8. Annual Clinical and Care Governance Report
North Ayrshire Council · 21 August 2025
Back to Integration Joint Board — 21 August 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 21st August 2025 Subject : North Ayrshire HSCP Clinical and Care Governance Report 2024-25 Purpose : This report is presented to IJB Members for :- • Awareness Recommendation : IJB Members are asked to note the contents of the annual 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 the people in North Ayrshire. 1.2 This paper provides an update and overview of governance activity for the period August 2024 – July 2025 for consideration by the Integration Joint Board (IJB). The Annual Report is attached at Appendix 1. 2. BACKGROUND 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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2.1 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 The Terms of Reference for the CCGG are included as Appendix 2 of this report. 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 • Operational Risk Register The CCGG has also had specific updates and assurance reports on: • Updates to the Strategic Plan • Ward 7A, Woodland view • Primary and Urgent Care • Front Door Service • Improving Cancer Journey Programme • MWC Young People Monitoring Report • KA Leisure Wellbeing Service • AHP highlight report 2.2 The Clinical and Care Governance Annual Report provides information on governance activity under Safe, Effective and Person centred headings. The paper provides details on how the CGG delivers on its function to review and consider operational risk management and escalation, oversight of reporting and reviewing adverse events within HSCP services including the outcome of significant adverse event reports. The paper highlights examples of key pieces of work during this period including activity on a range engagement activity with local communities. The paper provides an update on external inspection of NA HSCP services by the Mental Welfare Commission Information on services user feedback through engagement, complaints and compliments.
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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 No financial implications as a result of this paper 4.2 Human Resources None as a result of this paper 4.3 Legal None as a result of this paper 4.4 Equality/Socio-Economic None as a result of this paper 4.5 Risk Operational risks are reported to the PSMT and these risks are then remitted to the Clinical and Care Governance Group. The Group consider any High or Very High risks (as defined by the approved risk management strategy) and if required escalate these to the Partnership Senior Management Team (PSMT) for consideration for inclusion on the Strategic Risk Register. 4.6 Community Wealth Building None 4.7 Key Priorities Over the coming 12 months the NA HSCP CCG will: • Review the HIS Clinical Governance standards against local performance and identify areas of good practice and areas for improvement • Continue to develop consistent performance measures for health care services within the partnership to support governance scrutiny and assurance on quality of patient care. • Ensure that the NA HSCP Clinical Governance Group considers quality of care, safety and management of risk as part of discussion on financial recovery over the coming 12 months.
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4.4 Equality/Socio-Economic None 5. CONSULTATION None Caroline Cameron, Director For further information please contact Darren Fullarton, Lead Nurse/Associate Nurse Director Appendix 1 – NAHSCP Clinical and Care Governance Group Annual Report 2024/25 Appendix 2 – Clinical and Care Governance Group Terms of Reference
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North Ayrshire Health and Social Care Partnership Health and Care Governance Group Annual Report 2024/25 20250609 HSCP CG Reporting Template v1.0 1. Introduction 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. The North Ayrshire Health and Social Care Partnership (HSCP) has developed Clinical and Care Governance arrangements in line with the commitments and requirements contained in the Integration Scheme. The role and function of the North Ayrshire Clinical and Care Governance Group (CCG) is built upon strong partnership and collaboration and North Ayrshire HSCP continue to provide robust arrangements for the clinical and care governance of partnership services and wider relevant provision to deliver on statutory, policy and professional requirements and the achievement of partnership quality ambitions. The CCG is a standing group of the IJB. It is a requirement to submit an annual report on the activity of the CCG within the Partnership to the IJB and an annual report to the Healthcare Governance Committee. Key Messages • The North Ayrshire HSCP continues to have robust clinical and care governance arrangements in place to provide scrutiny and assurance on quality care and support for the people in North Ayrshire. • The partnership continues to face financial challenges in delivering and improving service within the available budget. • The partnership continues to strengthen its approach to engaging with our local communities to ensure that the design and delivery of service is done in collaboration with those that use the service. • The partnership has received positive feedback and learning from independent visits and inspection. • Healthcare Improvement Scotland (HIS) have published and consulted on Clinical Governance draft standards. Once approved we will measure our local performance against these standards. • The increased use of performance measures will support and promote scrutiny and assurance through the governance framework.
