Minute of the Joint Clinical and Care Governance Committee

Wednesday 8 April 2026

Attendance

Fiona Mackay (Non-Executive Board Member - Chair), Dr Kirsty Cole (Area Clinical Forum Chair), Debs Crohn (Head of Corporate Governance), Dr Anna Lamont (Medical Director), James Goodyear (Interim Chief Executive), Councillor Lindsay Hall (Orkney Island Council Elected Representative), Councillor Ivan Taylor (Orkney Island Council Elected Representative), Wendy Lycett (Interim Director of Pharmacy), Dr Louise Wilson (Director of Public Health), Darren Morrow (Head of Children’s Services, Criminal Justice and Chief Social Worker), Kat Jenkin (Head of Patient Safety, Quality and Risk) and Ryan McLaughlin (Employee Director, Non-Executive Board Member).

Guests

Dr Elvira Garcia (Consultant in Public Health), Sarah Walker (Infection, Prevention Manager), Michelle Mackie (Interim Deputy Director Nursing and Lead Midwife), John Daniels (Head of Primary Care Services for item 13.5), Diane Young (All Age Disability and Mental Health Service Manager for Item 15,2), Lynda Bradford (Head of Health and Community Care), Louise Willis (Service Manager – Children’s Services for Item 15.3) and Nick Crohn (Radiology Manager for item 15.4).

1. Cover Page

Joint Clinical and Care Governance Committee’s Purpose

The Chair reminded members that the purpose of the Joint Clinical and Care Governance Committee (JCCGC) (the Committee’) provides assurance through oversight of NHS Orkney and the Integrated Joint Board. The scope of the Committee’s oversight fulfils the purposes of:

• The function of the non-executive members of NHS Orkney and advisors providing the Board of NHS Orkney with the assurance that robust clinical governance controls and management systems are in place and effective in NHS Orkney, in relation to delegated and non-delegated services it delivers.
• The function of providing the Integration Joint Board with assurance that robust clinical and care governance controls and management systems are in place and effective for the functions that NHS Orkney and Orkney Islands Council have delegated to it.
• The requirements set out in MEL (1998)75, MEL (2000)29 and HDL (2001)74 around the guidance on the implementation of Clinical Governance in the NHS in Scotland.

Quoracy

Meetings of the Committee will be quorate when at least four members are present and at least two of whom should be Non-Executive Members of NHS Orkney, one of whom must be the Chair or Vice Chair, and two Orkney Island Council voting members of the Integration Joint Board. Meetings will not take place unless at least one Clinical Executive Director of NHS Orkney and the Chief Officer IJB, or nominated depute, is present.

2. Apologies (Presenter: Chair)

Fiona Mackay (Vice-Chair) opened the meeting at 2.00 pm, welcoming members.

Apologies received from Rona Gold (Chair, Non-Executive Board Member), Jean Stevenson (OIC representative), Stephen Brown (Chief Officer, Integration Joint Board), Sam Thomas (Executive Director Nursing, Midwifery, Allied Health Professionals and Chief Officer Acute Services), Morven Brooks (CEO, Voluntary Action Orkney).

Members agreed the meeting was quorate in line with the Boards Code of Corporate Governance.

3. Declarations of Interests Agenda Items (Presenter: Chair)

No declarations of interest were recorded.

4. Minute of Joint Clinical and Care Governance Committee 4 February 2026 (Presenter: Chair)

Minute of the Joint Clinical and Care Governance Committee meeting held on 4 February 2026 were discussed and reviewed for matters of accuracy.

Decision/conclusion

Members approved the minute of the Joint Clinical Care Governance Committee 4 February 2026.

5. Chair's Assurance Report (CAR) from meeting 4 February 2026 (Presenter: Chair)

The Chair presented the Chair’s Assurance Reports from the meeting held on the 4 February 2026 noting this was presented to Board in February 2026.

Members’ noted that issues raised at Board have been actioned in relation to PPE.

Dr Kirsty Cole asked if the weight management service update would be coming to Committee. Dr Elvira Garcia advised that this is covered in the Public Health Quarterly Report. It was agreed that a further update will be brought to the July 2026 meeting. Dr Anna Lamont advised that in Scotland injectable weight loss medication follows the same process as weight loss surgery. NHS Orkney are awaiting confirmation from NHS Grampian’s position; this remains under active discussion through the Area Drugs and Therapeutic Committee noting a national position has not yet been agreed.

