10. IJB Report- Clinical and Care Governance Report FINAL
North Ayrshire Council · 20 August 2026
Back to Integration Joint Board — 20 August 2026 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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Integration Joint Board 20th August 2026 Subject : North Ayrshire H&SCP Clinical and Care Governance Report Purpose : • Awareness Recommendation : • Note the establishment and ongoing development of the North Ayrshire H&SCP Clinical & Care Governance Group Governance Assurance Arrangements. • Note progress in implementing Healthcare Improvement Scotland (HIS) Clinical Governance Standards. • Note key governance risks, areas of assurance and improvement activity identified through the Clinical & Care Governance Group during 2026. Direction Required to Council, Health Board or Both Direction to :- 1. No Direction Required X 2. North Ayrshire Council 3. NHS Ayrshire & Arran 4. North Ayrshire Council and NHS Ayrshire & Arran Glossary of Terms NHS AA NHS Ayrshire and Arran HSCP Health and Social Care Partnership HIS Healthcare Improvement Scotland ORR Operational Risk Register MAPPA Multi-Agency Public Protection Arrangements IPC Infection Prevention & Control AHP Allied Health Professionals CMHT Community Mental Health Team 1. EXECUTIVE SUMMARY 1.1 The North Ayrshire H&SCP Clinical & Care Governance Group has continued to strengthen governance oversight arrangements throughout 2026. The Group has undertaken a review of its Terms of Reference, considered alignment with the Healthcare Improvement Scotland Clinical Governance Standards and commenced work to map existing governance structures and reporting arrangements across North Ayrshire HSCP services. 1.2 The group has received assurance reports relating to clinical quality, patient safety, professional practice, public protection, infection prevention and control, policy compliance and service developments.
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Governance oversight has included review of the Operational Risk Register, workforce pressures, Learning Disability services, adult Neurodevelopmental services, complex care provision, Public Protection arrangements and implementation of standards- based improvement programmes. 1.3 Work is ongoing to embed the HIS Clinical Governance Standards within North Ayrshire HSCP Governance Structures, identify areas requiring improvement and strengthen integrated governance arrangements across health and social care services. 2. BACKGROUND 2.1 The Clinical & Care Governance Group was established to provide assurance regarding quality, safety, clinical effectiveness, risk management and professional governance across North Ayrshire H&SCP services. During 2026, under new stewardship, the Group reviewed its governance arrangements and agreed updates to its Terms of Reference, including alignment to newly published Healthcare Improvement Scotland Clinical Governance Standards. 2.2 During 2026 the Group has considered a range of governance matters including, but not limited to: • Operational and Strategic Risks. • Workforce Pressures across Mental Health, Nursing, Social Care and Allied Health Professions. • Learning Disability Inpatient Provision and Ward 7A Service Redesign. • Adult Dysphagia Governance and Staff Competency Assurance. • Public Protection and MAPPA oversight. • Infection Prevention and Control Standards. • Implementation of National Standards, Policies and Guidance 3. PROPOSALS 3.1 The IJB is asked to note: • Progress in developing integrated Clinical and Care Governance arrangements. • Ongoing implementation and self-assessment against the HIS Clinical Governance Standards. • Continued monitoring and escalation of significant operational and strategic risks through established governance structures. • Work underway to strengthen governance assurance relating to workforce sustainability, patient safety, quality improvement and public protection. • Development of governance mapping and reporting arrangements to support integrated assurance across the HSCP.