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North Ayrshire Health and Social Care Partnership Health and Care Governance Group Annual Report 2024/25 20250609 HSCP CG Reporting Template v1.0 2. Health and Care Governance Arrangements The North Ayrshire Clinical and Care Governance Group Framework: 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 • Operational Risk Register Over the past 12 months the CCGG has also received specific updates and assurance reports on: • Updates to the Strategic Plan • Ward 7A, Woodland view • Primary and Urgent Care • Front Door Service • Improving Cancer Journey Programme • MWC Young People Monitoring Report • KA Leisure Wellbeing Service • AHP highlight report
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North Ayrshire Health and Social Care Partnership Health and Care Governance Group Annual Report 2024/25 20250609 HSCP CG Reporting Template v1.0 The North Ayrshire Clinical and Care Governance group has met on 5 occasions since August 2024 and the meeting was adjourned on 4 occasions as the group was not quorate. The next NA CCGG is scheduled for 29th September 2025. The Terms of Reference is included as Appendix 1. 3. Safe Operational Risk Register Operational risks are reported to the PSMT and these risks are then remitted to the Clinical and Care Governance Group. The Group consider any High or Very High risks (as defined by the approved risk management strategy) and if required escalate these to the Partnership Senior Management Team (PSMT) for consideration for inclusion on the Strategic Risk Register. The CCG received Operational Risk Register (ORR) updates at the October 2024 meeting and no items were escalated. At the January 2025 meeting the risk in relation to Ward7A was escalated to PSMT resulting in a new risk being added to the Strategic Risk Register called ‘Growth and expansion of specialist complex care developments’. This was subsequently reported to the IJB in March 2025. Safety Action Notices Safety Action Notices are issued to alert services of concerns/faults that require review from the area manager for consideration of attention and action: # Received Returns Within Timescale % Returns Within Timescale Returns Outwith Timescale % Returns Outwith Timescale Q4 (Jan-Mar '25) 3 2 67% 1 33% Q1 (Apr-Jun '25) 10 0 0% 6 60% Q2 (Jul-Sept '25) 9 4 44% 1 11% Total 22 6 27% 8 36% 43% 57% Safety Action Notices 2025 Returns within Timeframe Returns outwith Timeframe 0 2 4 6 8 10 12 Equipment (Medical) Equipment (Other) Health & Safety SAN Themes
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North Ayrshire Health and Social Care Partnership Health and Care Governance Group Annual Report 2024/25 20250609 HSCP CG Reporting Template v1.0 Performance in this area will continue to be monitored to ensure improvements in returning “Responsible manager response and assurance sign off” within timeframes (within 14 working days) 3.1 Adverse Events Adverse events are reported and investigated on the NHS Datix system. Each adverse event is reviewed and approved locally with weekly oversight from HSCP and MH Adverse Event review groups. The following chart shows the total number of adverse events reported by all services in North Ayrshire: The total number of adverse events reported in this period was 2979 with incidents of violence and aggression slips, trips and falls and self-harm/suicide being the top three categories. Category Number Violence/Abuse/Harassment 1242 Slip, Trip or Fall 448 Self Harm / Suicide 436 Mental Health Services report the most adverse events following by Helath and Community Care and then Children’s, Families and Justice. The Mental Health Adverse Event Review Group (AERG) meets weekly and the North Ayrshire AERG meets every two weeks to review all incidents reported on Datix within that review period. 0 200 400 600 800 1000 1200 1400 North H&SCP 01/07/2024 -30/06/2025 Adverse Event Category
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North Ayrshire Health and Social Care Partnership Health and Care Governance Group Annual Report 2024/25 20250609 HSCP CG Reporting Template v1.0 MH and North AERG: • ensures that the appropriate level of review are undertaken and that all learning from reviews is shared across appropriate services. • outstanding Adverese Event Datix and LMTR trackers are on the weekly agenda with encouragement to the Senior Managers to review for their service and to udpate with the RMT. Monthly SAER meeting with AND/AMD/RMT and Senior Managers to: • nominate review teams – this is now from locality management teams and has resulted in improved timescales • review outstanding SAER where review team not confirmed • reiew and discuss and make decisions on any other challenges within SAER process The progress of all SAERs is tracked by the AERG coordinator and the review teams attend the AERG to present on draft reports prior to submission for final approval. At all stages efforts are made to ensure families are informed and engaged in the SAER process. 3.2 SAERs and LMTRs Since 2019 the number of Significant Adverse Event Reviews (SAER) commissioned for North Ayrshire HSCP is 85. 