team list. Since 18 April 2022, 44 people have been removed from the Access Team waiting list. 3.8. Initial feedback from innovation sites indicates that workers are able to spend more face to face time with people; it is easier to achieve and maintain a person-centred focus; requests for support are being responded to more quickly; and time spent at a computer doing the bureaucracy has reduced. Workers have reported that the approach encourages and supports them to explore different options to support people other than formal/commissioned services, thus reducing reliance on these scarce resources. 3.9. Each innovation site meets in a daily huddle and there is clear evidence to suggest that these daily meetings are a positive development within teams. They allow for quicker and more responsive decision-making, greater autonomy and flexibility of approach. Another benefit has been improved peer support and a sense of team-working which practitioners felt had been missing since the introduction of home-working due to the COVID-19 pandemic. At evaluation time, all workers will contribute directly to the formal evaluation of their innovation site and as part of this they have been asked to submit confidential electronic questionnaires so that they are able to provide honest and direct feedback about their experience of the approach. 3.10. Feedback is also being sought directly from people and families who have been supported by practitioners from the innovation sites using this approach. This will form part of the formal evaluation but the initial indications are that people have had positive experiences; they have felt listened to, that workers understood them and that their choices and wishes have been respected and valued. There is also a sense from the feedback (Appendix 2) that informal carers feel valued and listened to by workers and that support provided is crucial in enabling them to continue in their caring role. 3.11. Challenges and difficulties highlighted by the innovation sites in implementing this approach include: • Authorisation - Social Workers being able to authorise budgets and support up to a set monetary amount was a goal set within the East and Learning Disability Team proposals to allow great autonomy and to reduce time spent by managers doing this. However, current organisational financial systems do not support this but work is underway with Finance to address these issues. • Paperwork/recording – New documentation has been developed on Care First which innovation sites have been using. These are very different to previous assessment forms. Although there are positives here (less cumbersome, quicker to complete, more person-centred) there are also some difficulties reported by those using it (does not suit all situations). Following the formal evaluation, work will be undertaken to review all paperwork and agree a format to take forward. The Three Conversations Approach operates on the principles of relevance and proportionality to reduce the amount of recording but it is acknowledged that this should not be to the detriment of professional standards and statutory requirements. Page 45
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• Infrastructure – Innovation sites still work within the wider health and social care systems and processes and this caused tensions at times. The processes which support other roles and services, in conjunction with unprecedented system pressures, have meant the principles of the approach have had to be compromised and this has caused frustration with those trying to work differently. Work is underway to improve understanding of the approach and the necessary collaborative working. • Interaction between teams - New processes and ways of working have had an effect on how Social Work teams interact and also how/when transfers between teams takes place. This has caused some challenges and difficulties, particularly between the East and Hospital Team innovation sites; discussions are continuing to address these issues 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1. Although innovation sites have been within Social Work Teams, significant work has been undertaken to promote this approach within the wider health and social care network and to improve collaboration with partners. There has been evidence of success with regard to this within the Hospital Discharge Team and improved collaborative working with external partners (Quarriers, North East Sensory Services and Third Sector Interface Moray) which has helped to achieve better outcomes for people and families/carers. This work with partners and stakeholders needs to continue. 4.2. The East Team and Hospital Discharge Team are approaching the end of their respective innovation periods and are in the process of preparing their formal evaluations, supported by Partners 4 Change. These will be presented to the Making It Happen Group on 09 and 23 August respectively. The Learning Disability Team will also present a formal evaluation once their innovation period has ended (around the end of August 2022). Once these findings are known, learning will be taken and incorporated into future practice. 4.3. Partners 4 Change are soon to start work with the Access Team to co-design an innovation site within their service. This will have a focus on reducing and streamlining process and systems (screening, triage etc.) with the aim of getting to the person more quickly and hopefully avoiding the build up of waiting lists. The work undertaken by the East Team with new people being referred showed that often a quick solution can be found to avoid people waiting on lists because they are not seen as a higher priority. This also reduces the likelihood of people becoming embedded in services and systems at too early a stage. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Moray Partners in Care 2019 – 2029” The Corporate Plan 2024 “Adults and Older People” identifies supporting health and well-being through community-based activities as a priority with an emphasis on early intervention and prevention. The Three Conversation Approach has a strong Page 46
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focus on early intervention and prevention and making best use of community resources. This report highlights the pressures on delivering this if the appropriate processes, systems and practice ethos are not in place. The LOIP priority “Empowering and Connecting Communities” recognises that Moray has an above average number of older people and identifies the challenges around delivering services with limited resources, often in rural areas. An aim is to achieve the benefits experienced by enabling quicker access to health services and social opportunities for people. This report identifies that a new approach is needed to address these issues. The Three Conversations Approach has allowed HSCM to make a start on this change process but the momentum needs to be maintained. Within the Moray Integration Joint Board Strategic Plan “Moray Partners in Care 2019 – 2029”, Theme 3 is identified as “Partners in Care; making choices and taking control over decisions affecting our care and support”. This is a strong improvement theme within social work practice and is embedded within the Self-directed support legislation and new standards. In order to achieve this, HSCM needs support to transform ‘old ways’ of working and ensure the renewed focus and direction provided by the Three Conversations Approach is maintained. (b) Policy and Legal As well as a means to facilitate change within health and social care, the Three Conversations Approach was also intended to be a means by which to implement the Self-directed Support Framework of Standards (Social Work Scotland), also outlined in the HSCM Action Plan for Embedding the SDS Standards. Moray is one of three test sites in Scotland undertaking this exercise. Again, the success of this will be considered as part of the formal evaluation process. (c) Financial implications There are financial implications if the support from Partners 4 Change is to continue beyond the agreed contract period. (d) Risk Implications and Mitigation There is a risk that without the support of Partners 4 Change, the progress made thus far in achieving change within the service will be lost. If HSCM are to continue this change management process on their own, then significant planning, preparation and resources will need to be available to maintain this momentum and mitigate risks. (e) Staffing Implications The impact on staffing levels and staff welfare as a result of the COVID- 19 pandemic should not be underestimated. Each innovation site has experienced this at different times and in different ways but there is consistency of agreement that lack of staff availability has impacted the ability of the innovation sites to carry out the work as planned with a Page 47
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resultant impact on people and their families. Some teams are operating with a number of vacancies and recruitment of staff across health and social care remains challenging. (f) Property The Hospital Discharge Team are currently trying to secure office space within the Dr Gray’s Hospital site to improve the response times and re- activeness of the team when working with people in hospital. (g) Equalities/Socio Economic Impact An Equality Impact Assessment is not required as there will be no impact, as a result of the report, on people with protected characteristics. (h) Climate Change and Biodiversity Impacts No climate change or biodiversity impacts have been identified with regard to this recommendation. (i) Directions None arising directly from this report. (j) Consultations Consultations have taken place with the following staff and their views have been incorporated into this report: Charles McKerron - Service Manager (HSCM) Jane Mackie - Head of Service / Chief Social Work Officer. Tracey Sutherland, Committee Services Officer 6. CONCLUSION 6.1. It is acknowledged that health and social care services and systems continue to face unprecedented pressures as a result of increasing demand and more recently, the impact of the COVID-19 pandemic. The delivery and design of services needs to change to respond to this competing and demanding environment. The Three Conversations Approach was commissioned by HSCM for this purpose and although some progress has been made through the work of the innovation sites, challenges and barriers remain. It is perhaps too early to draw conclusions from this innovative piece of work. Further information from the formal evaluation of the three existing innovation sites is required in order to inform longer-term planning and decision-making. 6.2. Partners 4 Change continue to work with HSCM to support the existing innovation sites and further innovation sites are planned. However, this support is time-limited so provision will need to made within HSCM to continue the support of this change management if their involvement is to end. There appears to be a clear message from the majority staff within the innovation sites that they do not wish to return to the ‘old way’ of working whilst acknowledging that further changes and improvements are required. Page 48
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Author of Report: Sammy Robertson, Consultant Practitioner in Social Work Background Papers: Ref: Page 49
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The 3 Conversations –what do we mean? APPENDIX 1 Item 8. Page 51
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Appendix 2 Three Conversations Approach – Stories of Difference. I know who to contact if I need help in the future and the worker made me feel it was ok to do this. I feel like I'm not on my own - you often feel on your own as a carer. Somebody listened to me. Worker made me feel at ease. Mum obviously felt at ease because she opened up to the worker who was a lovely lady. The worker speeded things up. Dad had been in hospital a while and I felt like we were left on a limb. Things moved quickly once the worker got involved. She found a connection with dad even though they only met twice and he is hard of hearing. They had a common interest (bowls) so that helped. The additional support arranged by the Social Worker has taken the pressure off me as a carer. He is safer now because he has the support he needs at mealtimes and I don't have to worry about him choking. The SW was so good and so lovely. When she came out she was great with him and completely understood the situation. It was nice that she also understood my situation as well as his, my needs are often overlooked… Item 8. Page 53
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REPORT TO: MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE ON 25 AUGUST 2022 SUBJECT: UNMET NEED IN HEALTH AND SOCIAL CARE MORAY BY: JANE MACKIE, HEAD OF SERVICE/CHIEF SOCIAL WORK OFFICER 1. REASON FOR REPORT 1.1. To update the Clinical and Care Governance Committee of the current position on unmet need within Health and Social Care Moray (HSCM). 2. RECOMMENDATION 2.1. It is recommended that the Committee: i) considers and notes the current situation within Health and Social Care Moray and the mitigation actions that have been introduced; ii) notes the continuing additional pressures placed upon Health and Social Care Moray staff; and iii) recognises the fragility of any improvements and the long-term impact on staff. 3. BACKGROUND 3.1. The impact of the COVID-19 pandemic continues to place a significant burden on health and social care staff. Patients, particularly the elderly and frail, are facing delays before they can leave hospital to receive appropriate care elsewhere, be that back at home, at a community hospital or residential care. There was a surge in cases this spring that petered out in May. Although the highest number of cases recorded in a day was almost half the January peak, this outbreak lasted longer than previous surges (Figure 1). It has been followed by a much smaller spike that peaked towards the end of July and appears now to be over. However, the testing policy in Scotland changed on 1 May 2022, which inevitably led to a reduction in the quantity and quality of the available data on positive cases in the population. Consequently, the data Item 9. Page 55
