Dashboard Report
Argyll and Bute Council · 12 May 2026
Back to Argyll and Bute HSCP Clinical and Care Governance Committee — 12 May 2026 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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Welcome.. We welcome our new Associate Nurse Director, James Mullins to A&B HSCP. A focus is to understand, develop and aspire to drive forward practices to constructively and effectively manage quality and patient safety across A&B HSCP. Key Dates: 8 May 2026 Integrated Clinical and Care governance Workshop 4 June 2026 Healthcare Guardian Go-live Argyll & Bute Clinical and Care Governance| Apr 2026 Data correct as of 22/04/2026 Clinical and Care Governance: Continuous Improvements • Integrated Clinical and Care Governance Structure. Mapping exercise to enhance quality and patient safety • Introduction of new Incident Reporting system (Healthcare Guardian) Planned to go live June 2026 • Training on Incident Reporting (Reporter and Reviewer) and Complaint Handling Procedure • Health Improvement Scotland – Clinical Governance Standards. – working with North Highland on a strategy to roll out the standards and utilise the improvement tool mechanism to support continuous improvements across all areas of our services • Aligned working with North Highland to advance our strategy in patient experience and how we engage with patient feedback to support improvements in practice and decision making • Review and refine our H&S governance structures • Review and refine our Risk Management across A&B HSCP (Includes clinical and operational risk)
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Argyll & Bute Stage 2 Complaints | April 2026 Data up to date as of 22/04/2026 *excludes cases with stage of further correspondence and SPSO Since December 2025 complaint volumes have begun to increase again.. Aspects such as complaints in Primary Care relating to GP services, quality of consultations,, dental service provision and lack of sexual health services have impacted an increase in volumes. The volume of cases by areas completed within the 20 day target are being specifically impacted as a result of high-level cases related to case reviews and SAERs. A significant factor in Oban relates to operational pressures impacting investigation time scales and time taken to draft responses. SPSO: There are 4 open SPSO cases. 3 are initial enquiries and are awaiting a response from the SPSO. 1 SPSO has come back with a provisional decision of partially upheld regarding complaint handling and urine testing protocols. .
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Complaint themes in sub categories relate to the length of time it is taking to respond to complaints, this leads to escalated concerns and drives work volumes in the Feedback Team. Poor care, relates to quality and standard of care, this has significantly been observed in Primary Care and CAMHS services. Communication issues relate to patients feeling they haven’t been given enough or consistent information, which ties closely in with staff attitudes and behaviours. Actions to support have involved staff reflections and sharing of complaints with the wider teams to support awareness over the significance of what to communicate, when and how. Argyll & Bute Stage 2 Complaints | April 2026 Data up to date as of 22/04/2026| *excludes cases with stage of further correspondence and SPSO
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In period a total of 27 Stage 1 complaints received and total of 43 Stage 2 complaints. An average of 5 complaints received per month over the period. A peak n the summer with 11 received. Complaint themes are around: • Provision of social work and social care service • Quality of care and services • Communication with key workers and consistency of communication Argyll & Bute Social Work & Care Complaints| April 2026
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Argyll & Bute Adverse Events | April 2026 Data correct as of 22/04/2026 Incident reporting volumes remain fairly consistent. A peak in the Mid Argyll area lends itself to the Succoth Ward, where during the summer of 2025 complex patients were on the ward, where persistent self-harming incidents were repeatedly reported. As patients have moved off the ward there has been a reduction. What we have seen instead is a volume in Succoth relating to dementia patients were falls have been a regular theme. Oban and falls issues are consistent along with medication errors . Since the introduction, we have observed a reduction in medication errors. The ‘other’ category is still too high on review, and further work to understand this is planned for June 2026.
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Argyll & Bute Adverse Events | Apr 2026 Data correct as of 22/04/2026 What we are observing with incidents is the quality of the incident report, and this has improved over the last 6 months. More information and immediate actions have been detailed to support incident review management which takes place weekly with professional lead input. We have observed a reduction in moderate and extreme cases and also an improvement in the handling, with less time taken to review and close Datix cases down.
