Read Standard 2: Collaborative leadership and governance

Standard statement

NHS boards demonstrate collaborative leadership and effective governance of services for people who have experienced rape, sexual assault or child sexual abuse.

Rationale

NHS boards have responsibility for effective clinical governance and collaborative leadership in the delivery of services for people who have experienced rape, sexual assault or child sexual abuse.^25-27 Being trauma informed requires a system-wide approach to service provision. This involves examining policies, processes and practice, and adapting where necessary. Leadership within NHS boards should establish and promote the culture, priorities and values of trauma-informed care. They should embed a person-centred and trauma-informed approach to service delivery.^8,9,21

NHS boards are accountable for ensuring high quality service delivery of SARCS and services for children and young people. NHS boards are also a key partner in the delivery of Bairns’ Hoose services, where there is one within their geographical area. Service delivery should be in line with these standards, national clinical pathways and relevant statutory requirements.⁵ This includes workforce capacity and capability,³¹³²performance monitoring, adverse event management, whistleblowing, quality improvement and assurance. Local protocols and pathways should describe roles and responsibilities, including senior clinical leadership for services for children, young people and adults.

NHS boards should ensure that they deliver inclusive services which take account of the populations they serve. This includes the impact of protected characteristics, cultural factors, socioeconomic factors and geographical considerations, including rurality.³³ NHS boards should co-design and regularly review services with people with lived experience to ensure equality and equity in access. Through the use of Equality Impact Assessments (EQIAs), Islands Communities Impact Assessments and community engagement and consultation, organisations can understand and effectively reduce health inequalities and improve outcomes.³³

Local care pathways should be in place to support transition between services or care provision in other NHS board areas. NHS boards and partners have collective responsibility for adult support and protection and child protection and safeguarding, in line with national guidance and the NHS public protection accountability and assurance framework.^{28, 29, 34}

NHS boards should work collaboratively to ensure that Regional Centres of Expertise for SARCS are adequately resourced.²⁵ This includes supporting the effective coordination and delivery of SARCS within their area. Opportunities for sharing learning and development should be available, as appropriate and within the principles of good information governance.

Clear referral pathways and coordination within the Bairns’ Hoose partnership ensures that all relevant services are part of the continuous planning process for children.¹⁸

NHS boards should collect and review feedback from people who access services, staff and partner organisations. This may include the use of EQIA’s, qualitative feedback or quantitative feedback. Alongside patient safety, people’s experiences are a valuable indicator of quality of care and should inform service improvements.

National documentation is in place to ensure data collection for healthcare and forensic medical services is consistently recorded. A national clinical IT system is in place to ensure that a secure, digital record is kept of all relevant patient data in line with e-health requirements. Consistent completion of the national forms and data input to the national clinical IT system minimises variation and error and ensures robust reporting and review of data. Any data and information shared is subject to the relevant legislation and national and local data sharing protocols, policies and procedures.

The national indicators set out areas for performance measurement and improvement in forensic medical services. NHS boards should collect and review data in line with the national indicators.²⁰

Criteria

2.1

NHS boards can demonstrate robust governance and assurance arrangements in line with national clinical pathways, which include:

clear roles, responsibilities and lines of accountability
a nominated lead for services
clinical leadership and supervision for staff
regular review of current service provision in line with relevant legislation and Healthcare Improvement Scotland standards and quality indicators
effective cooperation agreements and collaborative working across NHS boards, special health boards and other partners (including third sector organisations) to plan and deliver services.

2.2

NHS boards can demonstrate an inclusive, rights based and person-centred culture through:

collaborative leadership and management⁹
values based, compassionate and trauma-informed practice, service planning and delivery
routinely informing people and their representatives of their rights
aligning service delivery with the principles of trauma-informed leadership and management of systems.⁹

2.3

NHS boards can demonstrate reciprocal arrangements and protocols to support people during their care, which include:

pathways of care if a person requests or receives services outwith their NHS board area
pathways of care to support transitions, for example moving from children and young people’s services to adult services
the provision of preferred sex of sexual offence examiner from other
NHS boards, where appropriate
the provision of key information to minimise the need for someone to retell their experience and to reduce unnecessary delays in the person’s care.

2.4

NHS boards can demonstrate service improvement through feedback from people who access services, staff and partner organisations, which includes:

clear and accessible feedback and complaints processes
responsive approaches which recognise the different kinds of expertise and experiences that people have
using anonymised and aggregated feedback to monitor and improve services
mechanisms for updating stakeholders on how services have been improved following feedback
improvement plans with oversight by a clinical governance committee.

2.5

NHS boards demonstrate their commitment to addressing health inequalities through:

undertaking population needs and impact assessments to inform service provision
meaningful engagement with adults, young people and children
partnership working with third sector agencies and support services.

2.6

NHS boards demonstrate collaborative working with the SARCS Regional Centres of Expertise and Bairns’ Hoose, as appropriate. This includes:

supporting and encouraging audit and research to develop and share best practice to inform the continuous improvement of services
staff and service participation in relevant clinical and strategic networks, where appropriate.