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before and after 1 May 2022 is not comparable, and is only used here to indicate that there was a spike in number of positive cases over the summer. 3.2. The impact has been felt across Scotland with corresponding waves of increase and reducing hospital admissions. The data suggest that the most recent wave is coming to an end, but the number of admissions are considerable higher than a year ago, placing additional pressure on hospital beds (Figure 2). As noted in the previous report there has been little or no chance for health and social care staff to recuperate and recover, and there is no indication that there will be a significant lull before the usual increase in demand over winter. Note that data for hospital admissions due to COVID-19 is only published for Scotland as a whole and is not publicly available for individual health boards or local authorities. Figure 1: Positive PCR cases in Moray 1 Apr 21 – 31 July 22 (Public Health Scotland COVID-19 data) Figure 2: Hospital admissions in Scotland due to COVID-19 between 1 Apr 21 – 31 July 22 (Public Health Scotland COVID-19 data) 3.3. Nationally there has been higher than usual staff absence rates amongst both council and NHS employed staff for the first 6 months of this year (Figure 3). Amongst NHS staff there has been a dramatic reduction in absence due to COVID-19 compared to the peaks observed in January, March and early July. Indeed, at the end of May overall NHS staff absence in Moray was 4.2% 3.4. Moray Council employed staff absences have averaged 6.9% since May 2020, which is above the national average of 6.1%. However, for the week ending 5 August 2022, the latest data published by SOLACE, the figure for Moray was 7%. As the charts at Figure 3 illustrate absences have reduced for Council staff from over 11% in mid-March, suggesting the staffing absence rate is slowly reducing to a more typical level. Note that forecasting future trends from previous data during the pandemic has been almost impossible as new strains Page 56
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appear without warning and cause cases to rise again. Although the peaks tend to be getting smaller and the number of people unable to attend work appears to be reducing. Figure 3: NHS Scotland Covid-19 staff absences since April 2020 (TURAS data intelligence1) and Scottish Council staff absences since May 2020 (SOLACE) 3.5. Demand for health and social care service are likely to continue to grow as Moray’s population continues to age. Figure 4 is taken from the National Records of Scotland (NRS) principal population projection for Moray and is based on 2018 data. In mid-2021 NRS estimated there were 20,241 residents of Moray aged 66 years and over. The NRS principal population for 2043 estimates that this figure will have risen to 27,978 over the same period. At the same time the working age population (currently defined as 16 – 65 year olds) is estimated to decrease by almost 13% from 60,228 to 52,409. It will be interesting to see the impact of the current census on this population projection when the data become available. Figure 4: NRS principal population projection for Moray in 2033 by age and sex 3.6. There are 6 categories of unmet need that are routinely monitored that provide an overview of the number of people waiting for a social care assessment, a package of care, or a statutory social care review. Additionally, the number of hours of care not yet provided are also monitored. A weekly summary of trends is provided for managers (see Appendix 1). Overall, the level of unmet need remains much higher than it was before the pandemic. The latest trends for each measure are summarised below: 3.6.1. Number of people waiting for a social care assessment. The number of people waiting for a social care assessment overall has gradually increased since the end of April, rising from 110 to 156 at the start of August. Cases classified as URGENT have also risen over the same period from 25 to 48. These numbers continue to be well above the numbers waiting in September last year (8). Cases classified as HIGH 1 https://turasdata.nes.nhs.scot/data-and-reports/other-workforce-statistics/covid-19-staff-absence/ Page 57
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are half what they were a year ago (73), but have remained between 43 and 48 for the past 2 months. The East Team took over responsibility for assessing the people classified as MEDIUM and LOW priority through the innovation site that they have set up as part of the roll-out of the Three Conversations Approach. In the first week they were able to reduce the waiting list for people in the MEDIUM and LOW priority groups from 80 to 49. The numbers in this category have remained in the 50s since this change was introduced. 3.6.2. Number of people assessed and waiting for a package of care. During the second half of 2021 there was a steady increase in the number of people who had received a social care assessment but had yet to be provided with a package of care from 94 to 152. During the first 3 months of 2022 the number of people waiting remained reasonably static. From April to June there was a steady reduction in the numbers, but in recent weeks the number of people waiting for a package of care is back to the previous level of approximately 150. Approximately 85% of people are waiting in the community and the other 15% are in hospital. The numbers remain at one and a half times larger than last August. 3.6.3. Number of people in receipt of a care package and waiting for a statutory social care review. For most of 2022 the number of people who are receiving a care package has decreased steadily week by week from 300 to 230. The numbers are down considerably from the 339 recorded in September 2021, but are still high. 3.6.4. Number of hours of care yet to be provided for individuals in hospital. The number of hours not yet provided for people in hospital varies weekly, but had gradually risen over time from 226 hours August 2021 to over 450 hours in March 2022, but despite a small spike in June has now reduced to 322 hours. If this trend continues then within the next 2 or 3 months the outstanding hours could be back to August 2021 levels. 3.6.5. Number of hours of care yet to be provided for individuals in the community. Similarly, there had been an increase for people in the community over the same period from 266 hours to 778 hours at the end of January this year. Since then the number of hours not provided have reduced steadily to 439, despite a reversal of the trend at the start of July 2022. The number of hours not provided remains 173 higher than the position in August 2021 figure. 3.6.6. Number of hours of care assessed as needed and not provided for those in receipt of a care package. Since the start of April this year the number of hours of care not delivered to residents receiving a care package reduced steadily from 417 to 331 hours at the end of June. This was followed by a jump to 514, and the latest figure showed a reduction to 467 hours. This figure is much higher than in September 2021 when for 4 weeks this figure was consistently below 250 hours. 3.7. The status of care homes and care at home services, both internal and external is monitored regularly each week by the Care Homes Oversight Group. A RAG (Red/Amber/Green) rating is used to identify the ability to accept clients or deliver services. For the most recent data (27 July 2022) 13 out of the 14 care Page 58
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homes in Moray were assessed as Green, and just 1 as Red and unable to accept patients. This demonstrates a marked improvement from 18 January 2022 when there were only 4 care homes rated Green, 4 rated Amber and 6 at Red (Figure 5). Figure 5: Moray care home availability – December 2021 to 27 July 2022 3.8. There were 27 Care at Home external providers rated Green on 2 August 2022, none at Amber and 8 at Red with either a member of staff or a client with a positive confirmation for COVID-19. Again, this represented an improvement on the situation as reported on 16 March 2022, with 16 external providers rated Green, none at Amber and the remaining 21 at Red. Care at Home Day Services had all locations at Green at the end of July 2022. The Care @ Home team remain Red with COVID-19 cases and 22 non-COVID related absences. 3.9. Overall, the situation is showing improvements compared to March and April this year, and the service is closer to capacity. However, it is likely capacity shortfalls will continue to be faced in the short-term. Furthermore, the continuing levels of unmet need noted above is still contributing to high numbers of patients facing delays in being discharged from hospital. 3.10. HSCM is not alone in facing these demands and shortfalls. Across Scotland Health and Social Care partnerships are recording higher levels of non-COVID absences, and staff vacancy rates are stable, but not reducing. The number of people waiting for an assessment has increased by 8% since November, although the number of people waiting for a package of care has reduced by 2% over the same period. Hours of care across Scotland has increased by 3%2. The Director of Public Health developed a social care oversight and assurance return, to identify areas of challenge within health and social care partnerships during the pandemic. As the pandemic response has changed, the number of reported issues relating to COVID-19 have fallen. Instead, key themes such as general inability to recruit; lack of financial viability in light of the cost of living crisis; and the withdrawal of insurers from the care sector in light of Operation Koper3 are highlighted instead. 3.11. The impact of all of the above factors is illustrated by the rising numbers of delayed discharges being reported since April 2021, which remain well above 2 Taken from the minutes of the GOLD meeting held on 26 July 2022 3 The Police Scotland operation to collate information from Care Homes and Partner Agencies with regards to COVID-19 deaths within Care Home settings https://www.scotland.police.uk/access-to- information/freedom-of-information/disclosure-log/2020/december/20-2008-c19-operation-koper- deaths-in-care-homes/ Page 59
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historic levels (Figure 6). As the chart illustrates the recovery is fragile and any pressure on the system quickly reverses any gains. However, with fewer staff being away, and fewer care homes being closed due to COVID-19 cases, there are signs that the July peak of 51 people not able to leave hospital is over and numbers are reducing. On 8 August there were 42 people waiting, still well above the target of 10, but an improvement on just 2 weeks ago. Figure 6: Average number of delayed discharged patients in Moray per week (1 Jan 2021 to present) 3.12. Delayed discharges remain high across Scotland, but there were fewer people waiting at the June census point (1,671) than in May (1,690), but average delays had risen from 21 to 23 days over the same period. In June 2022 there were 36% more days spent in hospital than in June 2021 (50,340 days compared to 37,136 days)4. 3.13. In Moray the average number of people experiencing delays in being discharged form hospital has remained below the national average since the start of the pandemic apart from a blip last winter (Figure 7). Since Moray has a higher proportion of residents aged 65 years and older compared to the Scottish average, it is not unexpected that the rate per 1,000 of the population in this age group in Moray is above the Scottish average with 1.8 cases per 1,000 people (Figure 8). There is no clear indication of the numbers starting to reduce. Due to the small population size of Moray there is a much larger daily variation in numbers, but the trend appears to be increasing for both the number of daily delayed discharges and the rate per 1,000 for 65 year olds and older. An action plan is attached describing how services are working to reduce delayed discharges across Moray (Appendix 2). 4 Delayed discharges in NHS Scotland monthly (PHS) - Figures for June 2022 https://publichealthscotland.scot/publications/delayed-discharges-in-nhsscotland-monthly/delayed-discharges- in-nhsscotland-monthly-figures-for-june-2022/#section-1 Page 60
