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NEXT PHASE METHODOLOGY (2018) Operating Model area: Core services

Sector: Acute, Community and Independent Healthcare

Product title: 900468 Single Assessment Framework MATERNITY

Inspection framework: Maternity Framework (Acute, community, independent)

Log of changes since last version

Section / Report sub heading

Page number Detail of update

S1 Safeguarding 6 New Intercollegiate Guidance for Safeguarding Adults added as a professional standard

S1 Environment & Equipment

9 MHRA Guidance on Managing Medical Devices added as a professional standard

R4 Learning from complaints and concerns

80 External complaints review process for independent services and private patients

Services

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This includes all services for women that relate to pregnancy. It includes ante and postnatal services, as well as labour wards,

birth centres or units and theatres providing obstetric related surgery.

A hospital can provide some of these services in the community setting, or they may be the responsibility of a different provider.

We will look at the pathways between the two settings when we inspect. it is important that all providers are clear on what they

do, what others do and the agreements that are made between them with clear pathways. If a new born baby requires treatment

in a special care baby unit (SCBU) or neonatal unit where a paediatrician delivers the care, this comes under the core service for

children and young people.

Some aspects of maternity will link to gynaecology and termination of pregnancy services. Gynaecology and Termination of

Pregnancy Services are a separate additional service and have their own framework for inspection.

Areas to inspect*

➢ The inspection team should carry out an initial visual inspection of each area.

➢ Your observations should be considered alongside data/surveillance to identify areas of risk or concern for further inspection.

➢ Each of these areas should be considered as part of the Regulatory Planning Meeting (RPM) or inspection planning processes.

➢ The information about the service should identify all of these areas you have visited, and if you have not inspected any of these areas you must clearly explain why in the report.

Areas for inspection:

• Antenatal clinics including booking appointment activities both hospital and community based

• Maternity day assessment unit

• Early Pregnancy Unit, antenatal ward, induction of labour facilities

• Screening e.g. phlebotomy, ultrasonography, amniocentesis

• Consultant led obstetric unit – (including triage labour, delivery, recovery and postpartum rooms)

• Midwife led birth unit (alongside and/or freestanding) - (including triage, labour, delivery, recovery, postpartum) rooms and the escalation pathways.

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Interviews / observations You should conduct interviews of the following people at every inspection, where possible:

In the acute services you may wish to interview:

• Women who are using/have recently used this maternity service and those close to them

• Clinical director for directorate/division

• Directorate/Divisional Manager

• Head of Midwifery

• Clinical Lead for maternity

• Safeguarding leads (doctor and midwife)

• Risk / Governance Midwife

• Clinical Lead for fetal medicine

• Clinical Lead for early pregnancy unit

• Lead Midwife for midwife led services

• Lead Midwife antenatal services

• Lead Midwife for post natal services

• Lead Midwife Labour ward

• Antenatal & Newborn Screening Midwife

• Midwives at all levels

• Obstetric theatres (both primary and back-up) including recovery

• Newborn screening carried out by the maternity service.

• Postnatal ward and high dependency beds (including after caesarean section)

• Bereavement facilities

• Fetal medicine unit (where provided and the referral to fetal medicine services if not provided on-site).

In the community the inspection team may wish to visit ( as appropriate):

• Women’s homes

• Birthing Centres – all types including: o Free standing midwifery led units o Co-located Midwifery led units ( midwifery units alongside an obstetric unit) o “Pop-up” services or similar.

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• Labour ward coordinator on duty

• Obstetrician and junior medical staff on labour ward (day and night staff)

• Bereavement Lead (doctor and midwife)

• Lead Anaesthetist for labour ward

• Lead Neonatal Paediatrician

• Mandatory and statutory training lead

• Midwifery Support Workers

• Student Midwives

For community based services you may wish to interview:

• A sample of community midwifery teams across the geographical area covered by the provider and from different bandings (*)

• Women and those close to them, who are using or recently used community based services (**)

• Community Midwifery Matron/ Manager

• Home birth teams

• Clinical Governance Managers and Risk Managers (may be the same if linked to the acute service)

• Safeguarding Lead

• Midwifery Support Workers

• Student Midwives

• Health visitor lead (linked to community inspections)

(* &**) It may be advisable to seek to schedule interviews in advance of the inspection to maximise the number of participants.

(if linked to the acute trust refer to interview list above)

For independent midwifery services you may wish to interview:

• Women who are using/have recently used this maternity service and those close to them

• Chief Executive

• Clinical Director for the service

• Lead Midwife

• Clinical Lead

• Safeguarding Lead (Midwife)

• Risk / Governance Midwife

• Obstetrician

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• Bereavement Lead (Midwife)

• Mandatory and statutory training lead

• Midwifery support workers

• Student Midwives

• CCG lead for maternity contracts (interview prior to inspection)

For independent (Private) maternity services you may wish to interview:

• Women who are using/have recently used this maternity service and those close to them

• Clinical Director for obstetrics

• Directorate Lead for maternity and obstetrics

• Head of Midwifery

• Clinical Lead for maternity

• Safeguarding Leads (doctor and midwife)

• Risk / Governance Midwife

• Clinical Lead for fetal medicine

• Clinical Lead for early pregnancy unit

• Lead Midwife for Midwife led services

• Lead Midwife antenatal services

• Lead Midwife for postnatal services

• Lead Midwife Labour ward

• Midwives at all levels

• Labour ward coordinator on duty

• Obstetrician and junior medical staff on labour ward (day and night staff)

• Bereavement lead (doctor and midwife)

• Lead Anaesthetist for labour ward

• Lead Neonatal Paediatrician

• Mandatory and statutory training lead

• Midwifery support workers

• Student Midwives

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You could gather information about the service from the following people, depending on the staffing structure:

• Midwives and nurses at all levels e.g. Supervisor of Midwives (SoM), student midwives, maternity support workers, consultant midwives, specialist midwives; gynaecology nurse(s).

• Ultrasonographers and radiographers

• Clinical Lead for perinatal mental health

• Maternity educator for the trust

• Staff from the neonatal team, neonatal nurses, paediatricians

• Community outreach groups for service users

• Neonatal Leads

In the community you may wish to gather information about the service from the following:

• Community midwives

• Health visitors and GPs ( in terms of handover/discharge arrangements)

• Antenatal Screening & Newborn Midwife

• Maternity voices

• Ambulance trust

• Clinical Commissioning Groups

• Healthwatch

• Maternity Voices chair

• Obstetricians ( consultants, trainees)

• Fetal Medicine services.

• Anaesthetists (consultants and trainees)

• Other medical staff

• Clinical Risk/Governance Midwife

• Early pregnancy service staff

• Maternity counsellors/bereavement midwives

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The maternity pathway

Recognition of pregnancy

Confirmation by GP

Self-referral to chosen maternity

service provider Referral by GP to chosen

maternity service provider

Booking appointment at

maternity service

Screening/Scanning services.

Referral to specialist services e.g. Fetal

medicine. Counselling and support

services offered

Referral to consultant led

services

Referral to midwife led

services

Continued antenatal care and

appointments, may include specialist care

and Multidisciplinary Team shared care.

Termination of pregnancy

Book in for birth– consultant led,

midwife led or home birth

Visit/s to Early

Pregnancy Unit

may occur (less

than 14 weeks)

Visit/s to

antenatal unit

may occur (14

weeks and more)

Woman goes into labour. Attends birth place of

choice Pregnancy loss.

Counselling and

support offered Intrapartum care begins

Woman births baby – home, in labour ward, midwife led unit or in theatre

Postnatal (postpartum) care begins. At home, postnatal ward or midwife led unit.

Postpartum care provided for ten days routinely or until baby regains birth weight by community midwives (up to

28 days postpartum). Care transferred to the Health Visiting ream and the GP

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Safe

By safe, we mean people are protected from abuse* and avoidable harm. *Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse.

Key lines of enquiry: S1

S1. How do systems, processes and practices keep people safe and safeguarded from abuse?

Report sub-heading: Mandatory training

Prompts Professional standard Sector specific guidance

• S1.1 How are safety and safeguarding systems, processes and practices developed, implemented and communicated to staff?

• S1.5 Do staff receive effective training in safety systems, processes and practices?

• Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour.

