Integrated Inspections and Scrutiny Overview
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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1 A&B HSCP Clinical Governance Committee Date of Meeting: 12 May 2026 Title of Report: Integrated Inspections and Scrutiny Overview Presented by: Leah Smith, Clinical Governance Manager The committee is asked to: ▪ Review for transparency and assurance regarding continuous improvement arising from external body investigations across A&B HSCP. ▪ Please note all the items within the paper are available in the public domain and that people who make complaints to the SPSO are made aware that their outcome reports are made public and published on their website for learning purposes. 1. EXECUTIVE SUMMARY This report provides an overview of external inspections, investigations, and scrutiny activity across Argyll & Bute HSCP over a 12-month period (March 2025–March 2026), with the primary aim of assuring the Committee that learning is being identified, acted upon, and embedded to support continuous improvement in patient care, staff practice, and governance 2. RECOMMENDATIONS The committee is asked to: Review for transparency and assurance regarding continuous improvement arising from external body investigations across A&B HSCP. Please note all the items within the paper are available in the public domain and that people who make complaints to the SPSO are made aware that their outcome reports are made public and published on their website for learning purposes. 3. DETAIL OF REPORT The following information is taken from a reporting period of the last 12 rolling months (March 2025 – March 2026) Scottish Public Services Ombudsman (SPSO) Investigations Health Board SPSO:
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2 There are 4 open SPSO cases. 3 are initial enquiries and are awaiting a response from the SPSO to determine if they are taking them forward or not for formal investigation. These cases relate to Mental Health assessments for children and adults and dental service practice. 1 SPSO case has been reviewed by the SPSO and a provisional decision of being partially upheld has been approved by A&B HSCP. This SPSO relates to Community Hospital A and the care and treatment of an elderly patient with dementia. The areas upheld relate to: • Complaint handling; specifically around clarity for complainants over what areas are for the A&B HSCP to respond to, and what areas are for Medical Practice to respond to. • Urine testing protocols in dementia patients. Actions regarding management of such cases had been implemented prior to SPSO review and decision; as such we now have an agreed approach which requires a tailored acknowledgement letter to complainants to clarify areas of responsibility at the first opportunity. Actions regarding review or urine testing protocols are to be reviewed further with professional leads for continuous improvement. A Shared Learning Template will be drafted on the back of the final SPSO letter and this will be communicated to all relevant staff and published in our Library of Learning. In the reporting period 1 SPSO case which is not being taken forward by the SPSO has been returned with feedback regarding complaint handling and the management of communication via a single point of contact. A&B Clinical Governance Manager had already made changes to this practice and assurance has been given to the SPSO. Social work / Social Care SPSO 4 SPSO cases have been reviewed in the reporting period. SPSO cases relate the themes of: • Lack of care home for patients to be discharged to • Patients not receiving a care package • Quality of care Outcomes are: • 2 Partially Upheld • 1 Upheld • 1 Not Upheld The Upheld case related to quality of care at Residential Home A. Actions for improvement are relating to:
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3 • The need for senior staff reflections and review of care practices, • Staff medication training • Training for “Excellence in care dementia modules” and seeking face-to- face training • Recruitment work to stabilise staffing in the care home GOVERNANCE: - SPSO case discussions are held at local clinical and care governance meetings, e.g Mental Health Incident Groups and outcome of SPSO investigations are discussed at the Clinical and Care Governance Group where actions and learning are presented. Mental health Welfare Commission (MWC) On the 25 November 2025 there was a MWC visit to Succoth Ward specifically, which was successful and recommendation actions are being addressed. 5 recommendations were positioned regarding: • Specialist bed pathways • Engaging more with the police where appropriate, • Increased MDT to include nursing, • How there can be an increase in clinical psychology input • More resources to enhance the outdoor garden areas. Recommendations are currently under work for consideration and completion where possible. GOVERNANCE: - Actions are being discussed through a dedicated forum and outcomes are presented to the local clinical and care governance meeting and Head of Department forum. Oversight is shared at the Clinical and Care Governance Group meeting. Fatal Accident Inquiries (FIA) Enquiry In October 2024 we received a FAI Enquiry with request for information. This case was in regards to a care and treatment and a failure to identify patient as a ‘major trauma’ patient. Information has been shared along with updates on the SAER outcomes and improvement actions; we are awaiting a decision and outcome from the Procurator Fiscal. There is no further action at this time as actions from SAER have been concluded are now supported operationally. In November 2025 we received a Procurator Fiscal enquiry regarding Cowal & Bute A&E. This case related to wound care and onward communication with GG&C. This was also an SAER and A&B HSCP involvement and information has been shared with the PF and we are awaiting response or further instruction. GOVERNANCE – These cases were SAER and therefore, the governance route was via the Quality and Patient Safety Review meeting and outcomes were shared with the Clinical and Care Governance Group at the time. Health and Safety Executive (HSE) Inquiry Improvement notice following suicide – most recent meeting was on the 5 March 2026. Recent activity has been:
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4 • Refinement of the HSE Education Recommendations Scoping document, which was discussed on the 13 April 2026 – updates to be shared for the next H&S Group meeting. • A draft SOP for Urgent emergency Mental Health Service (EUMHS) was discussed on the 20 March 2026 – This is going forward via clinical governance and hospital/community care meetings for ratification. • Increased Levels of Care Policy draft has been circulated for initial review with a view to coming to the next meeting for discussion. GOVERNANCE: - Regular updates are discussed at the A&B HSCP H&S Group meeting and then shared at the North Highland Health and Safety Committee. Health Improvement Scotland (HIS) – Oban General Hospital Unannounced HIS inspection end of October 2024. The final report was published end of February 2025. At this time a high volume of information is being requested pulled from the site to support with the recommendations and actions which have come out of the report. HIS report and improvement plan work continues. Care Inspectorate (CI) Improvement Tracker A Care Inspectorate Improvement tracker is in progress, with areas of development in medication management, quality assurance, staff induction, and updated fire safety protocols. All such areas have been addressed in target time and shared with the (CI). Most recent update dated the 27 March 2026 is that since November 2025, 2 inspections that have been done were for Ardfenaig and Struan Lodge and neither had any requirements from them. April 2026 sees the start of the new inspection year where we are anticipating there being some new inspections. GOVERNANCE:- Development and improvement actions have been monitored via an Action Log and discussed in a dedicated forum. As actions are completed, update has been shared in the local clinical and care governance forum and any that require escalation of one to the Senior Management Team Leadership meetings and updated via the Clinical and Care Governance Group meeting. Whistleblowing Learning Activity: On the 8 December 2025 a Children’s Services area whistleblowing case was concluded. Meeting with Senior Leadership for Children’s Services and Clinical Governance Manager have been arranged for the actions and learning to be reviewed for onward oversight. Learning areas focus on:
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5 • Safe, Quality and Care – o Ensuring models of practice and consistent with national frameworks. o Staff are supported with using professional judgements o Review staff access to guidance and support o Review staff and patient/client feedback o Review communication methods and systems • Professional Working Standards Planning and Development o Review of integrated governance systems o Training for staff o Workforce reviews o Ensure we are working within Healthcare Staffing Act and time is managed operationally • Professional Practice and Accountability o Reviewing systems for monitoring compliance o Review engagement routes for patients/clients and families o Routes for raising and managing concerns o Assessment of roles and responsibilities • Research Design and Innovation o Review ideas for supporting service transformation and changing professional practice so Health Visitors have access to the woder A&B HSCP teams. o Review technology and how this can be further utilised in the service to support improvements and change. Meetings to progress actions with owners will commence on the 5 May 2026 and oversight meetings will be held with Clinical and Care Governance. GOVERNANCE: - Regular meetings have been set up with Service Lead and the Clinical Governance Manager for oversight and review – Update in activity and actions will also be shared at the Clinical and Care Governance Group meetings. 4. RELEVANT DATA AND INDICATORS As part of the continuous improvements to drive learning and actions from our external scrutiny reports Clinical and Care Governance have created a central repository for all known external scrutiny activity to be monitored and for governance oversight. This will support assurance that there is action on driving the areas of learning across our HSCP. 5. CONTRIBUTION TO STRATEGIC PRIORITIES The recently released Health Improvement Scotland (HIS) Governance Standards have been rolled out to via the Clinical and Care Governance Group and across NHS Highland Quality Assurance Groups. This report of external body scrutiny and assurance mechanism will aid our HSCP to comply with the standards set and provide committee oversight and assurance.
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6 6. GOVERNANCE IMPLICATIONS 6.1 Financial Impact This report is over oversight and transparency, there are no decisions being made impacting financial position. 6.2 Staff Governance This report is giving oversight and transparency. The actions within scope of the various external body reports are driven with the aim of supporting staff governance, quality and patient safety. 6.3 Clinical and Care Governance I can assure the Committee that these areas of governance and improvement contribute to agenda items within the Clinical and Care Governance Group for the A&B HSCP. These items support onward transparency to our Clinical Governance Committee. 7. PROFESSIONAL ADVISORY I can assure the Committee that all areas of scrutiny as detailed in the report are driven with Professional Leadership involvement and Senior Operational Leadership. 8. EQUALITY & DIVERSITY IMPLICATIONS I can assure the Committee that all areas of action for continuous learning and improvement consider the equality and diversity rights of our patients / clients, families and staff. 9. GENERAL DATA PROTECTION PRINCIPLES COMPLIANCE I can assure the Committee that this report along with the internal log of actions for learning are monitored in a safe and secure manner, with data protection principles in place. 10. RISK ASSESSMENT As mentioned in the introduction, when reporting with full transparency there is consideration regarding what aspects is published and is in the public domain. The SPSO does inform complainants that their report summaries and decisions are published on their website. Please see Appendix A for link to their findings page. 11. PUBLIC & USER INVOLVEMENT & ENGAGEMENT 12. CONCLUSIONS
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7 The report concludes that robust systems are in place to capture, monitor, and respond to findings from external scrutiny. Actions arising are actively progressing with professional and operational leadership oversight, contributing to improve clinical and care governance, patient safety, and staff support. 13. DIRECTIONS Directions required to Council, NHS Board or both. Directions to: tick No Directions required x Argyll & Bute Council NHS Highland Health Board Argyll & Bute Council and NHS Highland Health Board 14. PREVIOUS REVIEW OF THE REPORT Meeting Title of report Date Output (if relevant) REPORT AUTHOR AND CONTACT Author Name Leah Smith Email leah.smith2@nhs.scot Appendices: Appendix A - Our findings | SPSO