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Figure 7: Delayed discharge patients each day, May 2020 to April 2022 (SOLACE data) Figure 8: Delayed discharge patients (65 and over) each day, May 2020 to April 2022 (SOLACE data) 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1. Previous reports have included the observations made by Dr Gray’s Hospital (DGH) emergency department that patients were more acutely unwell or their condition had deteriorated more than was the case prior to the pandemic. In the previous quarterly report data suggested that the hours of care required from the Homecare Team by individuals are rising, with frailer people regularly requiring more than one carer, or more visits each day (or both). Between April 2021 and April 2022 the average number of hours of care provided to individuals by the Care at Home team rose by 17% from 13.1 to 15.3 hours. Page 61
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During quarter 1 the hours reduced slightly to 14.7 hours; time will tell whether this is the new baseline level (see Figure 10). Figure 9: Average number of hours of care per person – Care at Home (April 2021- June 2022) 4.2. Mitigation measures have been put in place and were described in the previous report. The following sections provide brief updates. 4.3. The Discharge 2 Assess team (D2A), which has been operating for a full year having gone live on 3 August 2021, is working at full capacity to provide early supported discharge for Moray patients from DGH, Moray Community Hospitals, Aberdeen Royal Infirmary (ARI) and Raigmore. A report on the impact of D2A was approved by the Moray Integration Joint Board at their meeting held on 26 May 2022 (Minute 9 refers). The report concluded that D2A was meeting the criteria in the initial business case, and was effective in meeting the outcomes for patients. 4.4. The recruitment cell continues to work closely with Moray Council Human Resources team to bring people into HSCM, and is working well. For example new members of the care at home have been recruited every month this year except July, with 2 more joining than leaving overall (Figure 11). Figure 10: Care at Home - new staff joining and staff leaving since April 2020 4.5. The previous report identified the adoption of the Three Conversation model to reduce bureaucracy and increase our responsiveness to people who approach us for support. Three of the innovation hubs are now in place: a Hospital Team innovation site, the East Team, and Learning Disabilities. The impact of 3- conversations is being examined and analysed, but initial feedback suggests that people requiring support and their families prefer this way of working as it Page 62
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provides better outcomes, more quickly. Social workers report being able to create a better rapport with people and families, gain a better understanding of the person and their needs, and spending less time on paperwork, 4.6. HSCM managers were asked for their thoughts on the current situation and this is a summary of their concerns and the issues being faced currently: 4.6.1. The fragility of staffing levels to meet demand, caused by absences due to COVID-19 and self-isolation requirements, which are unpredictable with peaks and troughs occurring in absence levels right back to March 2020. There are also absences due to other illnesses that have also increased since March 2020 (including stress due to working excessive hours to provide safe cover with reduced staff present). There was a reduction in contracted hours for care workers during the latter part of the pandemic, but staff are starting to request additional hours so the situation may be improving. Finally, there is a lack of young people willing to take-up social care work (Department of Work and Pensions data). 4.6.2. Care Home capacity from March 2020 to the present has been difficult to predict. Care homes have not been able to provide the pre-pandemic number of beds, with availability varying from week to week. The numbers were particularly low at the start of 2022. In addition, available beds are not necessarily in the right place for people requiring them (the impact of a rural and dispersed population). 4.6.3. There is considerable additional financial strain on care providers and care home owners. Since the start of the year price increases for fuel, heating and interest rates have added pressure to companies to remain solvent. For example Assist Homecare (Scotland) Ltd, operated in North Ayrshire, went into liquidation on 2 August 2022. The impact for Moray care home providers and care homes is not yet clear. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Moray Partners in Care 2019 – 2029” This report highlights the pressures on delivering the Corporate Plan 2024 priority of “Adults and older people”. In particular the aim of ensuring that people are supported at home or in a homely setting as far as possible through a HomeFirst approach and multi-professional teams at a local level. The LOIP priority “Improving wellbeing of our population” recognises that “health and wellbeing make a significant contribution to life experiences and can be adversely affected by many factors, including mental…health.” This report identifies additional pressures that HSCM staff are now facing and that will need to be addressed if the LOIP priority is to be met. “Theme 2: Home First” of the Moray Integration Joint Board Strategic Plan “Moray Partners in Care 2019 – 2029” notes that older people very Page 63
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quickly lose their independence through loss of confidence and often reduced mobility when admitted to hospital. The current situation is causing people to be delayed in hospital and is likely to prevent some residents from functioning as they did prior to admission. (b) Policy and Legal None directly associated with this report. (c) Financial implications None directly associated with this report, although the cost of providing care packages may rise due to patients presenting with higher morbidity than previously. (d) Risk Implications and Mitigation The risks to the service from the pandemic, and the winter period, have been realised. The mitigation measures are discussed in the report. There continues to be a risk of harm to individuals who are not receiving support that has been identified they require and also for those awaiting to be assessed. (e) Staffing Implications Staffing levels, availability of staff and their health and wellbeing are core factors at the heart of this report. Support for staff continues to be a vital role for managers. (f) Property None directly arising from this report. (g) Equalities/Socio Economic Impact An Equality Impact Assessment is not required because there will be no impact, as a result of the report, on people with protected characteristics. However, it should be noted that Public Health Scotland have identified that people who live in poorer areas in Scotland are more likely to die early from disease and have more years of ill health, including mental wellbeing and depression. Although no data are available it is likely that the additional time spent in hospital waiting for suitable care packages to be put in place will have a greater impact on Moray residents from deprived areas. (h) Climate Change and Biodiversity Impacts No climate change or biodiversity implications have been determined for this policy/activity. (i) Directions None arising directly from this report. (j) Consultations Consultations have been undertaken with the following staff and their comments have been included where appropriate: Corporate Manager (HSCM), Head of Community Care, and Consultant Practitioner in Social Work, HSCM service managers and Tracey Sutherland, Committee Services Officer, Moray Council. Page 64
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6. CONCLUSION 6.1. Unmet need levels in Moray remain higher than pre-pandemic levels, both for the number of people affected and the hours of care required to be provided. There is insufficient evidence to state with certainty the impact of the various mitigation measures that have been put in place. However, although the overall situation is not improving significantly it appears to have not deteriorated. Author of Report: Carl Bennett, Senior Performance Officer Health and Social Care Moray Background Papers: Ref: Page 65
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APPENDIX 1 Care Homes Oversight Group Weekly Unmet Needs Report - Week ending: 7 August 2022 Item 9. Page 67
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ACTION PLAN – REDUCING DELAYED DISCHARGES IN MORAY Context Moray delayed discharges remain higher than national averages. Aim to tackle issue with a 2 phased approach. Phase 1 = Current Delayed Discharges (actions 1 to 5) and Phase 2 = Prevention of future Delayed Discharges (remaining actions) Action Task Lead/Support Target for Completion Resource Required Notes Actual Completion Date RAG PHASE 1 1. Create more Care at Home Capacity Create more capacity in the Access Team Roddy Huggan Jane Mackie Lesley Attridge 26/07/22 Commissioning Team, internal and external providers Contractual negotiations ongoing Update 27/07/22 – Contracts should be in place by the end of the week which should increase care at home capacity 03/08/22 - Two Consultant Practitioners to support Access Team temporarily 09/08/22 - LAt highlighted at Response Group that POC information going to external provider does not give them enough information to progress the POC – LA to investigate and feedback. Resolved 10/8/22 2. Divert Capacity to Delayed Discharges as a priority. John Campbell 27/07/22 Care at Home Services A temporary measure to reduce Item 9. Page 69
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Meet with CITY colleagues around 1 stop allocation of care, prioritise DD’s and Palliative Care/EOL patients supported by National Care Eligibility Criteria Carers who cannot drive, support transport needs Process in place for carers to identify increase and decrease of care at home POC Alison Smart/Laura Sutherland/Jamie Fraser Cheryl St Hilaire John Campbell 11/08/22 11/08/22 Volunteers Carers the delayed discharges Transport for carers who don’t drive to increase hours of care at home Potential release of care at home hours Update 01/08/22 - AS/LS met with JC, legal issues around prioritising care for DD’s, discussed with CITY colleagues who use Eligibility Criteria to prioritise care for DDs, AS/LS/JF to meet with CITY to confirm process. 03/08/22 - Home First Team to spend day in CITY meeting those involved in the allocation of POC on 26/08/22 - invitation open to anyone who wants to attend. 3. Assess capacity of CRT, divert capacity to discharging delayed patients (action 1 and 2 will support onward care requirement if required two weeks from discharge) and supporting at front door Anita Gouldsbrough 27/07/22 CRT team A temporary measure to reduce the delayed discharges 09/08/22 Page 70
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of ED to avoid unnecessary admission Update 29/07/22 - Capacity in CRT to support the discharge of those delayed in DGH – Kay McInnes to progress with Anita Gouldsbough 01/08/22 -3 Patients identified to be discharge from DGH 09/08/22 - Process in place for KI and AG to discuss capacity in CRT 4. Continue to use D2A to provide early supported discharge from DGH Dawn Duncan/Katie Parry 27/07/22 D2A team Update 29/07/22 - currently working with patients of a higher acuity than normal and at full capacity. If START resource is freed up, the pathway from D2A to START/Care will create capacity and flow. AHP services in Community Hospitals continue to regularly review patients –these patients are on maintenance programmes 5. Monday Huddle – redesign process Jim Brown/Lisa Anderson/Kay McInnes 01/08/22 DD Team Ensures actions are captured and managed appropriately, detailed DD trajectory information needs to be available for SLG and SLT to see at any time Update 02/08/22 - LS/AS/JF to meet with JB and LA to develop the DD information and action process. 03/08/22 - Met with LAn and JB – test of change for huddle, use a problem-solving approach, plan to implement in 3 weeks, ensure senior decision maker for each patient Page 71
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6. Daily meeting to discuss unmet need and DDs with all providers Implement a Care Navigation Centre that holds all available Care at Home availability John Campbell SLG Will improve access to information and improve access to care at home Create a one stop Centre that holds all care at home capacity in the system, can be access by all professionals Update 7. Communication – Public, MSP’s and HSCP Moray Teams SLG Develop a collective concern for Delayed Discharges, ensure understanding of the reality Update 8. Challenge 4 x a day care and consider TEC, Medicines Management, and single- SLG Patient Centred Care Page 72
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handed risk assessments (Aberdeenshire Model) Develop processes to support staff Update 9. Analyse ‘transfers of care’ (D2A, START, BROKERAGE, CRT, DN, FNCT, VARIS, LOXA, JUBILEE CT, CARE HOMES AS/LS/JF Be clear on the pathway for patients when transitioning Update PHASE 2 1. Establish Targets for Unmet Need Home First Team August 22 Develop an alert system so that action can be taken when unmet need reaches a warning level 2. Produce a Dashboard to measure and assure Home First Team August 22 Ensure assurance that DD systems and processes are working Page 73