• Statutory and Mandatory training for staff working in maternity would be expected to include neonatal and obstetric emergencies as a minimum.

• Those working in the community or in independent services need to have training tailored to their need

• NICE Guidelines NG51: Sepsis Recognition, diagnosis and early management

If you are inspecting acute, community or independent midwifery or maternity services it is important to consider the following:

• Statutory and mandatory training records:

o How is the content decided upon?

o Is it multidisciplinary? o Does the content respond to

incidents? o Is it up-to-date

• Is there evidence of learning through simulation in acute, community or midwifery services on:

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Those working in the community or independent midwifery services need to have training tailored to their need

o How to recognise the deteriorating health of a woman

o A woman moving from low risk to high risk birth

o Management of a haemorrhage o Management of collapse of

mother and baby o Management of eclampsia o Resuscitation of a mother or

baby o Recognising the signs of sepsis o Shoulder dystocia o Third and fourth degree tears o Emergency evacuation from a

birthing pool

• In addition – within the community or independent midwife service how is this training provided? Do midwives attend the acute setting or is it delivered and practised in the community?

• Is there evidence of Cardiotocography (CTG) training and signed off competencies?

• With regards to sepsis, is there a policy for sepsis management in place, are staff aware of it, have staff had appropriate training in sepsis?

• Have staff received training to make them aware of the potential needs of people with:

• mental health conditions

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• learning disability

• autism

• Are staff competent to scan women in early pregnancy? What training have they received?

Report sub-heading: Safeguarding

• S1.1 How are safety and safeguarding systems, processes and practices developed, implemented and communicated to staff?

• S1.2 How do systems, processes and practices protect people from abuse, neglect, harassment and breaches of their dignity and respect? How are these monitored and improved?

• S1.3 How are people protected from discrimination, which might amount to abuse or cause psychological harm? This includes harassment and discrimination in relation to protected characteristics under the Equality Act.

• S1.4 How is safety promoted in recruitment practice staff support arrangements, disciplinary procedures, and ongoing checks? (For example Disclosure and Barring Service checks).

• S1.5 Do staff receive effective training in safety systems, processes and practices?

• Safeguarding Intercollegiate Document: Safeguarding children and young people: roles and competences for health care staff (2014)

• First edition of Intercollegiate Guidance for Adult Safeguarding (2018)

• Clinical staff working with children, young people and/or their parents / carers and who could contribute to assessing, planning, intervening and evaluating the needs of a child or young person should be trained to safeguarding at level 3.

• Safeguarding Children and Young People: Roles and Competencies for Health Care Staff’ (March 2014)

• HM Government: Working together to safeguard children: A guide to inter-agency working to safeguard and promote the welfare of children. March 2015

• What is the uptake of safeguarding training? (both acute and community)

• What level of training do staff have?

• What risk assessments are undertaken?(acute, community and independent services)

• Are there arrangements in place to safeguard women with, or at risk of, Female Genital Mutilation (FGM).

• If women with FGM are noted, how are the family concerns escalated?

• Is there a teenage pregnancy service? consider the safeguarding arrangements in this service.

• Have there been any important local safeguarding/serious case reviews/domestic murder/FGM reviews;

• How does the team get involved in these investigations (acute, community and IHC)?

• Has there been a recent local CQC and safeguarding looked after children’s review? If so, what were the

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• S1.6 Are there arrangements to safeguard adults and children from abuse and neglect that reflect relevant legislation and local requirements? Do staff understand their responsibilities and adhere to safeguarding policies and procedures, including working in partnership with other agencies?

• S1.7 Do staff identify adults and children at risk of, or suffering, significant harm? How do they work in partnership with other agencies to ensure they are helped, supported and protected?

• Female genital mutilation multi-agency practice guidelines published in 2016 This multi-agency guidance on female genital mutilation (FGM) should be read and followed by all persons and bodies in England and Wales who are under statutory duties to safeguard and promote the welfare of children and vulnerable adults. It replaces female genital mutilation: guidelines to protect children and women (2014).

The above guidance should be considered together with other relevant safeguarding guidance including(but not limited to):

• DH Female Genital Mutilation and Safeguarding: Guidance for professionals March 2015

• Working together to safeguard children: HM Gov. 2015

• FGM Mandatory reporting of FGM in healthcare

• FGM-video-resources for healthcare professionals

• Guidelines for physicians on the detection of child sexual exploitation (RCP, November 2015)

• Sexual Offences Act 2003

recommendations and how have the community team responded to it?

• What systems are in place to check whether families are subject to a child protection/child in need plan; and ensure that staff such as health visitors work with others to ensure they are followed?

• Is information on safeguarding shared in a timely way and are reports and learning from safeguarding incidents available to community staff?

• Are plans in place for the handover to the relevant social services support?

• Do the maternity SG leads attend MDT meetings with lead agencies (local authority) for the purposes of sharing good practice and policy updates?

• For services treating under 18yrs:

o Do staff have an awareness of Child Sexual Exploitation (CSE) and understand the law to detect and prevent maltreatment of children?(acute and community)

o How do staff identify and respond to possible CSE offences? Are risk assessments used/in place? (community and acute)

o What safeguarding actions are taken to protect possible victims of CSE?

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Under Section 5 of the Sexual Offences Act 2003, a girl under 13 years of age is not considered capable of giving her consent to sexual intercourse. Disclosure is not invariably required but it is usual in order that the interests of the child, which are paramount, may be protected.

• Not always restricted to, but includes interventions under the MHA, see MHA Code of Practice.

• Guidance for specified authorities

in England and Wales on the duty in the Counter-Terrorism and Security Act 2015 to have due regard to the need to prevent people from being drawn into terrorism.

Are timely referrals made? And is there individualised and effective multi-agency follow up?

o Are leaflets available about CSE with support contact details?

• Does the trust have an abduction policy? If you are inspecting a community or independent midwifery or maternity service it is also important to ask the following:

• Do community or independent midwives have sufficient time to carry out safeguarding activities?

• How do community or independent midwives assess and provide early help to:

▪ Young adults 16-18yrs ▪ Families in need ▪ FGM women

• Does the handover to health visiting in the postnatal period incorporate safeguarding?

• Who is accountable and responsible for the quality and impact of child protection arrangements?

• Is there a substance abuse service with liaison with community based addiction services

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• What are the safeguarding arrangements in the community setting for women with perinatal mental health concerns or substance misuse problems?

• What training is provided to community maternity staff in relation to the Government’s ‘prevent’ strategy?

• If a women is assessed to be at risk of suicide or self-harm, what arrangements are put in place to enable them to remain safe?

• Are there policies and procedures in place extra observation or supervision, restraint and, if needed, rapid tranquilisation?

Report sub-heading: Cleanliness, infection control and hygiene

• S1.1 How are safety and safeguarding systems, processes and practices developed, implemented and communicated to staff?

• S1.8 How are standards of cleanliness and hygiene maintained? Are there reliable systems in place to prevent and protect people from a healthcare-associated infection?

• NICE QS61 Statement 3: People receive healthcare from healthcare workers who decontaminate their hands immediately before and after every episode of direct contact or care.

• NICE QS61 Statement 4: People who need a urinary catheter have their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the catheter and its

• Are long gloves available for manual removal of placenta?

• What is the incidence of Puerperal sepsis and other puerperal infections within 42 days of delivery and readmission rates for infections in mothers and baby?

• Inspect the fridges where products of birth are stored. Are they cleaned and adequately maintained?

• How are standards of cleanliness and hygiene maintained e.g. hand washing,

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removal as soon as it is no longer needed.

• NICE QS61 Statement 5: People who need a vascular access device have their risk of infection minimised by the completion of specified procedures necessary for the safe insertion and maintenance of the device and its removal as soon as it is no longer needed.

• Code of practice on the prevention and control of infections

availability of hand gel, BBE (Bare Below the Elbow).

• Are there hand hygiene audits? Are the hand gels full? Are staff adhering to the trust/ service uniform policy?

In addition if you are inspecting a community or independent midwifery or maternity service it is also important to ask the following:

• What procedures are followed to maintain cleanliness and hygiene during home births? i.e. birth kits.

• What procedures are in place to obtain aprons and gloves?

• How is equipment cleaned between use?

Report sub-heading: Environment and equipment

• S1.1 How are safety and safeguarding systems, processes and practices developed, implemented and communicated to staff?