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3.2 Anticipated Outcomes Implementation of the proposals will: • Strengthen governance oversight and assurance arrangements. • Improve compliance with national clinical governance standards. • Enhance identification, monitoring and mitigation of clinical and care risks. • Support continuous quality improvement and learning. • Strengthen integrated working between health and social care governance systems. 3.3 Measuring Impact Impact will be monitored through: • Regular Clinical & Care Governance Group reporting. • Progress against HIS Clinical Governance Standards action plans. • Monitoring of Operational and Strategic Risk Registers. • Audit, Quality Improvement and Assurance Activity. • Monitoring of Incidents, Complaints, Learning Reviews and Public Protection Arrangements. • Reporting to established IJB and NHS Healthcare Governance structures. 4. IMPLICATIONS 4.1 Financial No direct financial implications arise from this report. Financial pressures associated with identified risks and service developments continue to be monitored through normal governance and financial reporting arrangements. 4.2 Human Resources The report highlights a number of workforce-related risks and improvement activities including Psychiatry workforce pressures, Community Nursing staffing, Social Care workforce sustainability, Neurodevelopmental services and AHP workforce planning. These risks are already identified via appropriate risk management processes. 4.3 Legal The work supports compliance with statutory governance duties and national clinical governance requirements. 4.4 Equality/Socio-Economic Implementation of governance standards and quality assurance processes supports the delivery of equitable, safe and effective care across health and social care services. Particular consideration has been given to equality, inclusion and wider socio-economic factors, with a focus on reducing inequalities, improving access to services and supporting meaningful involvement of individuals, carers and communities in line with Healthcare Improvement Scotland Standards.
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4.5 Risk The report highlights a number of high and very high residual operational risks, including adult neurodevelopmental services, children's placements, NHS workforce sustainability and Arran service pressures. These risks continue to be actively monitored through established risk management and governance arrangements, with mitigation plans in place and progress reported separately through Integration Joint Board governance processes to support oversight, assurance and scrutiny. 4.6 Community Wealth Building No direct implications identified. 4.7 Key Priorities The proposals support delivery of the HSCP Strategic Plan through improving quality, safety, governance, integrated care, workforce sustainability and continuous improvement. 5. CONSULTATION This report reflects discussions and assurance activity undertaken through the North Ayrshire HSCP Clinical & Care Governance Group, with representation from Heads of Service, Professional Leads, Operational Managers, Finance, Quality Improvement, Medical, Nursing, Psychology, Allied Health Professional, Pharmacy and Social Work Services. Director: Caroline Cameron, Chief Officer Author Name, Designation: Julie Barrrett, Associate Nurse Director/ Lead Nurse, North Ayrshire H&SCP Appendices • Appendix 1: Clinical & Care Governance Group Key Assurance Themes 2026 • Appendix 2: Summary of Key Governance Risks and Improvement Actions 2026 • Appendix 3: Updated Terms of Reference 18/05/2026
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Appendix 1 CLINICAL & CARE GOVERNANCE GROUP KEY ASSURANCE THEMES 2026 Purpose This appendix provides a summary of the key areas of assurance, oversight and improvement activity considered by the North Ayrshire HSCP Clinical & Care Governance Group during 2026. The group have met on 3 occasions since the beginning of 2026; • 30/03/2026 • 18/05/2026 • 27/07/2026 A copy of each note can be made available if required by the IJB. In general, the Key Themes identified during these meetings were as follows. 1. Clinical and Care Governance Framework The Group reviewed and updated its Terms of Reference to ensure alignment with the Healthcare Improvement Scotland (HIS) Clinical Governance Standards and agreed a programme of work to strengthen governance arrangements across health and social care services. Key developments included: • Review of governance reporting structures. • Governance mapping across North Ayrshire services. • Identification of decision-making and escalation pathways. • Establishment of quarterly governance review arrangements. 2. Healthcare Improvement Scotland Clinical Governance Standards The Group received detailed presentations and updates regarding implementation of the seven HIS Clinical Governance Standards. Areas reviewed included: • Leadership and staffing. • Quality management. • Clinical effectiveness. • Clinical safety. • Education and training. • Involvement and participation. • Data and information governance. A self-assessment and gap analysis process has commenced to identify areas requiring further development and improvement planning.