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3. Carry out a Self-Assessment of all Delayed Discharge processes focussing on: - • Leadership and Performance • Engagement and Accountability • Improving practice • Demand and Capacity (develop a meaningful Delayed Discharge Pathway) • Family and Friends involvement Home First Team August 22 Have a baseline of where we are now and plan for what we need to do 4. Tackle the medium to low waits for assessment in the community by utilising: - • Realistic Medicine • 3 Conversation Model • 3rd Sector • Volunteering • SDS (implementing March 2022 guidance) SLG August 22 Ensure Medium and Low waits for SW assessment do not occur due to slick transfer of care to services other than Care at home, avoid disabling the family and those that care for an individual 5. Divert resource to reviewing current care packages to create capacity SLG August 22 There are 271 outstanding reviews, undertaking these Page 74
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Ensure carer involvement in the review of packages of care MDT discussions if we believe we can reduce packages of care could increase available capacity 6. OT in Primary Care addressing unscheduled care and frailty. Twice weekly huddles with Local Authority OT to prevent duplication Analyse OT unmet need, particularly critical Dawn Duncan AS/LS/JF August 22 Upstream management of patients who may be admitted 7. Recruit to a team of ‘generic HCSW’s who can participate in all areas of the delayed discharge pathway LANARKSHIRE MODEL SLG August 22 Always have a team available to manage periods of increase activity (Winter) 8. Make SDS implementation a priority (divert the Quarriers SDS post from Hospitals to the community). Make SDS mandatory training for those who discuss discharge with patient and families. Aim to reduce care hours required by using SDS creatively Michelle Fleming August 22 The key to reducing waits for care, evidence shows that even those assessed for high levels of care at home can be safely managed using alternative solutions Page 75
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9. HR and Recruitment to apply ‘special measures’ to recruitment of all frontline vacancies in Moray HR Hub August 22 Make every opportunity for recruitment count, get people quickly into post before they find other employment 10. Scale up intermediate care (hospital without walls) Home First Team October 22 Have a suite of options for patients other than admission to hospital or care at home 11. Increase screening for Frailty (Frailty Team) Develop ‘outreach’ support in the community Frailty Team October 22 Re-look at over 75 community assessments – this can be done in conjunction with flu/adult/COVID immunisations, manage problems before they become a crisis 12. Review discharge planning and the role of MDT’s and golden ward rounds, Huddles Home First Team October 22 What are the outcomes from these? What do we achieve? 13. Assess Moray’s risk averse status amongst front line staff and manage results Home First Team October 22 Varying levels of risk appetite amongst frontline Page 76
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staff, need to have a standardised approach within a governance framework 14. Criteria Led Discharge Pilot DGH DGH October 22 Potential for reducing delays to discharge, will improve early pharmacy and transport requests 15. Combine H@H and HWW to produce a Virtual Community Ward Home First Team October 22 Potential for reducing delays, patients return home earlier with medical support and review Page 77
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REPORT TO: MORAY INTEGRATION JOINT BOARD CLINICAL AND CARE GOVERNANCE COMMITTEE ON 25 AUGUST 2022 SUBJECT: STRATEGIC RISK REGISTER – AUGUST 2022 BY: CHIEF OFFICER 1. REASON FOR REPORT 1.1 To provide an overview of the current strategic risks, along with a summary of actions which are in place to mitigate those risks, updated August 2022. 2. RECOMMENDATION 2.1 It is recommended that the Clinical and Care Governance Committee (CCG) agree to: i) consider and note the updated Strategic Risk Register included in APPENDIX 1; and ii) note the Strategic Risk Register will be further refined to align with the transformation and redesign plans as they evolve 3. BACKGROUND 3.1 The strategic risk register is reviewed regularly by the Senior Management Team as part of a robust risk monitoring framework, to identify, assess and prioritise risks related to the delivery of services in relation to delegated functions, particularly any which are likely to affect the delivery of the Strategic Plan. 3.2 The Moray Integration Joint Board (MIJB) Strategic Risk Register is attached to this report at APPENDIX 1 and sets out the inherent risks being faced by the MIJB, together with a current assessment on the level of the risks and mitigating actions being taken to reduce the impact of the risks. This report is presented to Audit Performance and Risk committee for their oversight and comment. 3.3 Risk scores are weighted, based on assessment according to their likelihood and corresponding impact, as per Section 5 of the MIJB Risk Policy. Item 10. Page 79
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3.4 The Strategic Risks received an initial review to ensure they align to the Moray Partners in Care 2019-2029 strategic plan which was agreed at MIJB on 28 November 2019 (para 13 of the minute refers). 4. KEY MATTERS RELEVANT TO RECOMMENDATION 4.1 The Risk Management Framework review was completed and outcome was approved by the Board on 25 June 2020 (para 9 of the minute refers). The approved Risk Appetite Statements have been included in APPENDIX 1. 4.2 Work initially overseen by NE Partnership continues to progress locally, in line with our Strategic Plan objectives. Hospital without Walls and Hospital at Home themes continue to be progressed through the Home First Programme. 4.3 The return to ‘business as usual’ from the Covid-19 pandemic continues to progress. However, these increases in demands for service are being faced by staffing resource that is reduced due to increasing sickness absence, staff vacancies, and annual leave. 4.4 The continued safe delivery of services is a priority and as such dedicated management time is being directed to support oversight of operational risks. Grampian Operational Escalation System (GOPES) continues to be utilised to assist in the identification of pressure points across the whole system so that they can be addressed and prioritised appropriately. 4.5 The ability to cope with unforeseen incidents continues to provide challenges to the systems. Most recently the national cyber attack on NSS Scotland systems and the drainage issue affecting clinical services at Dr Gray’s Hospital. Reassuringly, the contingency planning was effective and lessons learned will be considered. 4.6 There continues to be significant financial risk in the system which was highlighted at the MIJB development session on 6 June 2022. Future reports will incorporate updates to this committee. 4.7 Recruitment and selection to staff vacancies continues to prove challenging across several services. Staff wellbeing continues to be a key priority and a significant emphasis is being placed on ensuring that everyone is provided with the support that is readily available, where it is required. The issues that have been identified will be factored into the developing workforce plan and collaborative work will be progressed with partners across Grampian for recruitment. 4.8 Work continues with Allied, our partner for care at home on the outcome based commissioning approach. Delivering on outcomes, rather than a time and task approach, underpins the MIJB strategic principles of Home First and supports people having choice of how and where they are cared for. Care at home services and Allied continue to face staffing difficulties to meet service demand. Due to a range of factors, capacity is unable to meet demand which is demonstrated in the increase in unmet need. This situation is unlikely to improve in the short term, due to the increasing demand for care in the community. Page 80
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4.10 With the confirmation of the NHSG Portfolio arrangements across Grampian and the likely delegation of Children and Families and Criminal Justice services to MIJB, there will be a need for alignment of the governance frameworks and a transition phase to accomplish this effectively. 4.11 As plans evolve, the Strategic Risk Register will continue to be updated to ensure that it reflects any potential risks to realise the vision set out in our Strategic Plan. 5. SUMMARY OF IMPLICATIONS (a) Corporate Plan and 10 Year Plan (Local Outcomes Improvement Plan (LOIP)) and Moray Integration Joint Board Strategic Plan “Moray Partners in Care 2019-2029” The MIJB requires effective governance arrangements for those services and functions delegated to it and Risk Management systems are integral to this. (b) Policy and Legal As set out in the terms of reference, the Board has responsibility to provide assurance of the adequacy of the risk management framework. There are no legal implications arising from this report. (c) Financial implications There are no direct financial implications arising from this report however the Board should note the failure to manage risks effectively could have a financial impact for the MIJB. (d) Risk Implications and Mitigation This report forms part of the governance arrangements for identifying and managing strategic risks of the MIJB. The risks are outlined in the body of the report in section 4. (e) Staffing Implications There are no additional staffing implications arising from this report. (f) Property There are no property implications arising from this report. (g) Equalities/Socio Economic Impact An Equalities Impact Assessment is not required because there are no service, policy or organisational changes being proposed. (h) Climate Change and Biodiversity Impacts There are no impacts arising from this report. (i) Directions None arising from this report. (j) Consultations Consultations have been undertaken with the Senior Management Team, Iain Macdonald, Locality Manager and Tracey Sutherland, Page 81
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Committee Services Officer and comments have been incorporated in this report. 6. CONCLUSION 6.1 This report and appendices contains proposed risk appetite statements that, when approved, will underpin the MIJB approach to strategic decision making. Author of Report: Sonya Duncan, Corporate Manager Background Papers: held by HSCM Ref: Page 82
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Appendix 1 HEALTH AND SOCIAL CARE MORAY STRATEGIC RISK REGISTER AS AT 12 AUGUST 2022 Item 10. Page 83
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Appendix 1 RISK SUMMARY 1. The Moray Integration Joint Board (MIJB) does not function as set out within the Integration Scheme, Strategic Plan and in-line with Standing Orders and fails to deliver its objectives or expected outcomes. 2. There is a risk of MIJB financial failure in that the demand for services outstripping available financial resources. Financial pressures being experienced by the funding Partners will directly impact on decision making and prioritisation of MIJB. 3. Inability to recruit and retain qualified and experienced staff to provide safe care whilst ensuring staff are fully able to manage changes resulting from integration. 4. Inability to demonstrate effective governance and effective communication and engagement with stakeholders. 5. Inability to cope with unforeseen external emergencies or incidents as a result of inadequate emergency and resilience planning. 6. Risk to MIJB decisions resulting in litigation/judicial review. Expectations from external inspections are not met. 7. Inability to achieve progress in relation to national Health and Wellbeing Outcomes. Performance falls below acceptable level. 8. Inability to progress with delivery of Strategic Objectives and Transformation projects as a result of inability to resolve data sharing and data security requirements. 9. Requirements for support services are not prioritised by NHS Grampian and Moray Council. RISK RATING LOW MEDIUM HIGH VERY HIGH RISK MOVEMENT DECREASE NO CHANGE INCREASE The process for managing risk is documented out with the MIJB Risk Policy. Page 84
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Appendix 1 Description of Risk: Regulatory The Integration Joint Board (IJB) does not function as set out within the Integration Scheme, Strategic Plan and Scheme of Administration and fails to deliver its objectives or expected outcomes. Lead: Chief Officer Risk Rating: Low/ medium/ high/ very high MEDIUM Risk Movement: Increase/ decrease/ no change INCREASING Rationale for Risk Rating: The strategic plan “Partners in Care” 2019 to 2029 was developed and launched in December 2019. Membership of IJB committees has recently changed due to the elections in May resulting in 4 new Council members, the resignation of the third sector representative and the GP Lead and Non-Primary Care advisor. An amendment to the Scheme to increase membership by one from each of the partner organisations was ratified in March 2022 by the Scottish Government following due process and approval by Moray Council and NHS Grampian Board. During the initial Covid 19 response, normal business was suspended and emergency arrangements were implemented. IJB, CCG and APR meetings restarted during August 2020. Weekly meetings were instigated with Chair/Vice Chair and Chief Officer and these continue. Progress is underway to review the Strategic Plan “Partners in Care” 2019 to 2029 which will be completed by December 2022. Rationale for Risk Appetite: The Board, staff and providers across Moray are all committed to ensuring high standards of clinical care & governance through operational policies. Innovation and new ways of working may mean traditional regulations do not exist, or are contradictory. We will only take regulatory risks knowingly, following consultation with the relevant regulatory body and where we have clear risk mitigation in place. Controls: • Integration Scheme. • Strategic Plan “”Partners in Care” 2019 to 2029 • Governance arrangements formally documented and approved by MIJB January 2021. • Agreed risk appetite statement. • Performance reporting mechanisms. • Consultation with legal representative for all reports to committees and attendance at committee for key reports. • Standing orders have been reissued to all members Mitigating Actions: Induction sessions held for new IJB members after May elections. . IJB member briefings are held regularly as development sessions. 1 Page 85