15 new SAER were commissioned in 2024/25 with 9 commissioned since April 2026. Of the SAERs commissioned in 2024/25, four of these have been completed with seven overdue and four on target to be completed. The AERG chairs, supported by the NHS Risk Management Team, continue to support review team leads to address challenges and barriers to completing SAERs. There has been significant progress in reducing the number of overdue SAERs over the past 12 – 18 months. The activity on undertaking Significant Adverse Event reviews has increased steadily over the past 10 years. This is welcome evidence of an ongoing commitment by the organisation to learn when things do not go well. 0 2 4 6 8 10 12 14 16 18 19/20 20/21 21/22 22/23 23/24 24/25 25/26 Number of SAERs (year)
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North Ayrshire Health and Social Care Partnership Health and Care Governance Group Annual Report 2024/25 20250609 HSCP CG Reporting Template v1.0 Through the MH AERG it is recognised that the framework around SAERs required to be reviewed and the support in place for senior leads undertaking SAERS considered. Tests of change have been undertaken to improve on roles and responsibilities: lead reviewers have timeous support from subject experts, responsibilities including family and staff contacts are shared equally and time in diary consciously planned to improve capacity to undertake SAER activity. The learning from this has been shared and implemented in our approach to supporting lead reviewers. The Root Cause Analysis Training offered to staff has been reviewed by the NHS Risk Management Team with a revised training programme set to be introduced in 2025. Since 2019 the number of Local Management Team Reviews (LMTRs) commissioned for North Ayrshire HSCP is 170. 19 new LMTRs were commissioned in 2024/25 with 8 commissioned since April 2026 Of the LMTRs commissioned in 2024/25, eight of these have been completed with 11 overdue to be completed. The AERG chairs, supported by the NHS Risk Management Team, continue to support review team leads to address challenges and barriers to completing LMTRs. There has been significant progress in reducing the number of overdue LMTRs over the past 12 – 18 months and work continues to complete overdue LMTRs from 2020/21 (2), 2021/22 (1), 2022/23 (6) and 2023/24 (4). 3.3 Learning and Improvement A review of emerging themes from recommendation and learning from SAERs was undertaken in 2024 and this identified the following three top themes: • Record Keeping • Communication between service/professional groups • Communication with family A further thematic analysis undertaken in 2025 identified five main themes from SAERs: • Care Pathways 0 5 10 15 20 25 30 35 40 45 19/20 20/21 21/22 22/23 23/24 24/25 25/26 Number of LMTR (year)
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North Ayrshire Health and Social Care Partnership Health and Care Governance Group Annual Report 2024/25 20250609 HSCP CG Reporting Template v1.0 • Clarity of roles • Communication • Staff Training • Care Assurance There are currently 16 action plans active within North Ayrshire HSCP (mainly mental health services) as a result of learning and improvements identified within SAERs. 7 Action plans were closed in 2024/25 with evidence of actions undertaken and completed approved through the AERG. This year to strengthen the scrutiny and review of action plans and to ensure that activity to imbed learning in practice, the terms of reference for the Quality and Safe Observation Group (a sub group of the MH Clinical Development and Governance Group) was recently expanded to provide consistent governance oversight of learning and action plans from local reviews and from independent inspections and visits such as HIS and MWC. Learning Summaries are developed for all SAER and LMTR reports where required: # Received Returns Within Timescale % Returns Within Timescale Returns Outwith Timescale % Returns Outwith Timescale Q4 (Jan-Mar '25) 0 0 0% 0 0% Q1 (Apr-Jun '25) 11 3 27% 8 73% Q2 (Jul-Sept '25) 2 1 50% 1 50% Total 13 4 31% 9 69% Performance within this area will continue to be reviewed and monitored to ensure improvement in compliance with timescales. 31% 69% Learning Summaries 2025 Returns Within Timescale Returns Outwith Timescale 0 1 2 3 4 Patient Safety/ Falls Pressure Ulcer Death/ Suicide Documentation/ Communication Issues Referral/ Treatment Delay Medication Issues Learning Summary Themes