• S1.9 Do the design, maintenance and use of facilities and premises keep people safe?

• S1.10 Do the maintenance and use of equipment keep people safe?

• S1.11 Do the arrangements for managing waste and clinical specimens keep people safe? (This includes classification,

• Safer Childbirth: At a minimum a maternity unit offering obstetric care should have:

o Cardiotocography (CTG) machines

o Resuscitation equipment – for adults and the new-born

o Fetal blood analyser o Access to ultrasound

assessment of fetal wellbeing (Doppler, liquor volume)

• How far are the obstetric theatres/ Neonatal unit from the delivery suite? Are lifts required to transfer women and babies to these locations (potential sources of delay)?

• Is there a second theatre and what level of facilities does it have.

• How often is it used?

• All equipment must conform to the relevant safety standards and be regularly serviced. Electrical equipment must be PAT tested.

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segregation, storage, labelling, handling and, where appropriate, treatment and disposal of waste.)

o Laboratory facilities with availability of blood and blood products.

• Safer Childbirth: Facilities should be reviewed at least biannually and plans made to rectify deficiencies within agreed timescales

• Maternity care facilities should be designed in keeping with the DH guidance Health Building Note 09-02

• https://www.resus.org.uk/quality-standards/equipment-used-in-homebirth/

• MHRA guidance on managing medical devices (2015)

• Are items of equipment such as blood pressure monitors and scales calibrated according to manufacturer’s guidance?

In addition if you are inspecting a community, independent midwifery or maternity service it is also important to ask the following:

• Do community midwives have their own baby scales, sonicaids and bilirubinometers, blood pressure machines, thermometers? If so, how and when are these calibrated?

• Do they have access to Carbon monoxide monitors?

• Are weighing scales and BP cuffs available for mothers in settings for any community based ante natal care? Do the weighing scales allow the full weight range to be measured?

• Do midwives have access to specific equipment for women with a raised BMI?

• What emergency equipment do community midwives carry and how is this maintained and checked?

- How is the need for carrying this equipment assessed?

• How do midwives transport equipment, is this safe and secure and compliant with local protocols and legislation?

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• In births using a birthing pool in the home, are community midwives able to check for new liners and how the parents plan to use the pool in line with PHE/HSE guidance?

• Do they have “waterproof” sonicaids?

• Do they have access to resus trolleys at clinics and GP practices.

• Do they know where they are and who checks them?

• What equipment is routinely supplied to a woman’s home in advance of a home birth; and how is this equipment monitored to ensure it is fit for purpose when required?

• How are urine samples/ testing strips, sharps, placenta (unless the woman has opted to keep their placenta) and other waste disposed of when working in the home?

• How are midwives kept safe in the community: for example, what is the lone worker policy? What equipment are they given when working alone and how is their welfare checked upon?

• What happens if there are concerns about thewoman’s partner, another family member or pet in the woman’s home?

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• If they have to collect equipment or birth packs from closed or empty facilities late at night how is this managed?

• What about pop-up services? Are these safe? How are the trust assured that setting them up, running and maintaining them is safe?

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Key line of enquiry: S2

S2. How are risks to people assessed, and their safety monitored and managed so they are supported to stay safe?

Report sub-heading: Assessing and responding to patient risk

Prompts Professional standard Sector specific guidance

• S2.5 Are comprehensive risk assessments carried out for people who use services and risk management plans developed in line with national guidance? Are risks managed positively?

• S2.6 How do staff identify and respond appropriately to changing risks to people who use services, including deteriorating health and wellbeing, medical emergencies or behaviour that challenges? Are staff able to seek support from senior staff in these situations?

• Sepsis: recognition, diagnosis and early management (NICE Guideline 51)

• NICE CG 190: Section 1.10: Monitoring in labour.

• Safer Childbirth: The consultant obstetrician must be contacted prior to emergency caesarean section and must be involved when a woman’s condition gives rise for concern and attend as required.

• MBRRACE-UK report: Saving Lives, Improving Mothers’ Care – Surveillance of maternal deaths in the UK 2011-13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-13 (published Dec 2015).

• NICE QS3 statement 1: All patients, on admission, receive an assessment of VTE and bleeding risk using the

• Use of Modified Early Obstetric Warning (MEOWs) Score – is this used on women? At what stage of delivery or post delivery is it used? Is this audited to ensure compliance?

• What is the escalation policy on women who deteriorate and how is this tested? Scenario testing?

• Do staff use PEWS (paediatric early warning score) on babies in the post natal ward? Ask the staff.

• Are the hospital & community midwives trained to complete the newborn baby checks within 72 hours of birth?

• Do risk assessments at booking (around 10 weeks of pregnancy) include social and medical assessment and referral, as well as assessment of maternal mental health? What is the maternity triage process?

• Is there use of WHO surgical safety checklists in maternity surgery? Do they follow all three steps? How is compliance audited?

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clinical risk assessment criteria described in the national tool.

• NICE QS3 statement 4: Patients are re-assessed within 24 hours of admission for risk of VTE and bleeding.

• The service should ensure compliance with the 5 steps to safer surgery World Health Organization for patients undergoing surgery and the modified Maternity WHO surgical safety checklist in maternity.

• Pre-operative assessment should be in line with NICE CG3: Pre-operative assessments

• NICE QS 22: Risk assessments for raised BMI, Gestational diabetes, smoking and pre-eclampsia, VTE.

• NICE QS34 (Self harm) Statement 2 - initial assessments

• NICE CG16 (Self harm in over 8s)

• National Safety Standards for Invasive Procedures (NatSSIPs) Version number: 1 published: 7 September 2015

• Do consultants attend for difficult deliveries? e.g. trials, full dilatation caesarean section, placenta previa , caesarean section etc.

• What are their policies for transfer to secondary care (e.g. from a midwife-led unit or home birth)? How is this monitored?

• Are there service level agreements with specialist centres? What processes are in place to ensure a smooth transfer with support at both ends.

– What processes are in place to assess the risk level of the transfer?

– How is the risk level communicated to the receiving unit is ready to act on arrival of the transfer?

• Are there local agreements with the ambulance service on attendance at emergencies or when transfer is required?

• What happens when a woman arrives in labour without having booked? What will happen once care has been provided? How will this be followed up by the service? Does this link to overseas women accessing maternity services?

• What about bloods, safeguarding, social care assessments, risk assessments for women who arrive without having booked?

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• Brief guide: NatSSIPs and LocSSIPs (CQC internal guidance)

• What risk methodology is used to assess need for prophylactic antibiotic use?

• How does the provider ensure that appropriate liaison with critical care is available in the event of a woman requiring transfer or input from critical care services?

• How do leaders ensure that employees who are involved in the performance of invasive procedures develop shared understanding and are educated in good safety practice, as set out in the national standards?

• Have managers ensured that there is a plan in place to develop local Safety Standards for Invasive Procedures using the national Safety Standards for Invasive Procedures. Have they assessed the need for these against all invasive procedures carried out?

In addition if you are inspecting a community, independent midwifery or maternity service it is also important to ask the following:

• Is the booking appointment undertaken before 10 weeks of pregnancy and certainly before 12 weeks? What percentage of bookings, are undertaken by 12 weeks?

• Are women with risk factors identified and referred appropriately to an

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obstetrician? What is the working relationship like with obstetricians and what is the care pathway for escalation?

• Is there a service level agreement with an acute trust?

• Is there a service level agreement with the ambulance service? Or private ambulance service for transfers?

• Is there evidence of ongoing risk assessment, review and revision of care plans as necessary throughout the pregnancy?

• What are the arrangements for pregnant women and new mothers with mental health concerns or substance misuse problems?

• How are plans managed for those women with high risk factors wanting a home birth, or for those declining care or wishing to have a free birth?

• How are such plans communicated across the (multi-disciplinary) team?

• How is this information shared and communicated with others i.e. consultants/ambulance service?

• What processes are in place within the community for identifying and managing a deteriorating woman?

• What process is in place for sharing information with the local acute trust i.e. Service Level Agreement? For example,

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do they notify the acute trust of a woman in labour and how is that done?

• Is there a transfer policy in place and how does this operate? Are midwives familiar with the policy?