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Appendix 1 Conduct and Standards training held for IJB Members in June 2022 provided by Legal Services . SMT regular meetings and directing managers and teams to focus on priorities. Regular development sessions held with IJB and System Leadership Group Strategic Plan and locality management structure is in place The work that has been progressed through the Covid19 response has escalated developments in some areas as a matter of priority. This has been achieved through collaborative working with partner organisations and the third sector. Assurances: • Audit, Performance and Risk Committee oversight and scrutiny. • Internal Audit function and Reporting • Reporting to Board. Gaps in assurance: The Covid 19 Response caused a delay in producing the Transformation Plans which in turn has impacted on communication and engagement with staff and partners in respect of the intended outcomes. Work is underway on the refresh of the Strategic plan and will incorporate the work being taken forward for Self-Directed support, Three conversations, Locality Planning, Hospital at home and Hospital without walls. A delivery plan will be developed alongside the refreshed Strategic Plan. Current performance: Scheme of administration is reported when any changes are required. Legal advisors are currently working on the requirements to the integration scheme in relation to the proposed delegation of Children’s and Families and Justice Services. Report presenting the Strategic Plan, Communication Strategy, Organisational Development and Workforce Plans, Performance Framework and the draft Transformational Plan were presented and approved at MIJB on 28 November 2019 Governance Framework was approved by IJB 28 January 2021.Re-appointment of Standards Officer agreed by IJB 31 March 2022 Members Handbook has been updated and circulated to all members in June 2022. Comments: Strategic Planning and Commissioning Group approved the generic Terms of Reference and Chairs of the transformation boards at the meeting on 19 December 2019. It was intended that these boards would be established by April 2020 however this work has been on hold due to Covid19 and is being restarted but will incorporate the changes Covid is causing on ways of working and will recommend a revised way forward. The interim Strategy and Planning Lead is now taking this forward to prioritise and focus on strategic planning and priorities over the short and longer term. Page 86
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Appendix 1 2 Description of Risk: Financial There is a risk of MIJB financial failure in that the demand for services outstrips available financial resources. Financial pressures being experienced both by the funding Partners and Community Planning Partners will directly impact on decision making and prioritisation of MIJB. Lead: Chief Officer/Chief Financial Officer Risk Rating: Low/ medium/ high/ very high VERY HIGH Risk Movement: Increase/ decrease/ no change NO CHANGE Rationale for Risk Rating: Whilst the 2020/21 and 2021/22 settlement saw additional investment for health and social care that was passed through to the MIJB, there remains a significant pressure due to the recurring core overspend, since most of the new investment related to new commitments. Financial settlements are set to continue on a one year only basis, which does not support sound financial planning. In addition, many uncertainties have arisen through the Covid response and continue as we continue to remobilise. The full impact is not yet quantifiable. Demand on services is greater than before and the IJB has £1.2m remaining general reserves. There is however significant earmarked reserves by the end of the 2021/22 financial year relating to the ongoing response to Covid and Primary Care Improvement Plan and the Scottish Government additional national investment of £300m for winter funding. The Revenue Budget 2022/23 was approved by MIJB on 31 March 2022 as a balanced budget. A small savings plan of £0.11 million was approved. Additional Scottish Government investment is provided again for 2022/23, this is to meet additional policy commitments in respect of adult social care pay uplift for externally provided services and seeks to ensure that capacity can be maximised and ensuring system flow. The final outturn position will be finalised and reported to the MIJB in June where it is anticipated there will be a small general reserve. The update medium Term Financial Framework was presented as part of the budget papers on the 31st March 2022 however, it is imperative that this is further reviewed during the 2022/23 year to ensure alignment with the upcoming revisions to the Strategic Plan. Rationale for Risk Appetite: The Board recognises the financial constraints all partners are working within. While we are cautious and open about accepting financial risks this will be done: • Where a clear business case or rationale exists for exposing ourselves to the financial risk • Where we can protect the long term sustainability of health & social care in Moray Covid-19 continues to place additional risk on the MIJB finances as we continue through the pandemic, recover and transform Page 87
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Appendix 1 Controls: There is an interim arrangement for CFO cover from Moray Council. Permanent recruitment efforts have not been successful. The Chief Officer is working with both the Council and NHS Finance Leads to secure a longer term interim arrangement. The CFO and Senior Management Team have worked together to address further savings which will be presented to the Board for approval as part of the budget setting procedures for 2022/23. This should be a focus of continuous review to ensure any investment is made taking cognisance of existing budget pressures. A revised Financial Framework was presented to the MIJB on 31 March 2022, and a further review will take place once the current strategic plan has been reviewed to assure alignment. Mitigating Actions: Risk remains of the challenge that the MIJB can deliver transformation and efficiencies at the pace required whilst dealing with the pressures that are emerging as a result of the pandemic. Financial information is reported regularly to both the MIJB, Senior Management Team and System Leadership Group. The Chief Officer and Chief Financial Officer (CFO) continue to engage in finance discussions with key personnel of both NHS Grampian and Moray Council. These conversations have continued throughout the pandemic phase. Chief Officer and CFO will continue to engage with the partner organisations in respect of the financial position throughout the year. Cross partnership performance meetings are in with partner CEOs, Finance Directors and the Chair/Vice Chair of the MIJB. Assurances: MIJB oversight and scrutiny of budget. Reporting through MIJB, NHS Grampian Board and Moray Council. Gaps in assurance: None known Current performance: For the 2021/22 financial year, overspend have been reported throughout the year, however, although the core services recurring overspend remains, there is slippage in additional investments received late in the financial year. The provisional outturn it is expected that MIJB will finish the year with a small general reserve that has been created through non- recurring slippage and a large earmarked reserve. A final position will be presented to the MIJB on 30 June 2022. Comments: Senior managers to work with Chief Officer and Chief Financial Officer to address the continuing financial challenge, continuing to seek efficiencies and opportunities for real transformation as we look to make efficient and effective investment in services that are truly transformational. Page 88
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Appendix 1 3 Description of Risk: Human Resources (People): Inability to recruit and retain qualified and experienced staff to provide and maintain sustainable, safe care, whilst ensuring staff are fully able to manage change resulting from response to external factors such as the impact of Covid and the actions that arose from the recommendations from the Independent Review of Adult Social Care 2021. Lead: Chief Officer Risk Rating: Low/ medium/ high/ very high HIGH Risk Movement: Increase/ decrease/ no change INCREASING Rationale for Risk Rating: There continues to be issues with recruitment to some front line services that require specific skills and experience. This has been the case for some time now and continues to place pressure on existing staff. Allied Health Professions, Social Work are two particular areas experiencing difficulties with obtaining people with the appropriate skills and training. Care at Home staffing levels are pressured for Internal services and externally with local providers all experiencing the same difficulties. There are also impacts on recruitment of Dentists and other graduates arising from Covid as the number graduating has reduced during the period. The various impacts of Covid-19 has placed a significant strain on the Partnerships resources across frontline and support functions and this has resulted in delays for the progress of projects relating to the achievement of strategic objectives. The Care Homes in Moray have continued to do well to maintain their staffing levels throughout the pandemic however there are examples where there is a reliance on agency staffing. The difficulty with recruitment and retention of staff to care at home roles in particular is still being experienced. There is a particular issue with long term sickness, secondments and other absence in Care at Home management structure which is resulting in reduced support to frontline staff and increasing pressure on remaining management staff. Efforts are being made to provide support but the situation remains challenging. There have been some achievements in the appointment to the Geriatrician posts, and recruitment to agreed models for orthopaedics, anaesthetics, general surgery and the emergency department in Dr Grays. There is further work being undertaken to develop the model for General medicine. There has also been an appointment of an Adult Psychology consultant. The benefit of these appointments are being felt across the whole system. The transition from EU membership has not presented any specific concerns for workforce and this will continue to be monitored. Page 89
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Appendix 1 The impact of budgetary decisions by the Council in relation to reducing staffing levels has reduced levels of support provided in some key areas for Health and Social Care Moray (HSCM), such as ICT, HR, Legal and design. Rationale for Risk Appetite: Safety risks that could result in harm to service users, staff or the public are inherent in Health & Social Care services. The safety of individuals is paramount therefore standards of safety management and clinical care have to be high, and the Board will continue to seek assurances this is the case. The Board’s ambition is for health & social care to be people centred. This means supporting people in decision making about their own health & care, which may expose individuals to higher risk where they make an informed decision. The Board will also seek to balance individual safety risks with collective safety risks to the community. Controls: Management structure in place with updates reported to the MIJB. Organisational Development plan in place and Workforce Plans are being updated to align to the new strategic plan. Continued activity to address specific recruitment and retention issues. The chief social worker reviewed the situation with managers and employed a Consultant Practitioner to develop options for addressing some of the particular issues affecting social work services in Moray and to provide support to managers and staff. There continues to be pressures around Social Work as more requests for assessment are being received from the community and an additional 3.68 FTE have been appointed for a temporary period to progress outstanding reviews. Management competencies continue to be developed through Kings Fund training although this is suspended due to Covid19. Communications & Engagement Strategy was approved in November 2019 and is being implemented. Council and NHS performance systems in operation with HSCM reporting being further developed and information relating to vacancies, turnover and staff absences is integral to this. Managers are highlighting any areas of concern and where appropriate this is identified in operational risk registers. HSCM services have commenced weekly reporting of workforce sit reps for Senior Management Team oversight highlighting vacancies, annual leave, sickness absence and Covid impacts so that issues can be identified and assessed quickly. Mitigating Actions: System re-design and transformation. Organisational Development Plan and Workforce plan were updated and approved by MIJB in November 2019. The Workforce plan is currently being updated again and will be completed by September 2022. These plans are core documents for the Workforce Forum which has recently re-commenced following a temporary suspension during the first quarter of this year due to Covid impact. Staff Wellbeing is a key focus and there are many initiatives being made available to all staff including training, support, information and access to activities. Page 90