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3. Workforce Assurance The Group reviewed workforce sustainability risks and pressures affecting service delivery, including: Mental Health Services • Consultant Psychiatry vacancies. • Community Mental Health Team workforce pressures. • Community Eating Disorder Service workforce and funding challenges. • Development of Psychiatry Workforce Planning Arrangements. Nursing Workforce • Community nursing staffing levels and skill mix. • District nursing workforce resilience. • Demand and capacity within Adult Community Mental Health Services. Allied Health Professionals • Increasing complexity and demand. • Healthcare Staffing Act workforce review activity. • Professional assurance arrangements. Social Work and Social Care • Social work staffing sustainability. • Recruitment and retention challenges. • Service demand pressures. 4. Quality and Safety Assurance The Group received assurance reports relating to: • Falls prevention and management guidance. • Safe use of bed rails. • Adult dysphagia policy and training arrangements. • Infection Prevention and Control standards. • Provision and management of patient meals. • Chaperone policy implementation. The Group endorsed revised clinical guidance and policies where appropriate and identified areas requiring additional oversight and staff training.
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5. Public Protection The Group maintained oversight of Public Protection matters through updates relating to: • Adult Support and Protection. • MAPPA arrangements. • Management of Restricted Patient Cases. • Strategic Suicide Prevention Activity. • Drug Death Governance Arrangements. 6. Service Improvement and Clinical Effectiveness The Group received updates regarding: • Improving the Cancer Journey Programme. • Frailty Standards self-assessment. • Palliative and End of Life Care improvement work. • National clinical guidelines and standards implementation. 7. Learning Disability and Neurodevelopmental Services The Group considered several significant assurance issues including: • Demand and capacity challenges across specialist services. • Learning Disability patient safety considerations. • Ward 7A service redesign and options appraisal. • Lack of dedicated Learning Disability inpatient provision. • Adult Neurodevelopmental service demand. Overall Assurance Position The Clinical & Care Governance Group has established robust arrangements for Governance Oversight and Assurance. Positive progress has been demonstrated in strengthening governance structures, embedding national standards and improving risk oversight. The Group recognises that significant challenges remain in workforce sustainability, specialist service demand and delivery of improvement priorities, which continue to be actively monitored through established governance processes.
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Appendix 2 Summary of Key Governance Risks and Key Improvement Priorities for 2026/ 2027 Risk Area Current Position Key Mitigations/Actions Assurance Level Adult Neurodevelopmental Services (ORR65) Very High residual risk due to demand, access and treatment pressures. Review of service model, workforce planning and monitoring through governance structures. Moderate Children's Services Placements (ORR64) Very High risk relating to availability and sustainability of placements. Ongoing monitoring and escalation through senior management structures. Moderate NHS Staffing Levels and Skill Mix (ORR62) High residual workforce risk across services. Workforce review, recruitment activity and service redesign. Moderate Community Mental Health Services Workforce and capacity pressures affecting service delivery. Workforce planning, caseload review and medical leadership oversight. Moderate Learning Disability Inpatient Provision No dedicated inpatient resource for adults with learning disabilities. Ward 7A redesign, nursing competency review and escalation through governance structures. Moderate Arran Ferry Disruption Significant risk to access, transfers and patient safety. Ongoing monitoring and contingency planning. Moderate Complex Packages of Care High demand and resource pressures. Service redesign and operational oversight. Moderate Significant Adverse Event Reviews Historical backlog in completing reviews. Risk escalation and review of governance arrangements. Moderate Dysphagia Competency Assurance Inconsistent assurance across health and social care workforce. Training review, NES resources and monitoring arrangements. Developing Chaperone Policy Implementation New policy requiring awareness and workforce compliance. Communication, training and governance monitoring. Developing IPC Standards Compliance Predominantly compliant position with identified improvement actions. Quarterly performance monitoring and training assurance. Good
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HIS Clinical Governance Standards Implementation programme underway. Self-assessment, action planning and governance oversight. Developing Key Improvement Priorities for 2026/27 1. Complete HIS Clinical Governance Standards self-assessment and action planning. 2. Finalise governance mapping across health and social care services. 3. Strengthen workforce assurance arrangements across NHS and Social Care Services. 4. Improve oversight of high and very high risks through integrated governance reporting. 5. Strengthen assurance regarding Public Protection, MAPPA and restricted patient governance. 6. Enhance monitoring of staff training, competency and compliance requirements. 7. Maintain oversight of Learning Disability, Neurodevelopmental and Mental Health Service Pressures. 8. Develop integrated governance arrangements that better align health and social care standards and assurance frameworks.