Decision/conclusion

Members took assurance on the Chair's Assurance reports from the meetings held on the 4 February 2026.

6. Action Log (Presenter: Head of Corporate Governance)

The action log was discussed with corrective action taken and providing updates where required. Members were content to close the items listed on the action log, noting that two actions are not yet due (Public Protection Accountability Assurance Framework and His Majesty's Inspectorate of Constabulary in Scotland (HMICS) - Draft Custody Inspection Report).

One action remains open in relation to weight management and one action remains off-track (Patient falls data in the IPR).

Decision/conclusion

Members noted the action log updates.

7. Corporate Risks aligned to the Joint Clinical and Care Governance Committee (Presenter: Medical Director)

The Chair invited questions in relation to the Corporate Risks aligned to the Joint Clinical and Care Governance Committee.

Risk 122.5 (lack of capacity within social care) has been updated to reflect the impact on the GP systems.

Dr K Cole asked if the Committee was content that the risk in relation to the lack of capacity within social care sits within the IJB. The Head of Patient Safety, Quality and Risk advised that the discussion in relation to the risk is in relation to the acute impact, the risk in relation to social care sits with the IJB as the provider of community services. Dr Anna Lamont acknowledged that Committee does not currently have sight of the social care risk register.

Head of Patient Safety, Quality and Risk provided assurance that the risk in relation to social care is being managed by Orkney Islands’ Council with an update being provided ahead of the next meeting.

The Interim CEO asked that a conversation take place with the Head of Children’s Services, Criminal Justice and Chief Social Worker and the Chief Officer IJB to discuss visibility of the social care risk register at JCCGC.

The risk in relation to the Public Protection Framework has been revised and downgraded due to the work undertaken between Orkney Islands Council, the Board and the IJB.

Decision/conclusion

Members took assurance on the Corporate Risk Register aligned to the JCCGC.

8. Integrated Performance Report (IPR) (Presenter: EDoNMAHP)

The Medical Director noted improved compliance with stage 2 complaints in the Integrated Performance Report and thanked the Patient Safety and Clinical Teams.

The Head of Patient Safety, Quality and Risk advised that there have been no Scottish Public Services Ombudsmen upheld complaints.

Reporting fall rates is difficult. The Board is participating in the Scottish Patient Safety Programme falls programme, which aims to develop a national definition of falls with harm. This is expected to significantly reduce fall numbers once established.

Reduced compliance in relation to Serious Adverse Event Reviews (SAER’s) with 2 of the outstanding reports showing an improved position.

Paediatric Early Warnings Scores (PEWs) compliance has shown a month-on-month improvement.

The Interim CEO noted that there was a misalignment of data in the IPR and the Quarter 3 Report noting this may be in relation to timings of reports.

The Interim CEO asked for an update on the outcomes from the Maternity Early Warning Scores (MEWs) deep dive noting compliance is now at 100%. The Interim Director of Nursing and Lead Midwife advised that work has been undertaken with the team to support the collection of data and to track any trends.

The Interim CEO asked for clarity on the decrease in the number of bloodspot screening undertaken due to capacity. The Interim Director of Nursing and Lead Midwife advised that the target was not met due to timings but there was no significant risk to the patient in this instance. The Consultant in Public Health advised that the IPR was submitted without being updated, data presented to Committee was from December and January 2026. The Chair reminded the Executive Team that they have ownership of the IPR and the updates – not the performance team. Members were asked to note that 1 missed screening impacts significantly on the Key Performance Indicators.

The Chair asked that mitigating actions are updated and made clearer to improve assurance being provided to Committee with KPIs being owned by the Executive team.

The Chair noted that the number of SAERs remains stagnant, whilst 5 SAERs have been commissioned in the past 12 months, there are still 5 SAERs outstanding. The Head of Patient Safety, Quality and Risk advised that one has been closed since this data was pulled. One of the outstanding SAERs is extremely complex, the time taken to complete the reviews reflects their complexity. Two are awaiting external expert opinions and this is being followed up and escalated due to the delays. It is noted there is a need to increase the number of SAER trainers over the next 12 months and a plan for this is in progress. Chair thanked the Head of Patient Safety, Quality and Risk for assurance in relation to SAERs.