• What are the thresholds for postpartum haemorrhage 500mls within the community and independent midwifery service setting?

• Does the service have a service level agreement (SLA) or arrangement with an NHS trust or private ambulance service to support women?

• What are the escalation policies in relation to a deteriorating woman or baby? Are these understood by the midwives? And the women themselves?

• Are there local agreements with the ambulance service on attendance at emergencies or when a transfer is required?

• Do staff have access to 24/7 mental health liaison (covering the age range of the ward/ clinic) and/or other specialist mental health support if they are concerned about risks associated with a woman’s mental health?

• Do staff know how to make an urgent referral to them?

• Do they get a timely response?

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• Are staff provided with a debrief/ other support after involvement in aggressive or violent incidents?

Report sub-heading: Midwifery and Nurse staffing

• S2.1 How are staffing levels and skill mix planned and reviewed so that people receive safe care and treatment at all times and staff do not work excessive hours?

• S2.2 How do actual staffing levels and skill mix compare with the planned levels? Is cover provided for staff absence?

• S2.3 Do arrangements for using bank, agency and locum staff keep people safe at all times?

• S2.4 How do arrangements for handovers and shift changes ensure that people are safe?

• S2.7 How is the impact on safety assessed and monitored when carrying out changes to the service or the staff?

• NICE NG4: Safe Midwifery Staffing ➢ Women in established labour

should receive on-to-one care.

➢ A systematic process must be undertaken to calculate the midwifery staffing establishment every 6 months. The calculation should take into account historical data and acuity and dependency of women.

• Safer Childbirth: An experienced midwife (shift coordinator) is available for each shift on the labour ward.

• Safer Childbirth: All midwifery units must have one WTE consultant midwife.

• Safer Childbirth: Student midwives should be supernumerary to the midwife establishment.

• Staffing numbers need to be displayed outside all ward areas in line with NHS England / CQC: Hard Truths.

• What is the midwife to birth ratio? How does the service take into account the skill mix of staff and complexity of case mix? How often is this reviewed?

• Is there an assessment of safe staffing on a shift by shift basis?

• How many gaps are there on the rotas? How are these gaps covered?

• What is the number of and role of Maternity Support Workers, what training do they receive and how is this updated?

• If the service has midwife led units how is staffing calculated to incorporate the staffing requirements of this service? can they demonstrate safe staffing?

• NICE NG4: Staffing Red flags o Delayed or cancelled time critical

activity. o Missed or delayed care (for

example, delay of 60 minutes or more in washing and suturing).

o Missed medication during an admission to hospital or midwifery-led unit.

o Delay of more than 30 minutes in providing pain relief.

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• Birthrate Plus Assessment and use of the acuity tool,

o Delay of 30 minutes or more between presentation and triage.

o Full clinical assessment not carried out when presenting in labour.

o Delay of 2 hours or more between admission for induction and beginning of process.

o Delayed recognition of and action on abnormal vital signs (for example, sepsis or urine output).

o Any occasion when 1 midwife is not able to provide continuous one-to-one care and support to a woman during established labour

In addition if you are inspecting a community or independent midwife or maternity service it is also important to ask the following:

• How do actual staffing levels compare to the planned levels?

• What are the midwife caseload numbers?

• How is sickness and maternity cover dealt with i.e. agency/bank staff?

• How does the trust/ service’s internal escalation policy impact on community midwifery?

• In the community trusts are they expected to cover acute services? If they do what is the effect on the delivery of

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community services? How is this managed and assessed?

• In the independent services how is care for women safely managed when there are staffing shortages?

• What is the impact on women wishing to have a home birth, general staffing in the community, on call service and staff numbers and planned clinics?

• How are skills maintained for community midwives to work in the hospital setting, what buddying arrangements are in place, training provided? Are skills and drills customised for community settings?

• What supervision arrangements are in place for midwives?

• How are midwives supported in the community?

• What are the handover arrangements within their own teams?

• Do staff have access to a link hospital support service, do they know which consultant to contact for example?

• How do community midwives work with other staff such as maternity support workers and community administrator? (MSWs are often used as part of Birthrate Plus - admin provide essential info i.e. if there has been miscarriage).

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Report sub-heading: Medical staffing

• S2.1 How are staffing levels and skill mix planned and reviewed so that people receive safe care and treatment at all times and staff do not work excessive hours?

• S2.2 How do actual staffing levels and skill mix compare with the planned levels? Is cover provided for staff absence?

• S2.3 Do arrangements for using bank, agency and locum staff keep people safe at all times?

• S2.4 How do arrangements for handovers and shift changes ensure that people are safe?

• S2.7 How is the impact on safety assessed and monitored when carrying out changes to the service or the staff?

• Safer Childbirth/RCOG: The Future Workforce: Recommended Consultant presence on labour ward per week:

➢ <2500 births: 40 hours or based on risk assessments

➢ 2500 – 6000 births: 40 hours ➢ >6000 birth: 60 hours

• Safer Childbirth: There should be a minimum twice daily ward rounds, including bank holidays and weekends. They should be available within 30 minutes if required.

• AAGBI Obstetric Anaesthetic Guidance:

A duty anaesthetist must be immediately available 24/7. There must be 12 consultant sessions per week to cover emergency work on delivery suite. Scheduled obstetric anaesthetic activities (e.g. elective caesarean section lists, clinic) require additional consultant sessions over and above the 12 for emergency cover.

http://www.rcoa.ac.uk/document-store/guidance-the-provision-of-obstetric-anaesthesia-services-2015

• Is the recommended obstetric consultant staffing levels being met? i.e 40 hours present per week on the labour ward (dependent on size of the service).

• Is an anaesthetist available immediately throughout the whole of the day and night and at weekends? Are they free from other duties?

• Who is present at the morning handover? i.e. the midwife led handover, medical staff handover etc.

• Is there regular consultant presence and regular ward rounds? Do junior staff feel supported?

In addition if you are inspecting a community or independent midwife or maternity service it is also important to ask the following:

• In the case of high risk women what are the escalation pathways and policies in place across antenatal, intrapartum and postnatal services and for escalating to a consultant for a review?

• Are there consultant led clinics in the community?

• For independent services, how do women access the consultant appointed by the service?

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• Staffing numbers need to be displayed on boards outside all ward areas in line with NHS England / CQC: Hard Truths

• How many consultants work with the independent services? What are their other roles? Can they meet the needs of the caseload?

Key line of enquiry: S3

S3. Do staff have all the information they need to deliver safe care and treatment to people?

Prompts Professional standard Sector specific guidance

Report sub-heading: Records

• S3.1 Are people’s individual care records, including clinical data, written and managed in a way that keeps people safe?

• S3.2 Is all the information needed to deliver safe care and treatment available to relevant staff in a timely and accessible way? (This may include test and imaging results, care and risk assessments, care plans and case notes.)

• S3.3 When people move between teams, services and organisations (which may include at referral, discharge, transfer and transition), is all the information needed for their ongoing care shared appropriately, in a timely way and in line with relevant protocols?

• S3.4 How well do the systems that manage information about people who use services

• Records management code of practice for health and social care

• NICE QS15 Statement 12: Patients experience coordinated care with clear and accurate information exchange between relevant health and social care professionals.

• NICE QS22 Statement 3: Pregnant

women have a complete record of the minimum set of antenatal test results in their hand-held maternity notes.

• Safer Childbirth: The standard of record keeping and storage of data is clear, rigorous and precise

• records-management-code-of-practice-for-health-and-social-care

• Are electronic medical records used? How are they managing the transition from paper to electronic?

• Are documents dated, timed, with a signature and identifiable name? (acute and community settings)

• Do records accurately record the woman’s choice; are risk assessments documented clearly and womens individualised care plans clear? Are referrals to specialist services documented?

• How does the service ensure that referrals to specialist services are followed up?

• Has the service determined how pertinent information about the baby (from when it was inutero) will be held in the maternity records, and will be

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support staff, carers and partner agencies to deliver safe care and treatment? (This includes coordination between different electronic and paper-based systems and appropriate access for staff to records.)

• NICE QS121 Statement 3: People prescribed an antimicrobial have the clinical indication, dose and duration of treatment documented in their clinical record

transferred to the baby records once the baby has its own NHS number?