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North Ayrshire Health and Social Care Partnership Health and Care Governance Group Annual Report 2024/25 20250609 HSCP CG Reporting Template v1.0 4. Effective 4.1 Key programmes of work Service User Engagement Over the past six months, we have been reviewing our current mental health service engagement and participation mechanisms with the aim of improving and developing them further. During this time, we have created a comprehensive Mental Health Services Framework document. This outlines our vision, roles, and responsibilities in ensuring that the voices of people with lived experience and carers are central to shaping the services we provide. Key developments include: · A new public-facing engagement and participation leaflet, which explains what we mean by engagement and highlights the many ways individuals can get involved and share their views. · A new web page on the NA HSCP website https://www.nahscp.org/mental-health-addiction · The creation of a Mental Health Services Engagement and Participation Network, designed to maintain regular communication with members of the public who are interested in helping shape our services. · A year-round feedback mechanism, allowing people to share their views at any point in their care or experience journey. We are also in the process of establishing carer and lived experience forums and panels. Our first Carers forum will launch on 30th July and will meet monthly, offering essential information on mental health carers’ rights, and available support. In addition, a development group is currently exploring the creation of a permanent Lived Experience Panel, which will serve as an ongoing source of insight and guidance for future service development and review. Broader work is underway with clinical teams to create a consistent approach to the collation of patient and carer experience. Currently this is captured in a variety of ways with no single point of oversight. We are currently working on the development of revised carer and patient experience surveys and where possible will encourage the collaborative use of similar tools to ensure a consistent approach that is aligned with national strategy and mental health standards. A key area in providing this consistency is the use of Smart Survey. The recommendation involves all mental health engagement being located centrally using this tool allowing us to centrally monitor feedback but also for clinical teams to utilise this to create local reports and action plans that feed into governance structures. To support this, we propose to develop engagement oversight groups that will be attended by clinical teams, managers, Planning support and QI to review engagement data quarterly. This new area of development will take 6 – 12 months to embed and provide enough time to evaluate the effectiveness of the changes proposed.
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North Ayrshire Health and Social Care Partnership Health and Care Governance Group Annual Report 2024/25 20250609 HSCP CG Reporting Template v1.0 In addition to the areas of development above, ongoing engagement has continued relating to many areas of service change and review. This has included public consultations, focus groups and 1:1 interviews. Within mental health services engagement we also run regular public Connect events throughout the year and run the North Ayrshire mental health Arts Festival with the Mental Health Foundation every October. Psychological Services Psychological Services remain close to the LDP 90% RTT standard (88% in June 2025) with the LDP being over 90% for 9 months over the last year. Pressures in particular parts of the service (CAMHS Psychology and Adult CMHTs) have impacted upon our ability to meet this threshold in the remaining 3 months over the last year. Requests for Neurodevelopmental Assessments are putting extra pressures on these services. Recruitment to vacancies to psychology posts has become easier over the last year because availability of workforce. Unfortunately, the reason for this is a reduction in available funding from SG across Scotland. Vacancies in the service have been recruited to and have ensured that the LDP 90% RTT has been met the majority of the time over the last year.. Further improvement will require increased capacity in the struggling specialties. Over the last year we have been able to establish a full complement our new leadership structure, with a new Heads of Specialty for Adult services. Psychological services has a new established clinical governance structure with two new Clinical governance groups which have started in June 2024. The Psychological Therapies and Interventions CGG chaired by the Director of Psychological services is supporting the implementation of the National specification for the Delivery of Psychological Therapies and Interventions (SG Sept 2023). The implementation of the PT specification has been further progressed over the last year. Significant work has been undertaken to ensure that Psychological Services have the structure and procedures in place to facilitate the requirements of the Safe Staffing Act across all Psychological Specialties. There remains a substantial focus on improvement of data quality and reporting. Psychological Services is working closely with data analysts and digital systems leads in order to ensure that we have data required for service improvement. Brighter Pathways update - Strategic Recommendations & Implementation Area to be progressed: • Develop a Supported Accommodation resource that will support 6 young people leaving care – April 2026 • Increase the number of foster carers in North Ayrshire, via transformation of digital recruitment strategies – Implemented in November 2024 • Implement new fostering scheme with increased finances to retain current carers and attract new carers – New fostering scheme implementation April 2026 • Develop a revised model to provide intensive support to families and children who are at risk of being accommodated – January 2026 • Develop a Standard Operating Procedure between Education and HSCP to ensure shared understanding and transparency between services, supporting more consistent and equitable funding decisions. September 2025