Decision/conclusion

Members discussed the IPR and took assurance where Key Performance Indicators (KPIs) are off track and the improvement actions in place to bring deliverables back on track.

9. Feedback from National Meetings

9.1 Scottish Executive Nurse Directors (SEND)

The Chair invited questions on the SEND feedback report.

Decision/conclusion

Members noted contents of the report.

9.2 Scottish Association Medical Directors (SAMD)

No report received. The Medical Director advised that a SAMD meeting has not been attended since the last meeting.

9.3 Chief Officers network

No report received.

9.4 Directors of Public Health

No report received.

Decision/Conclusion

Feedback from national meetings to be moved to for noting section of future agendas.

10. CHAIR'S ASSURANCE REPORTS

10.1. Area Drugs and Therapeutics Committee Chair’s Assurance Report 4 March 2026 (Presenter: Medical Director)

The Chair asked members if they had any questions in relation to the report of the meeting held 4 March 2026.

The Medical Director provided assurance on digital dermatology, quoracy at meetings and prescribing.

Dr Kirsty Cole extended an invite to the ADTC to attend the Area Clinical Forum.

Decision/Conclusion

Members took assurance from the update.

10.2. Infection, Prevention Control Committee Chair's Assurance Report 4 February 2026 (Presenter: Infection Prevention Manager)

The Chair asked members if they had any questions arising from the Chair’s Assurance Report from the meeting held on 4 February 2026.

The Infection Prevention Manager advised that work in relation to the planned care maintenance at The Balfour has been escalated to the Director of Finance.

A preparedness plan for High Consequence Infectious Diseases (HCID) is underway, there is a challenge in relation to Personal Protection Equipment this has been raised nationally.

There has been a drop in the number of face-fit testing, this has been raised with our Health and Safety Team.

Funding has been identified to remove splash risks in clinical areas.

Dr K Cole asked that the assistance dog policy be shared with the 2 Balfour based GP Practices.

Decision/Conclusion

Members received escalated items and took assurance on performance.

10.3. Social Work and Social Care Governance Board (SWSCGB) Chair's Assurance Report - (Presenter: Head of Children’s Services, Criminal Justice and Chief Social Worker)

No report presented as the Board has not met since the last Committee meeting on to the Chair’s Assurance Report from the Social Work and Social Care Governance Board 9 January 2026.

10.4. Clinical Governance Group Chair's Assurance Report 10 March 2026 (Presenter: Medical Director)

The Medical Director invited questions from committee members in relation to the Clinical Governance Group Chairs Assurance Report from the meeting held 10 December 2026.

Self assesment against the HIS Clinical Governance Standards will commence shortly.

Decision/Conclusion

Members received escalated items and took assurance on performance.

10.5. Improving Together Programme Board Chair’s Assurance Report 27 February 2026 (Presenter: Medical Director)

The Chair invited questions from committee members in relation to the Improving Together Programme Board Meeting held 27 February 2026.

Dr Kirsty Cole inquired whether measures should be implemented to address the increased number of MRI scans and the accompanying rise in associated costs. The Medical Director explained that although the volume of completed scans has grown, the expenses pertain primarily to reporting and noted this has resulted in fewer patients needing to travel to Aberdeen. Funding has been secured for the next three months, and an additional update will be provided at the upcoming meeting.

Cllr L Hall reflected on the success of having an MRI scanner in Orkney.

The Interim CEO advised that a Business Case has been submitted to Scottish Government and funding has been secured for Quarter 1 2026/27.

It was noted that a further discussion on the MRI would be useful particularly in relation to savings made against travel costs.

Decision/Conclusion

Members received escalated items and took assurance on performance.

11. JCCGC Annual Report 2025/26 (Presenter: Chair)

The Chair presented the JCCGC Annual Report 2025/26 for approval.

Decision/Conclusion

Members approved the JCCGC Annual Report 2025/26 for onward submission to Audit and Risk Committee May 2026.