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Appendix 1 Locality Managers are developing the Multi-disciplinary teams in their areas and some project officer support has been provided to develop the locality planning model across Moray. Lead Managers are involved in regional and national initiatives to ensure all learning is adopted to improve this position. Lead Managers and Professional Leads are linked to University Planning for intakes and programmes for future workforce development. Assurances: Operational oversight by Moray Workforce Forum has resumed and will report to MIJB in accordance with the agreed Governance framework. The HSCM Response Group was in place over the whole period of the Covid19 pandemic providing focussed leadership around emerging issues and resolving them. This group stood up again in April and is meeting daily whilst the system is pressured, this will be reviewed as the situation evolves. The Heads of Service are co-ordinating and escalate to SMT where necessary. Gaps in assurance: Further work required to develop workforce plans to reflect strategic plan implementation programmes once they are agreed. Current performance: The IMatter survey results for 2021 were received by managers for review and action plans. Preparatory work is commencing on the action plans for IMatter 2022 Discussions are underway with HR in both Council and NHS to develop access to appropriate HR information at a summarised level to facilitate the necessary workforce planning and subsequent monitoring of plans. There continues to be a need for more streamlining in recruitment processes as the delay in approval to recruit to having a member of staff available is in excess of 8 weeks. There is also a lack of suitable applicants for various posts which is impacting on ability to appoint for some roles. Comments: Staffing issues are owned by the Systems Leadership Group who will work collaboratively across the system to seek opportunities to make jobs more attractive where it has proved difficult to recruit in the past. For some professions there is a potential risk that staff move from one position to a new position within HSCM will just move the vacancy to elsewhere in the system, so Senior Management Team are aware of this risk and taking it into account in considerations for vacancies. There is a concern that if there is a longer term continuing impact of Covid on system flow and beds continue to be blocked for new patients it will mean operations cannot be scheduled to reduce the backlog and key staff may not have the necessary time in surgery to maintain skills. Page 91
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Appendix 1 4 Description of Risk: Reputation: Inability to demonstrate effective governance and effective communication and engagement with stakeholders. Lead: Chief Officer Risk Rating: low/medium/high/very high MEDIUM Risk Movement: increase/decrease/no change NO CHANGE Rationale for Risk Rating: Locality planning assessed as medium in relation to ability to work at the pace required and current workforce capacity. Performance framework to be further developed from a planning perspective to show the links through operational service delivery to strategic objectives. The Third Sector rep stood down from MIJB and the substitute was only able to commit to attending until August 2021. Efforts are underway to recruit a replacement for this role and for other forums and it is anticipated that an appointment will be made for the 30 June 2022 meeting. Recent engagement with individuals representing their communities or third sector organisations in a variety of forums is highlighting that problems with their capacity to fulfil our needs so more co-ordination and clearer focus is required to ensure that the communication, engagement and outcomes are meeting identified needs. Rationale for Risk Appetite: The Board is cautious but open about risks that could damage relationships with different stakeholders. It recognises many of our aspirations depend on effective collaboration, coproduction and partnership working with a range of stakeholders. The appetite also recognises that while the aspiration is to be a co-operative partner, some partners will not be able to move at the same pace as us all the time. We will seek to protect relationships in the long term and will not set out to antagonise stakeholders deliberately. For example, we must not be seen to exclude or prevent participation in the design of services where there is an appetite to do this. We must be mindful that repairing relationships is easier when there is already a well of goodwill to draw on, and that further damage to an already damaged relationship will not be conducive to good long term outcomes. Page 92
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Appendix 1 Traditional methods of engagement are not possible at present as social distancing rules apply however alternative mechanisms for engaging with stakeholders are being used along with social media Controls: Governance Framework approved by IJB January 2021 Communication and Engagement Strategy approved November 2019 Annual Governance statement produced as part of the Annual Accounts 2019/20 and submitted to External Audit. Annual Performance Report for 2019/20 was published in August 2020 Performance reporting mechanisms in place and being further developed through performance support team, home first group and system leadership team. Community engagement in place for key projects areas such as Forres, Keith and Lossiemouth with information being made available to stakeholders and the wider public via HSCM website. Participation of stakeholders in a variety of meetings such as Home First project, carer strategy, Strategic, Planning and Commissioning groups. Mitigating Actions: Schedule of Committee meetings and development days in place and implemented. Good working relationship established with Audit Scotland, the MIJB’s appointed external auditors since 16/17. Annual Performance Report for 2020/21 published in August 2021. Social media is actively used as a method of engaging with the public, with short videos focussing on particular services being trialled. SMT have considered the existing arrangements for engagement with stakeholders and work is being undertaken to align our framework with the Scottish Government “Planning with people guidance” and ensure that mechanisms are in place across services to evidence and evaluate their impact. Assurances: Oversight and scrutiny by Clinical and Care Governance Committee, Audit Performance and Risk Committee and MIJB. Summary reports of minutes of MIJB meetings are submitted to Council committee and NHS Board. Gaps in assurance: Progress on implementation of the Communication and Engagement Strategy has been impacted by the Covid 19. Due to the impact of COVID and requirement for social distancing the normal mechanism for engagement were not all available. More use is being made of social media and Microsoft teams and other options and methods for engagement with staff are being used via NHSG such as videos on YouTube and one question surveys. Going forward there may be more opportunity for face to face meetings to take place again. Current performance: Communications Strategy was reviewed approved by IJB November 2019. Annual Performance Report 2020/21 published August 2021. Audited Accounts for 2020/21 were publicised by deadline 30 September 2021 Page 93
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Appendix 1 Due to Covid19 there have been increased levels of briefings to staff, the public and Chair/Vice Chair of MIJB with a focus on the key elements of the response. The staff newsletter commenced during Covid but will continue to be produced. Comments: A communication cell was established as part of the Local Resilience Partnership Covid and storms response with representation from Councils, HSCP and NHSG. This was led by Aberdeen City Council and was an example of the collaborative working that took place. This forum provides assurance that messages to all stakeholders are consistent. It also ensures that there is support for our Communications Officer and resilience provided with the access to other communication officers. There has been representation from the Home first project at the Wellbeing forum to facilitate sharing of information and seeking views. 5 Description of Risk: Environmental: Inability to cope with unforeseen external emergencies or incidents as a result of inadequate emergency and resilience planning. Lead: Chief Officer Risk Rating: low/medium/high/very high HIGH Risk Movement: increase/decrease/no change NO CHANGE Rationale for Risk Rating: Due to the response requirements for Covid 19 progress has been made in a number of areas. SMOC information is updated, control room guidance updated and expanded, control centre protocols were implemented and remain in place and management teams have responded in an agile, responsive and collaborative way under very challenging conditions. HSCM did not have a collectively approved list of critical functions at the start of the response however this was quickly completed and used to prioritise allocation of resources to the response. This list was reviewed in 2021 and managers are working to a schedule to update for any further changes that have been implemented as a result of Omicron. Covid infections continue in Moray however mitigations in place in accordance with Scottish Government guidance are intended to assist services maintain core staffing levels and service delivery. Teams continue to do their best but there are areas where they still feeling overwhelmed and service delivery is restricted to core elements. Page 94
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Appendix 1 With effect from March 2021 MIJB is defined as a Category 1 responder under the Civil Contingencies (Scotland) Act and there are additional requirements for preparedness that is being taken forward in partnership with NHSG and Moray Council emergency planners. Rationale for Risk Appetite: The MIJB understand the requirement to meet the statutory obligations set out within the Civil Contingencies Act and the Category 1 status applied in March 2021, and work with partner organisations to meet these obligations Controls: Winter Preparedness Plan was updated (but not tested as in previous years) alongside NHSG plans as NHSG implemented their crisis management framework which required participation of partners at Daily connect meetings to discuss and prioritise resource to address issues with system flow. HSCM Civil Contingencies group established and meeting regularly to address priority subjects. NHS Grampian Resilience Standards Action Plan approved (3 year). Business Continuity Plans in place for most services although overdue a review in some areas. Knowledge of critical functions and ability to respond quickly and effectively has been in evidence during incidents such as Gas outages in Keith (January and February 2021) and Covid response, Storms (Arwen, Malik and Corrie) – debriefs carried out and learning identified. Debriefs being undertaken for HSCM, Moray (Council and HSCM) and Local Resilience Response with lessons learnt being collated and prioritised for an action plan. Mitigating Actions: Information from the updated BIA/BCP informed elements of the Winter Preparedness Plan A Friday huddle is in place which gathers the status of services across the whole system to provide information and contact details to the Senior Manager on Call (SMOC) over the weekend. NHSG have introduced system wide daily huddles to manage the flow and allocation of resources which require attendance from Dr Grays and HSCM. NHS Grampian have amended their approach to Pandemic preparation so HSCM Pandemic plan will require redrafting and testing. This will be taken forward by HSCM Civil Contingencies Group. Practitioner group established for Moray with representation from HSCM, Dr Grays, Moray Council and NHSG to discuss matters arising from the Local Resilience Forum and within our respective organisations. In addition it will provide a forum for discussion of the linkages between organisational response plans to ensure there are no gaps or over reliance on particular local resources. HSCM continues to monitor the local situation regarding impacts on staffing and is engaged with NHSG emergency planning arrangements and Council Response and Recovery management team to be ready to escalate response if required. Work was undertaken within NHSG, Aberdeenshire HSCP and Aberdeen City HSCP to look at Surge flows Page 95