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North Ayrshire Health and Social Care Partnership Health and Care Governance Group Annual Report 2024/25 20250609 HSCP CG Reporting Template v1.0 • Placement Assurance Forum - scrutiny of all internal and external residential resources. September 2026 • Development of a service that provides psychological interventions, support and direct work to children on edge of care and care experienced young people -TBC Service Improvements already implemented • Revised Supported Care Scheme – revised scheme to support young people over sixteen. • Unaccompanied Asylum-Seeking Children Practice Guidance/Welcome Booklets • Moving on Forum/Tracker – to review and plan transitions for young people moving on from care settings. • Revised Housing Protocol - To ensure a co-ordinated response to the accommodation and support needs of care leavers. • The implementation of a new referral template for intensive support referrals to Rosemount for children in family-based care. • Pilot with Children’s House for psychological consultation to support children and young people. 4.2 Quality Improvement Capacity and Capability There is a focus on increasing QI capacity and capability through several learning opportunities. This includes Quality Improvement NHS Education for Scotland (NES) Modules, Ayrshire and Arran Improvement Foundation Skills Programme (AAIFS) and the national Scottish Improvement Leadership Programme (SCIL). • Over 30 staff have completed the Ayrshire and Arran Improvement Foundation Skills (AAIFS) programme since its inception. • 2 staff within mental health have a lead level qualification (SCIL) • The number of staff who have completed QI NES modules is difficult to identify as the data is reported organisationally. Staff undertaking quality improvement courses are encouraged to present their improvement journey and celebrate success and learning at celebration events which take place twice a year. The Quality Improvement and Innovation Group (QI and I) has witnessed an increased attendance, with staff joining to share their improvement ideas, feedback on tests of change and identify where QI support and education can be offered. Collaboration between the QI Partnership team and Senior Nurses has encouraged a streamlined, consistent and improved approach to the co-ordination and delivery of QI support across Mental Health Services. The QI and I Group are currently looking at whole service projects that can impact the patient journey experience. These include such projects as: • Introducing access to smart devices in a low secure setting to aid patient recovery • Taking therapy to the home within Perinatal MH • Cognitive Stimulation Therapy
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North Ayrshire Health and Social Care Partnership Health and Care Governance Group Annual Report 2024/25 20250609 HSCP CG Reporting Template v1.0 4.3 External Inspections of local service 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 Each year the MWC normally visits individuals in hospital, other care settings, and in their own homes to find out their views and check on their care and treatment. Where appropriate, they will also speak with friends and relatives. The Commission carries out their statutory duties by focussing on five main areas of work: • Visiting people • Monitoring the Acts • Investigations • Information and advice • Influencing and challenging NHS Ayrshire & Arran alongside their associated Health and Social Care Partnerships are subject to such visits. Between April 2024 and March 2025 the MWC undertook 5 announced visits to services across Ayrshire & Arran. • 3rd July 2024 – Ward 7A, Woodland View • 10th July 21024 – Ward 6, Woodland view • 16th August 2024 – Marchburn Ward, EACH • 25th September 2024 – Wards 9, 10 and 11, Woodland View • 6th March 2025 – Ward 8, Woodland View It is important to note that the structure of the visits are often based on the Commission’s thematic review of pertinent issues throughout the year. During the past year, the MWC have paid particular focus on the circumstances of people with learning disability and complex needs who have been in hospital for 10 years or more and published their thematic report “Hospital is not home” in January 2025. Following each visit ‘hot’ feedback is provided to the clinical site and senior management team. This is then followed up by a formal written report which is ratified and used as the basis for remedial work and improvement, as well as recognising positive practice. Of the 5 announced visits the MWC made recommendations for 3 of these.