12. STRATEGIC OBJECTIVE - PLACE

12.1. Quarterly Public Health Report (Presenter: Director of Public Health)

The Director of Public Health presented the Quarterly Public Health Report. The Committee was asked to note the positive work in the East Region on remote, rural and island impact assessments being led by Orkney. A presentation has been delivered to Public Health Scotland in relation to vaccinations. Funding has been awarded to implement the NASH sexual health system. There has been an increase in the number of workplace sexual health newsletters.

Councillor Taylor asked the Committee to consider if they were content with the data being presented in relation to screening. The Consultant in Public Health advised that data is only available on an annual basis. There have been challenges in relation to screening data quality, noting that more work is required to improve uptake.

The Interim CEO expressed appreciation to the Public Health team for their report and asked if the decrease in referrals and quit rates for smoking cessation suggested a reduction in overall smoking prevalence. The Director of Public Health responded that Orkney has the lowest rate of smoking in Scotland. The team continues its outreach efforts through social and local media and encourages referrals from within the organisation.

The Interim Deputy Director of Nursing and lead midwife advised that more work will be required in relation to cervical screening. From a maternity perspective the number of pregnant women has decreased, women are automatically referred from our maternity service.

Councilor L Hall inquired whether data is collected regarding the initiation of smoking among young people. The Director of Public Health advised that the data is not routinely available, there is a reliance on national data capture.

Dr K Cole asked if the pilot for vaping would continue. The Director of Public Health advised that the focus from Scottish Government is for smoking cessation, update to be provided at the next meeting. The Head of Children’s Services, Criminal Justice and Chief Social Worker advised that data could be obtained from the school nursing team on the number of young people vaping.

Decision/conclusion

Members took assurance on the update.

13. STRATEGIC OBJECTIVE - PATIENT SAFETY, QUALITY AND EXPERIENCE

13.1. Realistic Medicine Year-end Report 2025/26 and Action Plan 2026/27 (Presenter: Medical Director)

The Chair invited questions on Realistic Medicine Year-end Report 2025/26 and Action Plan 2026/27.

The Medical Director thanked Gina McMahon for the report and raising the profile of Realistic Medicine, particularly the work undertaken in schools which has been included in the national Realist Medicine Report.

Recruitment is underway to replace the Realistic Medicine Lead, who leaves to take up an opportunity with NHS Grampian shortly.

The Director of Public Health asked if the Board is fully leveraging values-based medicine in relation to our clinical services review and our financial position. The Medical Director advised that funding for realistic medicine is about ways of working/thinking within the clinical governance space. A good example of realistic medicine is the use of Near Me and moving to digital by default.

The Interim CEO advised that the principles of realistic medicine should be better aligned to our improvement team. There is an opportunity to focus more on this through the population health matrix.

Decision/conclusion

Members received assurance on the Realistic Medicine Year-end Report 2025/26 and Action Plan 2026/27.

13.2. Safety, Quality and Experience Quarter 3 Report 2025/26 - (Presenter: Head of Patient Safety, Quality and Risk)

The Chair invited questions on the Safety, Quality and Experience Quarter 3 Report 2025/26.

Key highlights include the increase in incident reporting. Falls remain the most frequently reported incident due to patient complexity.

No inpatient pressure sores reported.

Excellence in Care compliance has increased quarter by quarter, conversations are taking place in relation to metrics.

There has been an increase in relation to quality improvement across the organisation and the impact this has.

Decision/conclusion

Members welcomed the Safety, Quality and Experience Quarter 3 Report 2025/26.

13.3. External Maternity Peer Review (Presenter: Interim Deputy Director of Nursing/Lead Midwife)

The Interim Deputy Director of Nursing and Lead Midwife presented the external maternity peer review and advised that whilst an action plan was requested by Committee that was not provided due to information not being available.

Reassurance was provided from the external reviewers, in particular the culture and feedback from patients. Improvements were required in relation to clinical governance.

A maternity clinical governance group has been re-started this will look at Standard Operating Procedures, risks, pathways, the entrance to maternity and a dedicated bereavement room.

