The Health Board is taking steps to strengthen its quality governance arrangements, but there remain weaknesses which it needs to address. It has put in place key parts of a digital Quality Management System (QMS) and updated several governance frameworks. But the Health Board needs to agree clear quality priorities, with strong leadership and accountability across and throughout the organisation to deliver them.

Early work to implement the Duties of Quality and Candour is underway, but significant gaps remain in quality leadership, staff training and reporting. The Health Board has a new learning system, but it is not always demonstrating that lessons are learnt. Complaints response timeliness has improved. However, rising complaint volumes is placing pressure on teams. The volume of re-opened cases also suggests the quality of investigations needs strengthening.