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North Ayrshire Health and Social Care Partnership Health and Care Governance Group Annual Report 2024/25 20250609 HSCP CG Reporting Template v1.0 An assurance report was submitted to the NHS Healthcare Governance Committee on the 4th August provide further detail on the MWC visits, recommendations and action plans and is included as appendix 2. Wider inspection activity within the HSCP including reports and recommendations is available through the Care Inspectorate Publications and statistics website. 5. Person-Centred Care 5.1 Patient Experience - Concerns, Compliments, Complaints, and Feedback Gypsy Traveller – Mental Health Literature Engagement Report – August 2024 • participants) • The purpose of this engagement was to gather views on existing mental health and wellbeing resources and explore the communities’ opinions on the content, length and graphics of current mental health resources. • Participants suggested health information should be displayed simple and clear, resembling child like guides. More Infographics on health flyers and guides were strongly suggested to combat illiteracy. Suggestions were also made to include the gypsy traveller flag, and culturally appropriate photos and pictures that respect their lifestyle/ Locality Conversations – September 2024 (206 participants) • The purpose of this engagement was to gather views on service information and accessibility across the HSCP. • Participants noted Insufficient GP and dental services; difficulty getting appointments and long waiting lists. There were frustrations with triage procedures and receptionists seen as “gatekeepers.”. Many complaints about phone system and automated options, and elderly noted as being particularly challenged by these digital methods. Cultural needs (e.g., requesting a same-gender doctor) sometimes unmet, causing frustration and misunderstandings. Difficulty accessing mental health services, and multiple reports of long waiting lists for CAMHS resulting in insufficient support for young people. Claims of inadequate support for non-crisis situations and perceived lack of follow-up care within this service. Lack of continuity in staff across HCC and MH services. • Some positive experiences with certain healthcare practices and pharmacies were noted. NHS AA app beneficial for those who are digitally literate, and described as crucial for some, but hard to navigate for others. • Suggestions to Simplify video triage processes and emails; upgrade phone systems. Increase availability and flexibility of GP appointments (more face-to-face and out-of-hours options). Language line needs to be available at triage stage of GP, not just in appointment, or translate options. Equalities Engagement – September 2024 (206 participants – combines with above locality engagement) • The purpose of this engagement was to collect information from equalities groups across North Ayrshire to inform HSCP equalities outcome plan. Questions were designed to get on their views of accessing and receiving health and social care services, to discover any barriers they may face, and find out their suggested improvements. • Participants noted reduction in women’s health screenings. Long waiting lists for hearing aids were noted multiple times, forcing people to pay for private services. Some noted that
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North Ayrshire Health and Social Care Partnership Health and Care Governance Group Annual Report 2024/25 20250609 HSCP CG Reporting Template v1.0 when hearing aids were handed into Crosshouse, they were left without being able to hear for up to a week whilst they were fixed and returned. patient transport services noted as being unreliable. It was also noted that there is only 1-2 gender clinics in Scotland with long wating lists, and general insufficient resource and health support for trans people in the area. It was felt that Doctors often dismiss health concerns for pregnant women as pregnancy-related, Fear of being misdiagnosed with depression or post-partum issues. Inadequate resources for children with disabilities or neurodevelopmental disorders were noted, particularly difficulty accessing prescriptions and specialised care. Across the engagement many were fearful of understaffing in hospitals and shared experiences of delayed care. Difficulties with referrals for those with substance problems, particularly obtaining a CPN. • There were positive mentions of health visitors and sexual health clinics as they were praised for their reassurance, responsiveness, and support and provide valuable information and referrals. • Suggestions were made to Provide comprehensive information at diagnosis and E ensure consistent care, counselling, and support post-diagnosis. Additionally, suggestions to provide general health checks to the gypsy traveller community and signpost to relevant health services to support identified needs. There was also suggestions to provide training to community groups on suicide risk and low-level support and offer health training