The Interim CEO welcomed the report and asked if resources were available for a dedicated bereavement room and asked that women and families are involved in the design of the room. The Interim Deputy Director of Nursing and Lead Midwife advised that whilst space has been identified this does require additional space.

Dr K Cole asked for clarity on developing digital guidelines and Standard Operating Procedures (SOP’s) and asked if this was a bigger issue across the organisation in relation to the need for a central repository for clinical guidelines. This is particularly important in NHS Orkney because of the high number of locum and itinerant staff. The Head of Patient Safety, Quality and Risk advised that work is underway to review the clinical policy framework and where guidelines etc should be stored.

Director of Public Health celebrated the great work our staff does, which is reflected in the number of Daisy Awards.

The Head of Children’s Services, Criminal Justice and Chief Social Worker advised that Orkney Islands Council (OIC) are looking at policy storage, the vulnerable children policy has also been approved and will be presented to the Public Protection Committee shortly.

Decision/conclusion

Members received and noted the update.

Diane Young, Lynda Bradford and John Daniels joined the meeting at 4.00pm.

13.4. Quality Impact Assesement Quarterly Report March 2026 (Presenter: Interim Deputy Director of Nursing/Lead Midwife)

The Medical Director presented the QIA report noting that Scottish Government have complimented the Board on the use of the template.

Dr K Cole asked for confirmation on whether the reduction in postage costs in the paper include text messaging. The Medical Director advised that costs do not include text messaging, noting it is our ambition to move to digital letters as part of the roll out of the national Digital Front Door programme.

Decision/conclusion

Members received and noted the update.

13.5. Primary Care – Dental Services Update (Presenter: Director of Dentistry)

The Head of Primary Care Services provided an update on the public dental services. Whilst staffing challenges remain within the team, a new full-time dentist joined the team on the 30 March 2026.

A dental nurse has been appointed to the Garson Clinic and approval has been given to recruit additional dental staff removing the need for reliance on locums.

A new chair has been installed at the Garson Clinic improving access to patients.

The Chief Dental Officer visited Orkney 3 weeks ago, productive conversations took place within the private sector with further recruitment underway with Clyde Munro committing to have 100% of people in Orkney having access to a dentist in the near future.

The Employee Director asked for confirmation on the special care service and the number of cancellations patients have received. The Head of Primary Care Services advised that they continue to work with the dental teams to avoid short notice cancellations and how we can build resilience moving forward.

Decision/conclusion

Members took assurance from the verbal update.

14. STRATEGIC OBJECTIVE – PEOPLE

No papers to be presented to Committee.

15. STRATEGIC OBJECTIVE – PERFORMANCE

15.1. Healthcare Improvement Scotland un announced Inspection - Verbal Update (Presenter: Interim Deputy Director of Nursing/Lead Midwife)

Interim Deputy Director of Nursing/Lead Midwife provided a verbal update on the Healthcare Improvement Scotland unannounced inspection.

Feedback on the day was positive, particularly in relation to leadership. Evidence was submitted on 8 April 2026 as requested. The final report is expected within 12 weeks of the inspection.

The Interim CEO confirmed that the inspection team found no areas of concern; the inspection will be used as part of our commitment to continuous improvement.

Decision/conclusion

Members noted the update.

Lou Willis Service Manager – Children’s Services joined the meeting at 16.31.

15.2 Mental Health Assurance Update (Presenter: Head of Health and Community Care – Lynda Bradford)

The Head of Health and Community Care and All Age Disability and Mental Health Service Manager presented the Mental Health Assurance Report.

Key reportable targets for treatment continue to be met in respect of waiting times for CAMHS, Psychological Therapies; access to treatment for substance misuse and post diagnostic dementia support.

Recruitment issues prevent the full introduction of the All-Age Nurse Led Psychiatric Liaison Team. Dr K Cole asked if the difficulty recruiting to the Psychiatric Liaison service provides an opportunity to revisit recruitment in Primary Care. The Head of Health and Community Care advised that this has not yet been considered.

The imminent retirement of the GP with Special Interest (Dementia) will bring challenges albeit covered in the short term. Dr K Cole asked if this would impact post diagnostic support. The Head of Health and Community Care acknowledged this will be impacted.

Ongoing pressure with regard to the numbers of people seeking assessment, diagnosis and treatment for neuro- developmental conditions.