2.7

NHS boards ensure multidisciplinary and partnership working to deliver healthcare and forensic medical services.

2.8

NHS boards ensure processes are in place to support sharing of data and intelligence across organisations and services, which cover:

reporting, benchmarking and performance
audit to ensure care is informed by evidence and current practice
information governance and sharing with other services in line with national guidance and General Data Protection Regulations.

2.9

NHS boards ensure the consistent recording, collection and monitoring of data using national documentation including:

sexual offences against adults national form health assessment
sexual offences against adults national form: forensic examination
child protection proforma.

2.10

NHS boards have a robust process for the identification, management and response to risk, incidents and adverse events, which includes:

a standard and consistent approach to reporting
clear accountability and responsibility for local review and reporting
business continuity plans
processes for monitoring actions and shared learning
information and support for those impacted by adverse events, as appropriate.

2.11

NHS boards and statutory partners have systems and processes in place to monitor and review adult support and protection and child protection.^28,29^,34

2.12

NHS boards have systems and processes to ensure adherence to national Whistleblowing and Duty of Candour guidance.³⁵^{, 36}

2.13

NHS boards implement workforce plans that:

identify required staffing levels for the service, including building capacity and sustainability
provide clinical and restorative supervision and continued professional development
are in line with safe staffing legislation and policies and professional or clinical competency frameworks.³²

2.14

NHS boards demonstrate a commitment to internal and external quality assurance and improvement through:

assessment of current service provision against professional guidance, national standards and quality indicators¹⁸^{, 20, 26, 27}
review of data in line with national indicators including timeframes for access to a forensic medical examination with improvement plans developed as required
sharing best practice
acting on feedback from staff and other services, including the third sector
coordination of services in line with the FMS Act.⁵

What does this standard mean for...

What does the standard mean for people receiving care and support?

You can be confident that services are well run and safe.
You will be supported by staff who work together to provide you with a high-quality service.
Staff will coordinate your care, including if you move between services or areas.
You will have opportunities to provide feedback and participate in decisions about how services are designed.
Information about you and your care, including personal data, will only be shared with your consent unless there are concerns for your wellbeing. This will be explained to you.
Any clinical records, images and evidence (in self-referral cases) will be securely stored.
None of your identifiable information or data will be used to compile reports about service performance or improvement.
You will know how long information about your care will be kept for.

What does the standard mean for staff?

Staff, in line with roles, responsibilities and workplace setting:

are supported in their roles through effective leadership and clinical governance
are trained and knowledgeable in local and national clinical pathways, standards and guidance
encourage and empower people to share their views and experiences of services, including completion of the national feedback form
are aware of how to report and escalate public protection concerns, complaints or adverse events
can raise concerns and understand whistleblowing policies
share feedback to inform service improvements
ensure the consistent and accurate completion and submission of all relevant documentation including national forms and protection proformas on the national clinical IT system
ensure all data is stored and shared in line with legislation, national policies and guidance.

What does the standard mean for the NHS board?

NHS boards:

have clear and robust governance and assurance processes that detail responsibilities and partnership working
ensure robust accountability, assurance and reporting arrangements are in place for public protection³⁴
have clear processes in place to monitor the performance of SARCS against these standards, the FMS Act and other relevant guidance and protocols
ensure the implementation of coordinated and person-centred pathways of care
cooperate in the delivery of services, supported by the Regional Centre of Expertise, where appropriate
have systems and processes to ensure adherence to national whistleblowing and Duty of Candour guidance
record and monitor data in line with the national indicators, including time from acceptance of referral to commencement of forensic medical examination
record and monitor data and undertake learning activities to improve service delivery, multiagency and multidisciplinary working, planning of care and information sharing
ensure the completion of national documentation and the use of the national clinical IT system to support consistency in approach and high standards of reporting and monitoring
have systems in place for the collection, storage and review of data relating to medical examinations for people of all ages
ensure all documentation and data collection complies with relevant legislation, guidance, policies and procedures.

Examples of what meeting this standard might look like

Documentation describing accountability and governance arrangements for service delivery.
Audit of local public protection arrangements at strategic and operational levels.³⁴
Documentation such as service-level agreements describing any reciprocal workforce arrangements.
Audit of staff vacancies, staff retention and safe staffing levels and action plans.
Provision of information to inform people of their rights, for example to do with consent or sharing of patient information between services.
Use of EQIAs, Islands Impact Assessments and Children’s Rights and Wellbeing Impact Assessments.
Support recruitment process to ensure sustainable rota cover.
Board reports on adherence to provisions of the Health and Care (Staffing) Scotland Act 2019.
Examples of continuous improvement activity in response to performance data and feedback from adults, young people and children who access services.
Multidisciplinary working, including involvement of professionals across services and settings.
Audit and review of data of time from acceptance of referral to forensic medical examination to inform improvement plans.²⁰
Audit of a preference of sex of the sexual offences examiner involved in their care.
Audit and review of national documentation.
Adherence to information sharing protocols.
Quarterly submission of SARCS network quality framework data including adults, young people and children.