sessions, such as defibrillator use. Elderly groups suggested establishing annual well man’s clinics for comprehensive health check-ups, Including tests for diabetes, PSA, blood pressure, and other indicators. Locality Conversations – Young person Engagement – May 2025 (219 participants) • The purpose of this engagement was to gather young people’s views on HSCP services for our Locality Plans and the Children’s services plans. Questions were designed to get local priorities, uncover where young people look for support and any barriers they face, and suggestions of service improvement • Young people noted long waiting lists for mental health support and not being signposted to alternative options. Furthermore, they feel they are often dismissed by adults when raising concerns about their mental health which furthers stigma around the topic. Neurodiversity was largely raised, with concerns around lack of support and diagnosis. Young people noted feeling let down, misunderstood and alone. There were huge concerns of young people accessing substances, without knowledge of lasting health impacts. • Breathing space was noted as being helpful and young people liked being able to access support anonymously, as well as information on NHS website. • Young people suggest school staff need more neurodiversity training to better support their students, as well as updated training on mental health. further suggestions were made to have accessible routes for young people to find health information in their local area, with suggestions of school assembly awareness sessions of pathways as well as youth only clinics/drop in hubs. Young people called for more counsellors and ‘activity based’ mental health support as opposed to just support in clinical settings. Suggestions were also made about having support in localities, with difficulties getting to appointments (CAMHS/ physio) that are based in Irvine when from other localities.
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North Ayrshire Health and Social Care Partnership Health and Care Governance Group Annual Report 2024/25 20250609 HSCP CG Reporting Template v1.0 5.2 Complaints themes Final annual report currently being finalised and will be presented to the IJB. This final report will provide analysis of complaints performance and analysis. However, the following table provides high level overview of activity: Indicator Data Complaints received (2025) Stage 1 53 closed 3 ongoing (2 overdue) Stage 2 42 closed 7 ongoing (within timescales) Stage I performance Percentage closed in time 43 (79%) Stage 2 performance Percentage closed in time 31 (74%) 6. Priorities for forthcoming year • Review the HIS Clinical Governance standards against local performance and identify areas of good practice and areas for improvement • Continue to develop consistent performance measures for health care services within the partnership to support governance scrutiny and assurance on quality of patient care. • Ensure that the NA HSCP Clinical Governance Group considers quality of care, safety and management of risk as part of discussion on financial recovery over the coming 12 months.
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NORTH AYRSHIRE Health and Social Care Partnership In partnership with 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, in particular, 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 Page 2 of 4 Terms of Reference 1.0 Introduction The Clinical and Care Governance Group is identified as a sub group 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 sub group 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. 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.
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NORTH AYRSHIRE Health and Social Care Partnership Page 3 of 4 The Vice Chair of the Group will be the Clinical Director 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 • Psychology Professional Lead • Carer Representative • Risk Management Representative • Governance Representative (NHS) 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 of the professional leads will constitute a quorum. The professional leads are: • Clinical Director • Lead Nurse • Lead Allied Health Professional • Chief Social Work Officer • Associate Medical Director, Mental Health Services • Assistant Director of Public Health • Clinical Director for Psychological Services Members will be asked to identify deputies to attend in their absence however they will not be included in quorum numbers. 5.0 Attendance The group may co-opt additional advisors as required. 6.0 Frequency of Meetings The Group will meet every 4 weeks. 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
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NORTH AYRSHIRE Health and Social Care Partnership Page 4 of 4 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. 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 in order to provide assurance and accountability. • The group will monitor and review risks falling within it’s 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