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Appendix 1 and establish a mechanism that will provide easy identification of “hot spots” across the whole system in Grampian, to facilitate a collaborative approach to addressing the issues through the use of a common Operational Pressure Escalation approach. This work could underpin surge responses in winter and at other times of pressure and having a standard approach across Grampian could aid communication and understanding. Assurances: Audit, Performance and Risk Committee and NHS Grampian Civil Contingencies Group oversight and scrutiny. HSCM Civil Contingencies group review specific risks and action plans to mitigate, developing plans and testing arrangements in partnership with NHSG and Council Gaps in assurance: The recent experience of Storms and associated power outages proved challenging for all category 1 responders across Grampian however our staff responded extremely well. The debriefs have identified lessons learnt for Grampian Local Resilience Partnership and more locally for the response co-ordination within Moray. Action plans have been developed in collaboration with Moray Council’s emergency planning officer to address the issues identified. The main issues related to developing wider awareness of roles and responsibilities, and improving general awareness of response structures and meeting protocols. This will be incorporated into training schedules going forward. It has also highlighted the need for a more robust arrangement for out of hours contact and clarity of roles and responsibilities across the system which is being progressed through an organisational change steering group. Some table top exercises have been completed but the intended programme for 2020 is being rescheduled now we are out of response phase. Progress has been made however further work is required to address the targets in the implementation plan that have not been met and the Resilience standards as identified by the NHSG Civil Contingencies Group. Pandemic flu plans will require to be updated with the learning from Covid 19 The debrief reports following the gas outages from a Moray perspective and the Grampian Local Resilience Partnership (LRP), highlighted some issues for clarification in relation to the Care for People agenda. To address the local issues meetings have been taking place with Moray Council and HSCM representation to progress the Care for People plan and associated response structures. The Care for People group met in April and will meet again in June to review the draft Care for People plan for sign off. The intention is to hold a table top exercise with managers from HSCM and Moray Council to test the invocation arrangements to ensure common understanding of roles and responsibilities. Current performance: The Senior Management Team participated in Strategic Leadership in a Crisis training in 2020 and a programme of further training for the wider management team is scheduled. Many services have business continuity arrangements and some are overdue for an update. Work has progressed in identification of a critical functions list for agreement by System Leadership Group that will inform planning arrangements going forward. There will need to be changes made to business continuity plans following the Page 96
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Appendix 1 implementation of additional ICT resources in services which have provided a greater deal of resilience for some services and functions – albeit reliant on electricity supply. A schedule of review and exercising of business impact assessments and plans has been scheduled for this year across services. Annual report on progress against NHS resilience standards was reviewed by APR committee on 31 March 2022. Report on the implications of the designation as a Category 1 responder was presented to MIJB 25 November 2021. Information has been collated regarding dependencies of fuel for delivery of critical functions for submission to NHSG and Council for inclusion in the planned response to the invocation of the National Fuel Plan. Comments: Once the response phase is complete the HSCM Civil Contingencies group will schedule and review progress in achieving the NHSG resilience standards, reporting updates to System Leadership Group. Page 97
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Appendix 1 6 Description of Risk: Regulatory Risk to MIJB decisions resulting in litigation/judicial review. Expectations from external inspections are not met. Lead: Chief Officer Risk Rating: low/medium/high/very high MEDIUM Risk Movement: increase/decrease/no change INCREASING Rationale for Risk Rating: Considered medium risk due to the impact of Covid-19 and resultant efforts required to remobilise services and/or the increase in workloads stretching a workforce that has been under sustained pressure for a considerable time. The impact of the current level of Covid positive staff is stretching resources to deliver care in the community across all providers (internal and external) so there is a potential increased risk of expected standards not being achieved despite the best efforts of all concerned. Rationale for Risk Appetite: The Board, staff and providers across Moray are all committed to ensuring high standards of clinical care & governance through operational policies. Innovation and new ways of working may mean traditional regulations do not exist and require to be developed, no longer apply, or are contradictory. We will only take regulatory risks knowingly, following consultation with the relevant regulatory body and where we have clear risk mitigation in place. Controls: Clinical and Care Governance (CCG) Committee established and future reporting requirements identified Clinical Risk Management and Practice Governance group has oversight of their respective professional standards and feed into Clinical and Care Governance Group, which then escalates to CCG Committee as necessary. High and Very High operational risks are reviewed by System Leadership Group monthly and a review of all risks will be undertaken as part of the risk management framework. Complaints and compliments procedures in place and monitored. A complaints co-ordinator role is being developed and will be implemented to reduce duplication of effort, to provide co-ordination and improve information flow and support managers in responses with the intention of streamlining processes and improving achievement of target timescales. Clinical incidents and risks are being reviewed on a weekly basis to ensure processes are followed appropriately and consistently and responses are recorded in a timely manner. Adverse events and duty of candour procedures in place and being actioned where appropriate and summary reports submitted to CCG committee. Page 98
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Appendix 1 Reports from external inspections reported to appropriate operational groups and by exception to SMT for subsequent reporting to CCG or Audit Performance and Risk Committee as appropriate, albeit there has been a reduction in some areas of external inspection reporting during the Covid period due to social distancing restrictions Care Home Oversight Group was meeting daily but now three times a week to oversee and manage risks in care homes. Children and Adult Protection services are being delivered and reported to their respective committee on a regular basis. Mitigating Actions: This risk is discussed regularly by the three North East Chief Officers. Additional resource has been allocated to support the analysis of information for presentation to CCG committee Process for sign off and monitoring actions arising from Internal and External audits has been agreed Assurances: Audit, Performance and Risk and Clinical and Care Governance Sub-Committees oversight and scrutiny. Governance Framework in place and operational. Gaps in assurance: Process for highlighting recurring themes or strategic expectations from external inspections requires further development to ensure Committee has sight of significant issues. . Current performance: External inspection reports are reviewed and actions arising are allocated to officers for taking forward. A summary of inspections was included in the Annual Performance report. The level is marked as an increasing risk on the basis that services are under pressure with the issues with staffing capacity and the need to focus on delivery of critical functions which may mean external inspection are not the priority at this moment in time. The Adult Support Protection inspection took place in April/May and our action plan has been developed. Comments: No major concerns have been identified for HSCM services in any audits or inspections during 2021/22. The equipment store has received a follow up internal audit and the initial verbal feedback was positive. Page 99
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Appendix 1 7 Description of Risk: Operational Continuity and Performance: Inability to achieve progress in relation to national Health and Wellbeing Outcomes. Performance of services falls below acceptable level. Lead: Chief Officer Risk Rating: low/medium/high/very high HIGH Risk Movement: increase/decrease/no change NO CHANGE Rationale for Risk Rating: Potential impacts to the wide range of services in NHS Grampian and Moray Council commissioned by the MIJB arising from reductions in available staff resources as budgetary constraints impact. Unplanned admissions or delayed discharges place additional cost and capacity burdens on the service. The level of delayed discharges has remained high, reflecting the sustained pressure in the system as a result of Covid -19 impact and the lack of availability of care in the community. There are sustained focussed and collective efforts by all those working in the pathway. However this is a complex area and will require continued effort to realise reductions and maintain them. Rationale for Risk Appetite: The Board is cautious but open about risks that could affect outcomes that are priorities for people in Moray. There is a slightly higher appetite to risks that may mean nationally set outcomes – that by design are not given a high priority in Moray - are not met. This will only be accepted where there is a clear rationale, and preferably also a way of demonstrating what the IJB is doing to meet the aspiration the outcome was created for. Controls: Performance Management reporting framework. 2019 to 2029 “Partners in Care” Strategic Plan approved and refresh of Plan and development of implementation plans underway. Performance regularly reported to MIJB. Revised Scorecard being developed to align to the new strategic priorities. Best practice elements from each body brought together to mitigate risks to MIJB’s objectives and outcomes. Chief Officer and SMT managing workload pressures as part of budget process. A daily Huddle and write up circulates the picture on performance across community and acute services for the Portfolio and service managers have a shared understanding of the pressures in the system and mitigations taking Page 100
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Appendix 1 place. Work continues on refinement of G-OPES (Grampian Operating Pressures and Escalation System) led by NHSG but being developed locally to identify the triggers and resultant actions required in services to respond to pressure points. Mitigating Actions: Service managers monitor performance regularly with their teams and escalate any issues to the System Leadership Group (SLG) for further discussion to provide wider support, developing shared ownership and a greater understanding across the whole system. Key operational performance data is collated and circulated daily to all managers. A Daily dashboard is held on illuminate for managers to access to ensure any potential issues are identified quickly so action can be taken. This dashboard is being reviewed and will be further developed with the intention of further dashboards to provide a whole system overview. This has been discussed at SLG and agreed. Performance information is presented to the Performance sub group of Practice Governance Group to inform Social Care managers of the trends in service demands so that resources can be allocated appropriately. Assurances: Audit, Performance and Risk Committee oversight. Operationally managed by service managers, summary reports to Practice Governance and clinical and care governance group and to System Leadership Group. Strategic direction provided by Senior Management Team. HSCM Response Group continues to meet and reviews the key performance information and actions that are required to deliver the priority services. Gaps in assurance: Development work in performance to establish clear links to describe the changes proposed by actions identified in the Strategic Plan has recommenced but is at an early stage. This will be progressed as the revised outcomes are determined and associated KPI are identified. Progress will be reported to future Board meetings. Current performance: Covid19 has impacted on all areas of the service and work is underway to take the learning and experience gained during the response to collate performance information in dashboards to support mangers interpret the impact of Covid19 on their services, now and going forward. There are likely to be changes to ways of working and this may also have impact on the performance information required. Comments: Locality profile information has been provided to Locality Steering Group/Locality Manager to inform potential priorities for consideration in Localities and work will be taken forward regarding development of performance monitoring and reporting of key performance indicators in relation to Localities once it has been determined what the intended outcomes are. The delayed discharge group has produced an action plan for implementation and progress is being made. Page 101