The Mental Welfare Commission report and action plan was received by Committee.

Dr K Cole asked if consistency could be applied to all sections of the report going forward and asked for clarity on the timeframe for adults waiting for a review for ADHD. The Head of Health and Community Care advised that the move to MORSE will support the better presentation of data going forward.

The Interim CEO asked that Key Performance Indicators (KPIs) are included in the IPR going forward and asked that priority be given to reviewing people with a Learning Disability. The Head of Health and Community Care confirmed that this will be a priority.

The Employee Director asked if the whistleblowing actions plans have been closed and what is being done to look at alternatives to the psychiatric liaison model noting the inability to recruit to date. The Head of Health and Community Care advised that some of the actions remain open, it was agreed that the next report would be taken earlier in the agenda at the next meeting.

All Age Disability and Mental Health Service Manager advised that all activity is monitored, the team have worked hard to reduce the number of presentations at The Balfour. Recruitment remains a challenge across Scotland for Band 6s, development posts are being considered.

The Medical Director asked Committee to celebrate the work undertaken to date in relation to recruitment within the Mental Health Service.

Decision/conclusion

Members welcomed the Mental Health Assurance update.

15.2. Children’s Health Assurance Update (Presenter: Service Manager – Children’s Services- Lou Willis)

The Service Manager – Children’s Services asked for questions on the Child Health Assurance Report.

The Interim CEO asked for clarity on the training data being in progress. The Service Manager – Children’s Services confirmed that the training in progress is in relation to external supervision. The Interim CEO advised that they are content to ask other CEOs to support if this is required.

The Head of Children’s Services, Criminal Justice and Chief Social Worker asked Committee to note the progress being made in relation to the children’s neuro developmental single assessment pathway.

Decision/conclusion

Members welcomed the Children’s Health Assurance update.

Nick Crohn joined the meeting at 16.45.

15.3. Radiology Service Verbal Update (Presenter: Radiology Manager – Nick Crohn)

The Radiology Manager, Nick Crohn provided a verbal update on the Radiology Service.

The Board is currently unable to provide a safe ultrasound service due to ongoing staffing challenges. A risk assessment has been completed, and weekly updates are being shared with the Executive Management Team.

Although temporary support has been secured from NHS Shetland and a bank sonographer, there remains a national shortage of sonographers.

The Board is also receiving assistance from NHS Grampian and is considering bringing in a radiologist to cover additional activities.

The Medical Director thanked the Radiology Manager for their support, particularly the Obstetrics/Gynecology team who are supporting the service.

Decision/conclusion

Members noted the update.

16. STRATEGIC OBJECTIVE – POTENTIAL

No papers presented to Committee.

17. Emerging issues and key National updates (Presenters: Medical Director, Chief Officer Integration Joint Board, Executive Director of Nursing Midwifery, AHP and Chief Officer Acute, Consultant in Public Health)

Committee noted there may be additional work required following the HIS unannounced inspection.

18. Agree items to be included in Chair’s Assurance Report to Board (Presenter: Chair)

Members discussed areas to be included within the Chair's Assurance Report, these include:

Positive assurance

• Corporate risks associated with JCCGC.
• Paediatric Early Warnings Scores (PEWs) compliance has shown a month-on-month improvement.
• Compliance with stage 2 complaints was celebrated as an area of improvement with thanks being offered to the Patient Safety and clinical Teams.
• Following a deep dive, Maternity Early Warning Scores (MEWs) compliance is now at 100%.
• Assurance taken from the Chairs Assurance Reports (CARs) for Area Drugs and Therapeutics Committee (4 March), Infection Control Committee (4 February), Clinical Governance Group (10 March) and the Improving Together Programme Board (27 February).
• Quarterly Public Health Report.
• Safety, Quality and Experience Quarter 3 Report 2025/26.
• Quality Impact Assessment Quarterly Report March 2026.

Risks to be escalated to the Board

• Capacity in the Ultrasound service.

Work underway

• Weight management to be added to the July 2026 meeting.
• Insufficient social care capacity risk to be discussed with Orkney Islands Council.
• Chief Officer IJB to discuss the social care risk register's visibility at Committee with the Head of Children’s Services, Criminal Justice and Chief Social Worker.
• The Interim Deputy Director of Nursing and Lead Midwife will present the Maternity External Review Action Plan to the Committee in July 2026.