• How is any discharge communicated to GPs? How soon after discharge does this occur? What information is provided for GP reviews and follow up arrangements for example women with risk factors such as gestation diabetes?

• How does the service ensure timely communication on transfer of woman and baby‘s care from a maternity unit to community midwifery team; then to Health Visitors (HVs) and the GP; and when relevant, to their Community Mental Health or Learning Disabilities Team?

• Are care summaries sent to the woman’s GP on discharge to ensure continuity of care within the community?

• When people are prescribed an antimicrobial do they have the clinical indication, dose and duration of treatment documented in their clinical record?

• When appropriate, do records contain details of womens’:

o mental health needs o learning disability needs o autism needs o dementia needs

alongside their physical health needs?

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• Are staff confident the records will tell them if a woman has one of these underlying diagnoses?

• What systems are in place to identify woman with pre-existing

o mental health conditions o learning disability o autism diagnosis?

• If a woman has been seen by a member of the mental health liaison team, is their mental health assessment, care plan and risk assessment accessible to staff on the ward/ clinic?

• Does the staff team have advice from mental health liaison about what to do if the woman attempts to discharge themselves, refuses treatment or other contingencies?

• When relevant, do staff have access to woman-specific information, such as care programme approach (CPA) care plans, positive behaviour support plans, health passports, communication aids? Do they use or refer to them?

In addition if you are inspecting a community or independent midwife or maternity service it is also important to ask the following:

• Are any extra medical records transported between the acute trust and

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the community; if so, how are they kept safe and confidential?

• Is there sufficient storage for records to comply with data protection issues?

• Are the women’s held records kept with them at all times, what happens if the woman’s held records are lost?

• If IPads and laptops are used are they encrypted and what happens if they are lost or stolen?

• Are records returned to medical records in a time manner after discharge from maternity services?

• How are care documents handed over to the health visitor?

• How do staff access records remotely for example in GP surgeries?

• What is the process for collecting midwives diaries and ensuring they are stored securely?

• Is the ‘red book’ completed (personalised child record given to each parent/carer at the child’s birth to record the child’s health and development)?

• How are test results, reports made available to community midwives, uploaded or shared appropriately with staff in a timely way?

• Are they sent to them (physically or electronically) or do they need to look them up?

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• In the independent services how do staff access support for specialism such as autism or dementia?

• How does the service ensure timely communication on transfer of a woman and baby’s care from a maternity unit to the community midwifery team, and then to health visitors and the GP? If appropriate what happens in relation to out of area births?

• How is communication managed between local agencies and the maternity unit?

• What information about pregnancy is shared across different parts of the service, for example, how is the midwife informed of pregnancy loss?

Key line of enquiry: S4

S4. How does the provider ensure the proper and safe use of medicines, where the service is responsible?

Prompts Professional standard Sector specific guidance

Report sub-heading: Medicines

• S4.1 How are medicines and medicines related stationery managed (that is, ordered, transported, stored and disposed of safely and securely)? (This includes medical gases and emergency medicines and equipment.)

• S4.2 Are medicines appropriately prescribed, administered and/or supplied to people in

• Nursing and Midwifery Council NMC - Standards for Medicine Management

• NICE QS61 Statement 1: People are prescribed antibiotics in accordance with local antibiotic formularies.

• Are allergies clearly documented in the prescribing document used? Are there local microbiology protocols for the administration of antibiotics and are prescribers using them?

• When people are prescribed an antimicrobial do they have a

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line with the relevant legislation, current national guidance or best available evidence?

• S4.3 Do people receive specific advice about their medicines in line with current national guidance or evidence?

• S4.4 How does the service make sure that people receive their medicines as intended, and is this recorded appropriately?

• S4.5 Are people's medicines reconciled in line with current national guidance on transfer between locations or changes in levels of care?

• S4.6 Are people receiving appropriate therapeutic drug and physical health monitoring with appropriate follow-up in accordance with current national guidance or evidence?

• S4.7 Are people’s medicines regularly reviewed including the use of ‘when required’ medicines?

• S4.8 How does the service make sure that people’s behaviour is not controlled by excessive or inappropriate use of medicines?

• NMC - Standards for Medicine Management

• NICE QS 61: People are prescribed antibiotics in accordance with local antibiotic formularies.

• NICE QS121 Statement 4: People in hospital who are prescribed an antimicrobial have a microbiological sample taken and their treatment reviewed when the results are available

• Start Smart then Focus: Antimicrobial Stewardship Toolkit

• https://www.rcm.org.uk/news-views-and-analysis/analysis/changes-to-midwives-exemptions

• NICE CG52 Drug misuse in over 16s: opioid detoxification

• NICE CG100 Alcohol-use disorders: diagnosis and management of physical complications

microbiological sample taken and is their treatment reviewed when results are available?

• When someone dependent on alcohol or illegal drugs is admitted, are they offered medicines to assist their withdrawal and associated side-effects?

• Do individuals and teams responsible for antimicrobial stewardship monitor data and provide feedback on prescribing practice at prescriber level?

In addition if you are inspecting a community or independent midwife or maternity service it is also important to ask the following:

• How are community medicines managed in terms of obtaining, storage and returned to pharmacy? What audits are undertaken to show procedures are safe and medicines are in date?

• In the case of home births how are Controlled Drugs including pethidine obtained, stored and used; what audits are completed?

• How do midwives ensure the controlled drugs are safely disposed of? And recorded?

• How are medical gases obtained and stored in the community?

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• What risk assessments are conducted to ensure the midwife or their car or premises are not a target for someone wanting to access medical gases inappropriately?

• How do midwives ensure they do not run out of medical gases?

• How are medical gases transported by community midwives? How would emergency services be made aware their vehicle may contain nitrous oxide?

• Do community midwives administer the flu or pertussis vaccines? How are these transported and stored? Is there a PGD in place?

Key line of enquiry: S5 & S6

S5. What is the track record on safety?

S6. Are lessons learned and improvement made when things go wrong?

Prompts Professional standard Sector specific guidance

Report sub-heading: Incidents

• S5.1 What is the safety performance over time?

• S5.2 How does safety performance compare with other similar services?

• S5.3 How well safety is monitored using information from a range of sources

• A never event is a serious, wholly preventable patient safety incident that has the potential to cause serious patient harm or death, has occurred in the past and is easily recognisable and clearly defined.

• Serious Incidents(SIs) associated with maternity include:

➢ Unexpected admission to NICU ➢ Maternal unplanned admission to

ITU ➢ Postpartum haemorrhage ≥1500

mls

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(including performance against safety goals where appropriate)?

• S6.1 Do staff understand their responsibilities to raise concerns, to record safety incidents, concerns and near misses, and to report them internally and externally, where appropriate?

• S6.2 What are the arrangements for reviewing and investigating safety and safeguarding incidents and events when things go wrong? Are all relevant staff, services, partner organisations and people who use services involved in reviews and investigations

• S6.3 How are lessons learned, and themes identified and is action taken as a result of investigations when things go wrong?

• S6.4 How well is the learning from lessons shared to make sure that action is taken to improve safety? Do staff participate in and learn from reviews and investigations by other services and organisations?

• S6.5 How effective are the arrangements to respond to relevant external safety alerts, recalls, inquiries, investigations or reviews?

➢ Revised never events policy and framework (2015)

➢ Never events list 2015/16 ➢ Never Events List 2015/15 -

FAQ

• Serious Incidents (SIs) should be investigated using the Serious Incident Framework 2015.

• Safer Childbirth: There is evidence of multi-professional input in protocol and standard setting and in reviews of critical incidents.

• Safer Childbirth: Meetings involving all relevant professionals are held to review adverse events.

• (NICE QS66 Statement 4): For adults who receive intravenous (IV) fluid therapy in hospital, clear incidents of fluid mismanagement are reported as critical incidents.

• Duty of Candour: As soon as reasonably practicable after becoming aware that a notifiable safety incident has occurred a health service body must notify the relevant person that the incident has occurred, provide reasonable support to the relevant

➢ Venous thromboembolism (VTE) ➢ 3rd or 4th degree trauma

(Obstetric Anal Sphincter Injury (OASIS)

➢ Rupture or perforation of the uterus

Consider looking at:

• Copy of the last 3 Root Cause Analyses and subsequent action plans. Who carries these out? Are external reviewers used?