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Appendix 1 Practice Governance have reviewed their operational performance requirements and have a comprehensive data set used to inform operational priorities. The Home First priorities are being taken forward and updates are reported to this committee or MIJB on a regular basis. Progress in this area has been hampered due to the increased demand for urgent or critical services requiring staff resource to be prioritised to frontline service delivery. The Council has procured new modules for their performance reporting system Pentana and HSCM performance team has been developing its its use for reporting. 8 Description of Risk: Transformation Inability to progress with delivery of Strategic Objectives and Transformation projects. Lead: Chief Officer Risk Rating: low/medium/high/very high HIGH Risk Movement: increase/decrease/no change NO CHANGE Rationale for Risk Rating: There are many issues that will impact on the ability to progress to deliver Strategic Objectives. The Strategic Planning & Commissioning group has been refreshed and re-launched and key work is being progressed. There was an initial meeting held on 22 September 2021 to consider terms of reference and the proposed structure for oversight, prioritisation and assurance in relation to key developments, their fit with IJB strategy and enabling elements. The interim appointment of the Strategic and Planning Lead provides capacity to take this forward and to align the priorities arising nationally, Grampian-wide and locally. The remobilisation plan for HSCM services that were suspended or reduced is progressing with Providers services and social work implementing the IJB decision to return to delivery of both substantial and critical eligibility criteria. Work has progressed risk assessments are completed and assessments have been or are in the process of being reviewed to ensure equality. There are still some restrictions of social distancing on some services mean that capacity for services is impacted. There are some tests of change underway with a focus on delivery of individual outcomes which may mean service users receiving a different type of service (after discussion and agreement) which will meet their defined outcomes. It is anticipated that a hybrid service will be offered which will facilitate tailoring of services to meet specific individual outcomes where this is appropriate. Page 102
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Appendix 1 The time period and extent of Covid 19 the impact on the population of Moray will not be fully understood until well after the response is over. It is therefore not possible to predict the extent of the impact on the ability to progress with delivery of Strategic Objectives. There are some aspects that have progressed very well such as introduction of Near Me consultations but there are others that are more difficult to progress. There is concern that due to the workloads and challenges over the last year that teams are weary and/or do not have capacity at this moment in time, to progress with delivery of development plans at this moment in time. In addition the pandemic is still present in the community so services are still responding to the impacts it has for the population of Moray. Managers are working with teams to establish “readiness” and their capacity and sense of wellbeing and the collated output will inform plans going forward. One key aspect to facilitate transformation is the need for progress in relation to ICT infrastructure, data sharing and data security across the whole system. Work was undertaken by NHS GRAMPIAN and partners to address the needs for ICT kit and information during the response to Covid and it is hoped that this progress can be built on Rationale for Risk Appetite: The Board has a high appetite for risks associated with delivery of transformational redesign. The following should be considered when accepting these risks: • We understand and can mitigate other risk types that may arise, e.g. safety or financial within appetite • Service users are consulted and informed of changes in an open & transparent way • We will monitor the outcome and change course if necessary Controls: Home First strategic theme is being progressed across the whole system and a local Home First Group is meeting monthly. A newsletter is being produced to keep staff and partners informed. It is recognised that there will be significant changes taking place in Social Work practice with the implementation of the Self Directed Support standards and the move to outcomes based services, so governance arrangements are being set up to facilitate the same type of oversight and communication that is in place for the Home First programme. Mitigating Actions: Integrated Infrastructure Group previously established, with ICT representation from NHSG and Moray Council, to consider and provide solutions to data sharing issues and ICT infrastructure matters which is an area that will be taken forward alongside the Moray Growth Deal projects. Linkages to Infrastructure board and Information sharing groups have been established albeit these meetings are not taking place regularly at the moment. Data sharing groups for Grampian and Health and Social Care Moray have been established and meetings were held regularly but have not taken place for several months due to Covid. These meetings have oversight of any issues arising from Data protection and GDPR matters from either Council or NHS systems. It is anticipated that these will restart during the next quarter. Page 103
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Appendix 1 Assurances: Strict ICT and data sharing policies and protocols in place with NHS Grampian and Moray Council. Gaps in assurance: Transformation/implementation planning is in development and will inform outcomes and performance reporting on the delivery of the strategic plan. Protocol for access to systems by employees of partner bodies are in place. Information Management arrangements to be developed and endorsed by MIJB. Process of identification of issue and submission to data sharing group requires to be reinforced to ensure matters are progressed. Hybrid working arrangements and preparation of offices for return require to be progressed in partnership with Council and NHSG. Current performance: Training programme to be developed on records management, data protection and related issues for staff working across and between partners. Comments: Where national systems are involved it may not be possible to identify a solution however the issues will be able to be raised at the appropriate level via the Grampian Data Sharing Group where all three partnerships are represented. Page 104
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Appendix 1 9 Description of Risk: Infrastructure Requirements for support services are not prioritised by NHS Grampian and Moray Council. Lead: Chief Officer Risk Rating: low/medium/high/very high HIGH Risk Movement: increase/decrease/no change NO CHANGE Rationale for Risk Rating: Changes to processes and necessary stakeholder buy-in still bedding in. Moray Council is undertaking a Property review of office and depot accommodation and the potential impact for HSCM services requires consideration. The output was anticipated in October 2019 however due to changes with roles and responsibilities within the Council however the paper has been out for consultation. The changes required to places of work as a result of Covid19 continue to restrict the number of people that can use an office. These decisions are being made by NHSG and Moray Council and we await their development of policy regarding workspace and availability of facilities going forward as highlighted in the Premises Strategy report to MIJB in May 2021. NHSG have advised that staff should continue to work from home at present whilst policies and protocols are developed. Moray Council are promoting a hybrid method of working and are limiting occupancy in offices at present to 50% of desk capacity. A dedicated MC officer is leading on hybrid working plan with input from HSCM inputing their requirements. ICT infrastructure service plans in NHS Grampian and Moray Council are not yet visible to HSCM and development of communication and engagement process is required. The impact of Covid has resulted in a change in ICT strategy for Moray Council. Council employed staff requiring mobile technology have now been provided with it and many staff are working from home. This is a necessity where the number of desks available in offices has been reduced due to implementation of social distancing guidance. There is still an issue with availability of kit for NHS employed staff which has been escalated There are some significant risks in relation to accommodation for services on operational risk registers which are taking longer than would be ideal to resolve. Rationale for Risk Appetite: Low tolerance in relation to not meeting requirements. Controls: Chief Officer has regular meetings with partners Page 105
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Appendix 1 Computer Use Policies and HR policies in place for NHS and Moray Council and staff are required (through and automated process) to confirm they have read these every 6 months PSN accreditation secured by Moray Council Infrastructure Programme Board was established with Chief Officer as Senior Responsible Officer/Chief Officer member of CMT. Process for submission of projects to the infrastructure board approved and implemented to ensure appropriate oversight of all projects underway in HSCM. The Board is not meeting at present, so in the interim, project requests are being processed via Senior Management Team. The interim Strategy and Planning Lead will support the the Infrastructure Programme Board for Moray portfoilio to be re established. Mitigating Actions: Membership of the Board was reviewed and revised to ensure representation of all existing infrastructure processes and funding opportunities. Process for ensuring infrastructure change/investment requests developed Interim Infrastructure Manager in post and linking into other Infrastructure groups within NHSG & Moray Council to ensure level of ‘gatekeeping’. Dr Gray’s strategy (vision for the future) is being produced collaboratively with input from NHSG and HSCM management Work is progressing on identification of needs for some services with regard to accommodation which will be communicated with partners to find the most effective solution. Assurances: Infrastructure Programme Board functions to provide robust governance and assurance that proposed projects have a robust business case and meets requirements of the respective partner organisations. This board reports to Strategic Planning and Commissioning Group. Both of these groups are being refreshed and remobilised. Workforce Forum meeting regularly with representation of HR and unions from both partner organisations Gaps in assurance: Further work is required on developing the process for approval for projects so that they are progressed timeously. Need to review all existing processes in relation to infrastructure changes/projects/investments and streamline to avoid duplication of effort. Infrastructure Board is in development and priority issues are being addressed in relation to infrastructure and premises risk. Legal services have reduced capacity to provide support due to budget cuts so any requests may take longer. Page 106
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Appendix 1 Recruitment for vacancies takes considerable time due to various factors and is presenting a strain on services to maintain normal service whilst covering vacancies. There have been several posts that have had to go out to advert more than once extending the time other staff are covering gaps. Current performance: The Infrastructure Board is currently suspended, with the intent to re-establish the Board by Nov 22. Its purpose is for highlights/exceptions to be taken to SLG for communication and information purposes. Access to support for development of HSCM priorities is difficult at time because projects/requests are prioritised against all other services in the partner organisations. The challenges and impact on the ability to adopt efficient working processes for HSCM staff and managers whilst have to use networks/systems from two organisations, which cannot be accessed by all members of teams due to data sharing, matters is very significant. Comments: Existing projects will be reviewed as part of the development of the transformation plans for the Strategic Plan to ensure resources are being dedicated appropriately and aligned to the emerging Strategic priorities. Our requirements for support will be communicated via appropriate channels There remains issues with access to ICT equipment for staff with orders over 6 months old outstanding with both NHSG and Moray Council. This impacts on services effectiveness. The matter has been escalated by senior managers with colleagues in the partner organisations. Page 107
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