Decisions made

• Minute and Chairs Assurance Report of Meeting 4 February 2025 approved.
• JCCGC Annual Report 2025/26 approved for onward submission to Audit and Risk Committee May 2026.
• Realistic Medicine Year-end Report 2025/26 and Action Plan 2026/27 approved.

19. AOCB (Presenter: Chair)

No other competent business raised.

20. EVALUATION OF THE MEETING (Presenter: Chair)

21. ITEMS FOR INFORMATION AND NOTING ONLY

21.1. Colloborative Community Care Group (CCC) Chair’s Assurance Reports

Members noted the following papers:

• 21.1a - Collaborative Community Care Group (CCCG) Chair’s Assurance Report 5 February 2026.
• 21.1b - Collaborative Community Care Group (CCCG) Chair’s Assurance Report 5 March 2026.

21.2. Schedule of Meetings 2026/27

• Members noted the schedule of meetings 2026/27.

The meeting closed at 17:15.

Joint Clinical and Care Governance Committee Chair’s Assurance Report to Board

Matters of Concern or Key Risks to Escalate

1. There are no concerns or key risks to escalate to the Board.

Major Actions Commissioned / Work Underway

1. Patient experience – the Head of Patient Safety, Quality and Risk advised that stage 2 complaints relate to communication. Complaint numbers will be monitored and reported to the Committee if themes emerge.
2. Serious Adverse Event Reviews – Medical Director to bring a report to Committee in October 2026 in relation to closing SAERs.
3. The Executive Director of Nursing, Midwifery and AHPs will provide a Public Protection Accountability Framework (PPAF) update to the Committee 4 February 2026.
4. Still awaiting confirmation of funding for the MRI Business case, noting this is an extensive for 12 months only.

Positive Assurances to Provide

1. The Committee thanked Morag Linklater, NHS Orkney’s first DAISY Award honouree, and noted her reflections on more than 34 years as a midwife in Orkney.
2. Assurance was provided that the ultrasound service currently has no waiting list.
3. Assurance was provided that processes are in place to respond to dental inspections, and the Committee recognised achievements across public and general dental services.
4. Assurance provided on the Corporate Risks aligned to Committee.
5. Assurance provided from the Integrated Performance Report in particular safety, governance, complaints and population health.
6. Assurance taken from the Chairs Assurance Reports (CARs) for Area Drugs and Therapeutics Committee (10 June), Infection, Prevention and Control Committee (26 May), Social Work and Social Care Governance Board (& May), Clinical Governance Group (16 June).
7. Assurance provided from the Social Work and Social Care Service Annual User Experience report with positive examples of the work delivered across the service in the past 12 months.
8. Assurance provided through the Quality, Safety and Experience Quarterly Report.
9. Committee took assurance that significant progress has been made in embedding the Public Protection Accountability Framework (PFFAF), noting an annual report will be presented to Committee going forward.
10. Committee took assurance on the exceptionally positive Healthcare Improvement Scotland (HIS) inspection of Maternity Services.
11. Committee welcomed and took assurance on the Public Health Quarterly Report noting the roll out of MenB vaccination and the new Child Health IT system.
12. Assurance taken following the presentation of the Maternity external Peer Review Action Plan.
13. Committee noted the following documentation:
    • Feedback Sottish Executive Nurse Directors (SEND).
    • Collaborative Community Care Group (CCCG) Chair’s Assurance Reports 2 and 30 April 2026.
    • Approved Infection Prevention Control Committee Terms of Reference - 2026-27.

Decisions Made

1. Minute and Chairs Assurance Report of Meeting 8 April 2026 approved.
2. Healthcare Improvement Scotland (HIS) Inspection action plan (Maternity Services) approved.
3. NHS Orkney Patient Feedback Annual Report 2025/26 approved for onward submission to the Board August 2026.
4. Duty of Candour Annual Report 2025/26 approved for publication.

Comments on Effectiveness of the Meeting

• The Chair reflected on the quality of papers presented to Committee.