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NORTH AYRSHIRE Health and Social Care Partnership In partnership with Appendix 3: Updated Terms of Reference 18/05/2026 Clinical and Care Governance Group Background The main purpose of integration is to improve the wellbeing of people who use our health and social care services, of families, our communities, and particularly those whose needs are complex and involve support from across health and social care at the same time. The North Ayrshire Health & Social Care Partnership (NAHSCP) Integration Scheme is intended to achieve the National Health and Wellbeing Outcomes prescribed by the Scottish Ministers in Regulations under section 5(1) of the Public Bodies (Joint Working) (Scotland) Act 2014 (hereinafter referred to as “the Act”). In Annex C of ‘Clinical and Care Governance of Integrated Health and Social Care Services’ (A Scottish Government publication) it contains the following description of clinical and care governance. 1. Clinical and care governance is the process by which accountability for the quality of health and social care is monitored and assured. It should create a culture where delivery of the highest quality of care and support is understood to be the responsibility of everyone working in the organisation - built upon partnership and collaboration within teams and between health and social care professionals and managers. 2. It is the way by which structures and processes assure Integration Joint Boards, Health Boards and Local Authorities that this is happening - whilst at the same time empowering clinical and care staff to contribute to the improvement of quality - making sure that there is a strong voice of the people and communities who use services. 3. Clinical and care governance should have a high profile, to ensure that quality of care is given the highest priority at every level within integrated services. Effective clinical and care governance will provide assurance to patients, service users, clinical and care staff and managers, Directors alike that: a. Quality of care, effectiveness and efficiency drives decision-making about the planning, provision, organisation and management of services; b. Unacceptable clinical and care practice will be detected and addressed 4. Effective clinical and care governance is not the sum of all these activities; rather it is the means by which these activities are brought together into this structured framework and linked to the corporate agenda of Integration Authorities, NHS Boards and Local Authorities. 5. A key purpose of clinical and care governance is to support staff in continuously improving the quality and safety of care. However, it will also ensure that wherever possible poor performance is identified and addressed. All health and social care professionals will remain accountable for their individual clinical and care decisions. 6. Many clinical and care governance issues will relate to the organisation and management of services rather than to individual clinical decisions. All aspects of the work of Integration Authorities, Health Boards and local authorities should be driven by and designed to support efforts to deliver the best possible quality of health and social care. Clinical and care governance, however, is principally concerned with those activities which directly affect the care, treatment and support people receive.
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NORTH AYRSHIRE Health and Social Care Partnership In partnership with Terms of Reference 1.0 Introduction The Clinical and Care Governance Group is identified as a subgroup of the North Ayrshire Health and Social Care Partnership, Integration Joint Board (IJB). The approved Terms of Reference and information on the composition and frequency of the group will be considered as an integral part of the standing orders of the Integrated Joint Board. The Group will be known as the Clinical and Care Governance Group of the Integration Joint Board and will be a subgroup of the Integration Joint Board. 2.0 Remit To provide assurance to the IJB as follows: • On the quality and safety of health and social care partnership services. • That staff across the Partnership are supported to provide quality services and are appropriately skilled and registered to discharge their professional responsibilities. • That proposed changes in practice, within one professional group, do not adversely impact upon another profession, and that there is a whole system approach to improvement. • That services are able to learn and develop from service user and carer experiences and that effective mechanisms are in place to do so. • That self-evaluation and quality assurance mechanisms are in place to inform improvement. • That a systematic and proportionate approach to the review of critical incidents, significant incidents and near misses is embedded in the Partnership; and pan- Ayrshire where this relates to mental health services. • That findings of critical incidents, significant events and near misses, locally and nationally, are considered and used to review and improve practice. • That services commissioned through registered, third and independent sector have appropriate contract monitoring arrangements in place and that those services are delivered to a high standard. • That medical devices (and where required - devices to support care), that are used, are sourced and maintained appropriately. • That appropriate links to Infection Control structures are in place. • That a learning culture is encouraged and that good practice and success is shared widely. • That current Partnership governance structures report into and through the Clinical & Care Governance Group. • That practice improvement plans are delivered, as appropriate. • That all Health and Care arrangements are developed with service users at the centre.