• What training have the investigators received in root cause analysis?

• Last 3 months morbidity and mortality meeting minutes. Who attends? Is it Multidisciplinary?

• Evidence of dissemination of learning by staff from incidents? Can staff tell you about learning from a particular incident?

• Is there evidence in incident investigations that duty of candour has been applied?

• Does the service ensure that all births between weeks of 22+0 and 23 +6 gestational age who do not survive the neonatal period are report to MBRRACE-UK?

• Do perinatal and maternity mortality and morbidity reviews feed into service improvement? Are these undertaken

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person in relation to the incident and offer an apology.

• RCOG: Improving Patient Safety:

• Recommendation 8 of the MBBRACE report published June 2015 sets out that All organisations responsible for maternity services should report to MBRRACE-UK all births between 22+0 and 23+6 weeks gestational age who do not survive the neonatal period

monthly, MDT attended minuted and lessons learnt and cascaded appropriately?

In addition if you are inspecting a community or independent midwife or maternity service it is also important to ask the following:

• How many and what kind of incidents are reported in the community or in independent midwifery or maternity services? Who maintains oversight of these?

• Do members of the team have appropriate access to computers or the internet to complete incident reports in a timely way? and do they receive feedback from investigations and what evidence of change in practices is available?

• How are lessons shared from incidents occurring in the trust or provider? How well does this work?

Report sub-heading: Safety Thermometer/ Maternity Dashboard

• S5.1 What is the safety performance over time?

• S5.2 How does safety performance compare with other similar services?

• NICE QS3 Statement 1: All patients, on admission, receive an assessment of VTE and bleeding risk using the clinical risk assessment criteria described in the national tool.

• How does the service measure metrics on the safety thermometer?

• Is there a maternity dashboard in the service?

• How does the service decide its thresholds for the dashboard?

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• S5.3 How well safety is monitored using information from a range of sources (including performance against safety goals where appropriate)?

• NICE QS3 Statement 4: Patients are re-assessed within 24 hours of admission for risk of VTE and bleeding.

• Safety Thermometer

• How does the dashboard compare to last year?

• What meetings, groups or committees monitors activity on the dashboard?

• Is this displayed publicly within the service?

• What about wound non healing or infection? in order to identify trends of poor technique or hygiene do they monitor this? what actions are they taking to improve any identified trends?

In addition if you are inspecting a community or independent midwife or maternity service it is also important to ask the following:

• Is this information displayed for women, other visitors and staff so they can see how the service is performing?

• Does the dashboard have any links to an acute service?

• Do the Clinical Commissioning Groups or NHS England monitor the dashboard?

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Effective

By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.

Key line of enquiry: E1

E1. Are people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence.

Prompts Professional standard Sector specific guidance

Report sub-heading: Evidence-based care and treatment

• E1.1 Are people's physical, mental health and social needs holistically assessed, and is their care, treatment and support delivered in line with legislation, standards and evidence-based guidance, including NICE and other expert professional bodies, to achieve effective outcomes?

• E1.2 What processes are in place to ensure there is no discrimination, including on the grounds of protected characteristics under the Equality Act, when making care and treatment decisions?

• E1.3 How is technology and equipment used to enhance the delivery of effective care and treatment and to support people’s independence?

• E1.4 Are the rights of people subject to the Mental Health Act 1983 (MHA) protected and

• NICE QS66 Statement 2: Adults receiving intravenous (IV) fluid therapy in hospital are cared for by healthcare professionals competent in assessing patients' fluid and electrolyte needs, prescribing and administering IV fluids, and monitoring patient experience.

• (NICE QS3 Statement 5): Patients assessed to be at risk of VTE are offered VTE prophylaxis in accordance with NICE guidance.

• NICE QS90 (2015) UTI in adults

• Safer Childbirth: Comprehensive evidence-based guidelines and protocols for intra-partum care are

• How does the service ensure that maternity is managed in accordance with RCOG: ‘Safer childbirth: minimum standards for the organisation and delivery of care in labour’? Is the service managed in accordance with NICE guidelines and quality standards for maternity? Which guidelines does the service follow? If they do not follow all of the national guidelines, why is this? How does the service ensure that the care of women with a multiple pregnancy is planned and provided in accordance with NICE quality standards for management of twin and triplet pregnancies in the antenatal period?

• Are all women with risk factors for gestational diabetes identified and offered glucose tolerance testing as

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do staff have regard to the MHA Code of Practice?

• E1.7 Are people told when they need to seek further help and advised what to do if their condition deteriorates?

agreed by the labour ward forum or equivalent, ratified by the maternity risk management group and reviewed at least every 3 years.

• NICE QS22 - 12 quality statements in respect of antenatal care.

• NICE QS32 - 9 quality statements in respect of caesarean section.

• NICE QS37 - 11 quality statements in respect of postnatal care.

• NICE CG192: Antenatal and post- natal mental health: clinical management and service guidance.

• MBRRACE-UK Perinatal Confidential Enquiry into Term, singleton, normally formed, antepartum stillbirths (November 2015).

• NICE guideline: Diabetes in pregnancy: management from preconception to the postnatal period (NG3, 2015).

• NICE Clinical Guideline: Antenatal care for uncomplicated pregnancies (CG62) (See 1.10 Fetal growth and well-being)

highlighted by MBRRACE-UK (2015) and in line with the current NICE guideline (NG3, 2015).

• Is growth monitored from 24 weeks by measuring and recording the symphysis fundal height as highlighted by MBBRACE-UK (2015) and in line with current NICE Guideline (CG62,) and is there a clear escalation policy and pathway for any abnormal findings? Do midwives and obstetricians emphasise the importance of fetal movements to women at each antenatal contact as a method of fetal surveillance, as highlighted by MBRRACE-UK (2015) and in line with the current RCOG guideline (Green-top Guideline No. 57), and document the detail of this conversation?

• Do prescribers in secondary care use electronic prescribing systems which link the indication with the antimicrobial prescription?

• Is there a bereavement care plan or pathway for women and families in maternity? Does this cover:

o Communication with parents

o Continuity and consistency of approach

o Parent-led family involvement

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• RCOG: Reduced fetal movements, Green-top Guideline No. 57 https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg57/

• NICE CG 190: Recommendations for intra-partum care.

• NICE QS46 statement 1: Determining chorionicity and amnionicity

• NICE QS46 statement 2: Labelling the foetuses

• NICE QS46 statement 4: care planning

• NICE QS46 statement 5: monitoring for fetal complications

• RCOG Third- and Fourth-degree Perineal Tears, Management (Green-top Guideline No. 29)

• NICE QS90 urinary tract infections in adults

• NHSE Care bundle for still birth Saving Babies Lives: https://www.england.nhs.uk/ourwork/futurenhs/mat-transformation/saving-babies/

NB: In assessing whether NICE guidance is followed, take the following into account:

• Details of the provider’s Clinical Audit programme to support and monitor implementation of NICE guidance;

• Details of additional prescribing audits that may be completed by junior doctors on rotation.

• Utilisation of NICE implementation support tools such as the baseline assessment tools.

• A Provider submission demonstrating good practice to the NICE shared learning database. NICE checks that the examples are in line with their recommendations and quality statements.

• Participation in National benchmarking clinical audits.

• Do staff follow best practice for assessing and monitoring the physical health of people with severe mental illness? For example do they undertake appropriate health screening for example cardiometabolic screening and falls risk assessment?Are staff able to deal with any violence and aggression in an appropriate way?

• Do staff handovers routinely refer to the psychological and emotional needs of

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• NICE QS 75 Neonatal infection: covers the use of antibiotics to prevent and treat infection in a new born baby from birth to 28 days in primary (including community) and secondary care

• NICE QS57 Jaundice in newborn babies under 28 days: covers diagnosis and treating jaundice, which is caused by high levels of bilirubin in the blood in new born babies (neonates). It aims to detect and or prevent high levels of bilirubin.

• NICE guidelines NG25 Preterm labour and birth: covers guidelines for women at increased risk of or with symptoms and signs of a preterm birth and women having a planned preterm birth

• NICE QS35: Hypertension in Pregnancy : Covers pre-pregnancy advice for women with pre-existing hypertension as well as the antenatal, intrapartum and postnatal care of women at risk of or who have hypertensive disorders in pregnancy.

