Clinical and Care Governance bi-annual Report
North Ayrshire Council · 20 March 2025
Back to Integration Joint Board — 20 March 2025 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 March 2025 Subject : North Ayrshire HSCP Clinical and Care Governance bi-annual Report 2024-25 Purpose : This report is presented to IJB Members for :- • Awareness Recommendation : IJB Members are asked to note the contents of the biannual Report 2024-25 Direction Required to Council, Health Board or Both Direction to :- 1. No Direction Required √ 2. North Ayrshire Council 3. NHS Ayrshire & Arran 4. North Ayrshire Council and NHS Ayrshire & Arran Glossary of Terms CAMHS Child & Adolescent Mental Health Services CCGG Clinical Care Governance Group HSCP Health and Social Care Partnership IJB Integration Joint Board NHS AA NHS Ayrshire and Arran MWC Mental Welfare Commission NA North Ayrshire 1. EXECUTIVE SUMMARY 1.1 North Ayrshire HSCP continues to have robust clinical and care governance arrangements in place to provide high quality care and support for people in North Ayrshire. 1.2 This paper provides a biannual update of governance activity for the period August 2024 – February 2025 inclusive for consideration by the Integrated Joint Board (IJB). An annual report will be provided to the IJB in July 2025. 2. BACKGROUND 2.1 As part of the integration of health and social care services, a National Clinical and Care Governance Framework was developed. Clinical and Care Governance is the system in which the HSCP’s are accountable for continuously improving quality and safeguarding high standards of care. The Partnership has developed Clinical and Care Governance arrangements in line with the commitments and requirements contained in the Integration Scheme.
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2.2 The Clinical and Care Governance Group (CCGG) provide assurance to the IJB that: • Quality of care, effectiveness and efficiency drives decision-making about the planning, provision, organisation and management of services • The planning and delivery of services take full account of the perspective of patients and service users • Unacceptable clinical and care practice will be detected and addressed 2.3 The CCGG has a standing agenda that ensures routine consideration of: • Public Protection • Professional Updates • Heads of Service updates • Adverse Events • Complaints/Enquiries • Inspection Reports/Action Plans/SPSO • Workforce • Consultation and Safety Action Notices • Infection Control and Infection 2.4 The CCGG has had specific updates and assurance reports within this period on: • Operational Risk Register CCG reviewed the 5 new risks added to the Operational Risk Register since May 2024 and agreed appropriate monitoring and escalation requirements No increase in scores for current risks on register in this period Two risks have reduced in score 5 risks removed from the register and being appropriately managed • Updates on KA Leisure Wellbeing Service This project supports the HSCP health and wellbeing agenda, focussing on activity for the most vulnerable groups Tiered programme with people being identified as those who would benefit from physical exercise to assist with their condition Contract is in place for one year and then will be subject to review in years two and three Monitoring visits are set with KA Leisure throughout the year In terms of data management, KA Leisure will be a pilot site for a national data set which will analyse information to gauge impact for these types of services • Allied Health Professional Update 5 professional groups form the AHP workforce Approximately 200 Whole time equivalent staff within AHP staff groups Speech and Language Therapy risk raised and discussed due to workforce challenges • Development of workforce reports to inform CCG of challenges and issues that may impact on quality of care • Risks in meeting statutory duties – these have been captured in Strategic and Operational Risk registers and are reported through appropriate governance routes.
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2.5 Mental Welfare Commission The Mental Welfare Commission (MWC) for Scotland’s mission and purpose is to be a leading and independent voice in promoting a society where people with mental illness, learning disabilities, dementia and related conditions are treated fairly, have their rights respected, and have appropriate support to live the life of their choice. To achieve this mission and purpose the Commission have identified four strategic priorities: • To challenge and to promote change • Focus on the most vulnerable • Increase their impact • Improve their efficiency and effectiveness 2.6 Between August 2024 and February 2025 mental health services across Ayrshire and Arran received two announced visits from the MWC. Full reports are available for all visits, however, in summary: • The MWC made 7 recommendations following both visits and received responses to all recommendations within 3 months of the report being published. • Action plans in response to the MWC on the recommendations were submitted back to the MWC within 3 months and are reviewed and monitored through the Mental Health Clinical and Care Governance framework. • The insights, recommendations and positive acknowledgement of the delivery of high quality care provided by the MWC review and visit process is seen as positive by our organisation. • Any improvements identified provide the clinical site, senior management and staff teams with a clear focus, helping to prioritise areas of work which in turn provides the assurance required to evidence the continued delivery of high quality care. • An annual assurance report providing details of all visits, recommendations and action plans and thematic reports will be developed by the North Ayrshire CCG and presented to the IJB and NHS Ayrshire and Arran Healthcare Governance Group in 2025. 2.7 Inspection of Local Services Between August 2024 and February 2025, a total of four inspections took place by the Care Inspectorate - all four were unannounced. Full reports are available for all visits, however, in summary: • Canmore Care Home Service: unannounced inspection on 05 August 2024. The Care Inspectorate evaluated the service as 3 (adequate) with one requirement and one area of improvement highlighted in the report. • Trindlemoss Day Opportunities Support Service: unannounced inspection 15 – 17 October 2024. The Care Inspectorate evaluated the service as 5 (very good) with one area of improvement highlighted in the report.
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• Montrose House Care Home Service: unannounced inspection 29 October 2024. The Care Inspectorate evaluated this service as 4 (Good). The report noted that the service had made significant improvements since the previous inspection and the service met two previous requirements and four areas of improvement since last inspection. • Supported Carers Scheme Adult Placement Service: unannounced inspection 24 – 25 October 2024. The Care Inspectorate evaluated the service as 5 (very good) for how well they support people’s wellbeing and 3 (adequate) across leadership, staff team and how care and support is planned. There was one requirement and two areas of improvement noted. 2.8 North Ayrshire HSCP Risk Management Activity A quarterly report is developed by the NHS Risk Management Team and reviewed by the NA CCG. The report was reviewed and discussed at the NHS Risk and Resilience Scrutiny and Assurance Group on 24 January 2025. In summary, within the last quarter (Q3), a reduction in the number of adverse events were reported on the NHS Datix system. The number of adverse events with a high consequence score (4 or 5) were also lower than previous quarter. The HSCP continues to support and encourage all services to review and approve all adverse incidents within an appropriate time frame. 3. PROPOSALS 3.1 Anticipated Outcomes Further meeting dates for the NA HSCP’S CCGG are planned for 2024/25, and future update reports will be provided to the Integration Joint Board. 3.2 Measuring Impact It is anticipated that through continuous quality improvement and enhanced reporting structures, the CCGG will ensure services are safe, effective, person-centred and responsive to the ongoing needs of the population. 4. IMPLICATIONS 4.1 Financial None 4.2 Human Resources None 4.3 Legal None 4.4 Equality/Socio-Economic None
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4.5 Risk Governance contributes to risk management and risk mitigation activities. 4.6 Community Wealth Building None 4.7 Key Priorities As part of the integration of Health and social care services, a National Clinical and Care Governance Framework was developed. Clinical and Care Governance is the system in which the Health and Social Care Partnership are accountable for continuously improving quality and safeguarding high standards of care. 4.4 Equality/Socio-Economic None 5. CONSULTATION None Caroline Cameron, Director For further information please contact Darren Fullarton, Lead Nurse/Associate Nurse Director