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NORTH AYRSHIRE Health and Social Care Partnership In partnership with 3.0 Group Membership The Clinical and Care Governance Group will be chaired by the Lead Nurse, on behalf of the Chief Officer. The Group will report to the Chief Officer and through the Chief Officer to the Integration Joint Board. The Vice Chair of the Group will be the Clinical Director (Primary Care) who will cover the meeting in the Chair’s absence. The group will comprise of the following members: • Lead Nurse • Clinical Director • Lead Allied Health Professional • Chief Social Work Officer • Associate Medical Director, Mental Health Services • Director of Public Health or representative • Head of Children, Families & Justice Services • Head of Health and Community Care • Head of Mental Health • Quality Improvement Lead • Director of Psychological Services • Risk Management Representative • Governance Representative (NHS) • Pharmacy Lead Service Users and Carers, Third and Independent sector representation will be sought via the IJB. The Chair and members will be appointed by the IJB. Group membership will be reviewed annually and the first meeting of the year. 4.0 Quorum Four members including two core members will constitute a quorum. Members will be asked to identify deputies to attend in their absence. 5.0 Attendance The group may co-opt additional advisors as required. 6.0 Frequency of Meetings The Group will meet quarterly. The Chair may, at any time, convene additional meetings of the group. 7.0 Authority The group is authorised to investigate any matters which fall within its terms of reference and obtain external professional advice. The group may form sub-groups to support its functions. The group is authorised to seek and obtain any information it requires from any employee whilst taking account of policy, legal rights and responsibilities.
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NORTH AYRSHIRE Health and Social Care Partnership In partnership with 8.0 Duties The Group shall be responsible for the oversight of clinical and care governance within North Ayrshire Health and Social Care Partnership and specifically it will: • Consider matters relating to; professional governance relevant to Strategic Plan development, service user feedback and complaints, standards, education, learning, continuous improvement and inspection activity. • Provide advice to the strategic planning group, audit and performance committee and locality groups within the Council area. The strategic planning group, audit and performance committee and locality groups may seek relevant advice directly from the Group. • Provide assurance to IJB on the operation of clinical and care governance within the Health and Social Care Partnership in compliance with relevant national standards, highlighting problems and action being taken where appropriate. • When clinical and care governance issues relating to Lead Partnership Services are being considered, the Clinical and Care Governance Group for the Lead Partner will obtain input from the Clinical and Care Governance Groups of the other Health and Social Care Partnerships. • When Clinical and Care Governance issues relating to Public Health are being considered, the Clinical and Care Governance Group will obtain input from the Public Health Governance Group. • The Integration Joint Board may seek advice on clinical and care governance directly from the Clinical and Care Governance Group. In addition, the Integration Joint Board may directly take into consideration the professional views of the professional leads as outlined previously. • Receive minutes and annual reports from the sub-groups established by the Clinical and Care Governance Group to provide assurance and accountability. • The group will monitor and review risks falling within its remit. 9.0 Conduct of Business Meetings of the group will be called by the Chair of the group. The agenda and supporting papers will be sent to members five working days prior to the date of the meeting. 10.0 Reporting Arrangements Minutes will be kept of the proceedings of the group and will be circulated in draft within five working days to the Chair of the meeting and within three working days thereafter to group members, prior to consideration at a subsequent meeting of the committee. The Chair of the group shall provide assurance on the work of the group, and the approved minutes will be submitted to the IJB for information. The group will conduct an annual review of its role, function and achievements. The group will hold a repository for annual reports from Stakeholder Groups.