• NICE Guidelines NG51: Sepsis Recognition, diagnosis and early management

women, as well as their relatives / carers?

• Are women who are suspected to be experiencing depression referred for a mental health assessment?

• Do pregnancy and delivery plans routinely address the mental health and emotional wellbeing of women?

• How and when are women who are at risk of perinatal mental health issues assessed?

• Are staff aware of the latest Sepsis guidelines and treatment options

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• NICE QS121 Statement 6: Prescribers in secondary and dental care use electronic prescribing systems that link indication with the antimicrobial prescription

• NICE QS 135: preterm labour and birth: Covers care for women who are considered to be at risk of, or with symptoms and signs of preterm labour and birth

• Assessing mental health in acute trusts – guidance for inspectors

• Use of the Lester tool supports the recommendations in NICE CG 178 Psychosis and schizophrenia in adults: prevention and management and NICE CG 155 Psychosis and schizophrenia in children and young people: recognition and management

• NICE NG10 - Violence and aggression: short-term management in mental health, health and community settings

• NICE CG42 - Dementia: supporting people with dementia and their carers in health and social care

• NICE CG90 - Depression in adults: recognition and management

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• NICE CG91 - Depression in adults with

a chronic physical health problem: recognition and management

Report sub-heading: Nutrition and hydration

• E1.5 How are people's nutrition and hydration needs (including those related to culture and religion) identified, monitored and met? Where relevant, what access is there to dietary and nutritional specialists to assist in this?

• NICE QS15 Statement 10: Patients have their physical and psychological needs regularly assessed and addressed, including nutrition, hydration, pain relief, personal hygiene and anxiety.

• How does the service ensure that new mothers are supported in feeding their baby / babies as they choose?

• What food/drink is offered to women in labour; and after caesarean section?

• How is the woman’s hydration checked during labour? (Applies in all settings postdelivery).

In addition if you are inspecting a community or independent midwife or maternity service it is also important to ask the following:

• What processes and policies are in place to monitor weight loss in babies in the community including specialist support services?

• What processes and policies are in place to monitor jaundice in babies in the community including specialist support services?

• What processes are in place in the community to support mothers feeding their babies?

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- Are there staff with specialist skills in supporting feeding of babies?

Report sub-heading: Pain relief

• E1.6 How is a person’s pain assessed and managed, particularly for those people where there are difficulties in communicating?

• Core Standards for Pain Management Services in the UK

• NICE QS15 Statement 10: Patients have their physical and psychological needs regularly assessed and addressed, including nutrition, hydration, pain relief, personal hygiene and anxiety.

• NICE CG 190: Recommendations for non-regional and regional pain relief during labour.

• AAGBI Obstetric Anaesthetic Guidance:

➢ Women should have antenatal access to evidence based information about the availability and provision of all types of analgesia and anaesthesia.

➢ When a 24-hour epidural service is offered, the time from the anaesthetist’s being informed that a woman is requesting an epidural

• How does the service ensure that there is 24hr availability of choice of pharmacological (e.g. opioids, epidural) and non-pharmacological (e.g. immersion in water, support to use relaxation techniques) pain relief?

• What are the rules followed about the use of opioids frequency and timing approaching delivery?

• What is median time from women requesting an epidural to when they receive one (should be 30mins). How is audited?

• How does the service ensure that during and following induction and delivery of babies that women receive effective pain relief during labour?

• What monitoring tools for pain are used on the postnatal ward? Or post delivery?

In addition if you are inspecting a community or independent midwife or maternity service it is also important to ask the following:

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and ready to receive one should not normally exceed 30 minutes.

➢ This period should only exceed one hour in exceptional circumstances.

• Safer Childbirth: 95% of women should receive regional anaesthesia for elective CS and 85% for emergency CS.

• What methods of pain relief are used in the community setting? What arrangements does the service make for providing pain relief at home for women requesting a homebirth or for women giving birth in an FMU?

Do staff use an appropriate tool to help assess the level of pain in womenwho are non-verbal? For example, DisDAT (Disability Distress Assessment Tool) helps to identify the source of distress, e.g. pain, in people with severe communication difficulties. GMC recommended.

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Key line of enquiry: E2

E2. How are people’s care and treatment outcomes monitored and how do they compare with other similar services?

Prompts Professional standard Sector specific guidance

Report sub heading: Patient outcomes

• E2.1 Is information about the outcomes of people's care and treatment (both physical and mental where appropriate) routinely collected and monitored?

• E2.2 Does this information show that the intended outcomes for people are being achieved?

• E2.3 How do outcomes for people in this service compare with other similar services and how have they changed over time?

• E2.4 Is there participation in relevant quality improvement initiatives, such as local and national clinical audits, benchmarking, (approved) accreditation schemes, peer review, research, trials and other quality improvement initiatives? Are all relevant staff involved in activities to monitor and use information to improve outcomes?

• Safer Childbirth: There is an evaluation of midwifery and obstetric care through continuous prospective audit to improve outcomes, which are published as an annual report

• National audits and enquiries in respect of maternity services include the following: o UK national screening committee

antenatal and new born screening education audit

o Royal College of Obstetricians and Gynaecologists Clinical Indicators Project, 2013 (RCOG 11 quality indicators)

o Local audits (e.g. reason for unplanned caesarean section)

o LSA Midwifery Officer – annual report

o Unexpected admissions to neonatal intensive care unit (NICU)

o Maternal unplanned admission to critical care services

o National Patient Safety Agency Intrapartum Scorecard

• Is there evidence that the service regularly reviews the effectiveness of care and treatment through local audit and national audit/enquiry?

• What do the maternity satisfaction surveys say? Is there anything linked to outcomes of relevance to include? Pain relief choice survey etc.?

• Is there evidence that the service is making measurable improvements in the light of audit(s)?

• Are there national audits that the service does not contribute to and what is/are the reason(s) for this?

In addition if you are inspecting a community or independent midwife or maternity service it is also important to ask the following:

• What are the numbers of women choosing to birth at home or in an FMU, what is the number transferred before labour, and what are the numbers

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o Intrapartum death o Maternal death o RCOG Maternity Dashboard o Outcomes Framework for the NHS

2013/14 (maternity specific indicators)

o Public Health Outcomes Framework 2013-2016 (maternity specific indicators)

beginning labour in their chosen care setting.

• How many women are transferred during labour? What are these numbers, broken down by:

- first baby

- those who have previously delivered through a standard vaginal delivery (SVD)?

• What is the total number of transfers before and after birth from home or community to hospital and what are the reasons for this?

• What is the outcome for women who started labour at home and are transferred into hospital?

• How are unplanned or unexpected transfers to intensive care or neonatal intensive care reviewed for themes and action plans put in place, who does this and how often?

• Is there a risk rating (RAG) system used on transfer ? i.e. How do they take into account:

- the priority status of the patient

- the issue with which they have been transferred in to hospital.

• What was the time from admission to assessment depending on risk? (Acute only)

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• How is high risk care assessed, and how are high risk births communicated to the acute trust?

• What arrangements are in place for newborn hearing tests at home or in FMUs

• What arrangements are in place to babies born before arrival (BBA) i.e. babies born before arrival at the hospital or for home births, born before arrival of the midwife?

• Have benchmarking exercises been undertaken against national reports?

o Kirkup o National Maternity Service

Review o MBRRACE

• Are perineal tears monitored separately for home births – are there any trends, actions in place?

Key line of enquiry: E3

E3. How does the service make sure that staff have the skills, knowledge and experience to deliver effective care, support and treatment?

Prompts Professional standard Sector specific guidance

Report sub heading: Competent staff

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• E3.1 Do people have their assessed needs, preferences and choices met by staff with the right skills and knowledge?

• E3.2 How are the learning needs of all staff identified? Do staff have appropriate training to meet their learning needs to cover the scope of their work and is there protected time for this training?

• E3.3 Are staff encouraged and given opportunities to develop?

• E3.4 What are the arrangements for supporting and managing staff to deliver effective care and treatment? (This includes one-to-one meetings, appraisals, coaching and mentoring, clinical supervision and revalidation.)

• E3.5 How is poor or variable staff performance identified and managed? How are staff supported to improve?

• E3.7 Are volunteers recruited where required, and are they trained and supported for the role they undertake?