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Inpatient falls have reduced over three consecutive months, demonstrating encouraging progress, although rates remain close to average, and continued focus is required to achieve the falls reduction target. Where falls occur, they are most often associated with a small number of highly complex patients. Argyll & Bute Inpatient Falls | Apr 2026 Data correct as of 22/04/2026
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Highlighting falls prevention to staff remains a priority, through continued use of the Safe Care Pause. The Argyll & Bute Inpatient Falls Meeting continues to support shared learning and best practice, with key messages disseminated via the Focus on Falls graphic, which remains well received. The Falls Lead has introduced monthly short educational sessions focused on specific falls-related topics to further strengthen staff knowledge and preventative practice. Next steps: • Maintain focus on staff engagement and Safe Care Pauses • Continue monthly Falls Lead education sessions • Falls lead to target interventions for patients with complex falls risk as appropriate • Monitor trends to sustain and build on recent reductions Argyll & Bute Inpatient Falls | Apr 2026 Data correct as of 22/04/2026
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Argyll & Bute Tissue Viability | Apr 2026 Data correct as of 22/04/2026 Grade 2 Pressure Ulcers continue to be the most frequently reported pressure injuries- of the 22 PUs reported (March/April), 1 was for a patient transferred from NHS GG&C, 1 was for a resident of a care home and 1 was device related and acquired in the MacmIllan Day Bed Unit. The remaining 19 PUs were acquired in the community. Within this reporting period a number of the PUs related to falls where there have been a long lie, reflecting the frailty and vulnerability of patients within the community setting. Contributory factors continue to be: - Frailty - Immobility - Acute illness -End of Life -Fall with a Long Lie A level 2a case review undertaken within the reporting period identified the following learning points: - Guidance to be developed to support consistent reporting of wounds/pressure ulcers on DATIX, particularly in primary care setting - Training related to tissue debridement for A&E and community staff to be developed - Awareness raising re use of information leaflet on pressure area care and management for patients and carers
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Improvement work underway: Re-launch of VIP Pathway and CRP for Feet (mandatory nursing assessment of feet for neuropathy) - joint initiative with TV and podiatry. Note the DATIX reports captured here include PUs which develop on the ankle and below, which are the remit of podiatry. Leg ulcer wound pathway development between A&B and GG&C progressing well - aim to improve early intervention and vascular referral processes. Contracture SLWG commenced – plan audit for prevalence followed by MDT review of current guidelines in terms of postural management and prevention of contractures. Sharp Debridement SOP in development – aim to clarify remit and scope of practice when undertaking this procedure. Care Home skin tear audit underway with ‘Train the Trainer’ sessions planned. Following review of a number of community acquired PUs- training re mattress selection and mattress settings and a Pathway with links to training videos and QR codes to equipment instructions completed . Roll-out of an enhanced Risk Assessment for frail, low weight, bed bound patients who require a high spec mattress. Argyll & Bute Tissue Viability | Apr 2026 Data correct as of 22/04/2026
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Argyll & Bute Violence & Aggression | Apr 2026 Data correct as of 22/04/2026 . The graphical data shows a dramatic turn of events for reported V&A cases with a significant drop from September onwards. This correlates with incident volumes overall, as after that time period, 2 key Succoth ward patients were no longer at the location, as such, reported incidents overall dramatically reduced. Post September we have seen a rise in V&A cases reported in GP services, this relates to vaccinations and CTAC services, relating to cancellations, and aggressive behaviours from patients observed n these settings. .
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There is more 'Physical' subcategory reported in March and previous months than any other subcategory. This does suggest that more verbal form of aggression are perhaps not being logged. Staff are encouraged to log verbal, as these are equally as significant. There are relatively few Adverse Events reported from Oban , with such a large Hospital within the Locality a higher volume is expected. The volume of VA& training cancelled in Oban due to low staff numbers has been an area for concern. There have been four courses cancelled in the last year to March 2025, leaving potentially 48 staff untrained. We have the importance of Datix reporting running through our training, and as such feel with the training the volumes may increase with more consistent reporting. Argyll & Bute Violence & Aggression | Jan 2026 Data correct as of 09/01/2026
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Medication error reporting is still an area of need for focus and deep dive, with ‘other’ category still significantly high. HEPMA has now been introduced into the Acute setting in Oban, and although this is the case, there are still high administration errors which are identified through pharmacy regularly. Argyll & Bute Medication Errors | Apr 2026 Data correct as of 22/04/2026
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An action which came from the deep dive in Oban, pre HEPMA introduction, was the setting up of a medications error sub meeting. This is still on the agenda, and due to staffing pressures, has not been put into action at this time. A Lead Pharmacist post in Oban is currently vacant and this is a priority of the service to address this need. A recent SBAR has been requested in Oban relating to prescribing, and it is expected a review will support continuous learning in Oban. Argyll & Bute Medication Errors | Apr 2026 Data correct as of 22/04/2026