• Safer Childbirth: A professional (midwife, neonatal nurse, and paediatrician) trained and regularly assessed as competent in neonatal basic life support must be immediately available for all births, in any setting.

• Safer Childbirth: There should be adequate clinical support and supervision for newly qualified midwives, junior doctors and students.

• Safer Childbirth: Multi-professional in-service education/training sessions should be mandatory and attendance documented. And recommendation 5.2 of the National Maternity review Feb 2016

• NICE QS121 Statement 5: Individuals and teams responsible for antimicrobial stewardship monitor data and provide feedback on prescribing practice at prescriber, team, organisation and commissioner level.

• For guidance on replacement work for SOMs see https://www.england.nhs.uk/mat-transformation/midwifery-task-force/a-equip-midwifery-supervision-model/

• How does the service ensure the arrangements are in place for training to deliver competence in:

o Interpretation of Cardiotocogram (CTG) understanding and escalation. Are there guidelines for this?

o Newborn screening?

o Assessment of fetal growth in all setting including recording and escalation do they use GROW (gestational related optimal weight)?

o Are staff trained in using GROW?

• Is multi-professional training a standard part of professionals’ continuous professional development, both in routine situations and in emergencies?

• What processes does the service have in place that replace the Supervisor of Midwives role? Do they use A-Equip?

• What training do staff in maternity receive on bereavement, and how can they demonstrate their knowledge of this to you?

• Are staff supported to access bereavement training?

In addition if you are inspecting a community or independent midwife or maternity service it is also important to ask the following:

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• Are midwives competent to work across the service as a whole?

• How often do community midwives work in the hospital? What impact does this have on community services?

• What is the staff rotation policy?

• What training and support is provided to keep their skills current? Are these skills community focused?

• Are staff rotated through all aspects of maternity to maintain their competency? i.e from a midwife or community led setting into an acute setting where available?

• For community, private and independent midwives, are they able to continue to care for the woman in the acute trust if they have to be admitted (delivery rights or practicing privileges)?

• What are the practicing privilege arrangements for medical staff working in the service? Or are they employed directly?

• How is the service assured that medical competencies are up to date?

• How often will the service liaise with the responsible officer for the doctor? RO as defined by the GMC usually sits with the employing NHS Trust (check the GMC website for the doctor’s named RO.)

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• How are newly qualified or early career midwives supported in community settings? How are midwifery units staffed and by whom, how is continuity of care ensured?

• Depending on the setting ( in the home or FMU), how does the service ensure appropriate arrangements are in place for training to deliver competence in:

• Obstetric emergencies

• Newborn screening

• Resuscitation

• Perinatal suturing

• What support is provided from managers when there has been poor outcomes in the community or independent services in terms of de-brief?

• How is the service assured that staff have the skills, knowledge and experience to identify and manage issues arising from women with the following:

- mental health conditions

- learning disability

- autism?

• Does the mental health liaison team or similar team have members with the

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skills, knowledge and experience to work with women with

• learning disabilities

• autism?

o Is there a specialist perinatal mental health midwife available 24/7? Do staff know how to access him/her?

Key line of enquiry: E4

E4. How well do staff, teams and services within and across organisations work together to deliver effective care and treatment?

Prompts Professional standard Sector specific guidance

Report sub-heading: Multidisciplinary working

• E4.1 Are all necessary staff, including those in different teams, services and organisations, involved in assessing, planning and delivering care and treatment?

• E4.2 How is care delivered and reviewed in a coordinated way when different teams, services or organisations are involved?

• E4.3 How are people assured that they will receive consistent coordinated, person-centred care and support when they use, or move between different services?

• E4.4 Are all relevant teams, services and organisations informed when people are discharged from a service? Where relevant,

• PHSO: A report of investigations into unsafe discharge from hospital

• Transition between inpatient hospital settings and community or care home settings for adults with social care needs (NICE guideline 27)

• Safer Childbirth: Local multi-disciplinary maternity care teams, comprising midwives, obstetricians anaesthetists, paediatricians, support staff and managers, are established.

• Examples of how the maternity service works with other services to meets the needs of women: ➢ combined clinics such as diabetic and

antenatal clinics? ➢ Are there simple referral systems for

combined case management? ➢ Access to medical care from other

specialities during stay on maternity unit e.g. cardiology

➢ Is there an intensive care unit on site? Is it maternity specific or are women cared for in the main intensive care or high dependency service?

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is discharge undertaken at an appropriate time of day and only done when any necessary ongoing care is in place?

• Safer Childbirth: There are effective systems of communication between all team members and each discipline, as well as with women and their families.

• Safer Childbirth: There must be 24-hour availability in obstetric units of senior paediatric colleagues, who have advanced skills for immediate advice and urgent attendance, who will attend within 10 minutes

• AAGBI Obstetric Anaesthetic Guidance: There should be an agreed system whereby the anaesthetist is given sufficient advance notice of all potentially high-risk patients.

• NICE QS46 statement 3 : Women with a multiple pregnancy are cared for by a multidisciplinary core team

• NICE QS46: statement 6 Women with a higher-risk or complicated multiple pregnancy have a consultant from a tertiary level fetal medicine centre involved in their care.

➢ What arrangements are in place to care for women with a high BMI? i.e. above 35.

➢ Is there an anaesthetic assessment clinic for women?

➢ Communication with community maternity team during ante-natal care/ home births/ discharge from maternity unit.

➢ If community midwives are employed by a different trust, how does the service being inspected liaise with them to ensure quality care?

➢ Continuity of care on transfer between midwife led care and consultant led care

➢ Joint working with mental health teams.

➢ How does the service ensure that the objectives of The Academy of Royal Colleges Guidance for Taking Responsibility: Accountable Clinicians and Informed Women has been implemented?

➢ Are women with a multiple pregnancy cared for by a multidisciplinary core team that have the expertise needed to provide high-quality care for women with a multiple pregnancy?

➢ Is there ongoing communication and joint working between the maternity and neonatal team once anomalies are identified inutero?

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➢ What arrangements are there with the neonatal team for anomalies or complications following birth?

➢ Is there clear communication with tertiary centres for fetal medicine? Is the outcome of this recorded in maternity notes and followed up during antenatal and intrapartum care?

If you are inspecting a community or independent midwifery or maternity service it is also important to ask the following: ➢ How does the service work with other

services to meet the needs of women, examples of working arrangements e.g. Family nurse Partnerships (FNP), GPs, learning disability services, Social Services, health visitors, ambulance service, acute service?

➢ How does the service work with the

early pregnancy unit? Are women informed about this service? if so how?

• Are there established links with

• mental health services

• learning disability services

• autism services

• Is there evidence of multi-disciplinary/ interagency working when required? If

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not, how do staff ensure safe discharge arrangements for people with complex needs?

Report sub-heading: Seven-day services

➢ E4.5 How are high-quality services made available that support care to be delivered seven days a week and how is their effect on improving patient outcomes monitored?

• NHS Services, Seven Days a Week, Priority Clinical Standards:

• Time to first consultant review All emergency admissions must be seen and have a thorough clinical assessment by a suitable consultant as soon as possible but at the latest within 14 hours from the time of arrival at hospital

Diagnostics

• Hospital inpatients must have scheduled seven-day access to diagnostic services such as x-ray, ultrasound, computerised tomography (CT), magnetic resonance imaging (MRI), echocardiography, and pathology. Consultant-directed diagnostic tests and completed reporting will be available seven days a week:

• Within one hour for critical patients

• Within 12 hours for urgent patients

• Within 24 hours for non-urgent patients

• Does the provider meet NHS England’s seven day services priority standards around o Time to First Consultant Review? o Diagnostics? o Intervention / key services? o Ongoing review?

• What is the ultrasound provision in the

trust to provide fetal growth

assessment? ➢ Do hospital inpatients have scheduled

seven-day access to diagnostic services such as x-ray, ultrasound, computerised tomography (CT), magnetic resonance imaging (MRI), echocardiography, endoscopy and pathology?

In addition if you are inspecting a community, independent midwifery or maternity service it is also important to ask the following: ➢ What are the on call arrangements, how

do women contact a midwife; communicate with maternity services out of hours?

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Intervention / key services

• Hospital inpatients must have timely 24 hour access, seven days a week, to consultant-directed interventions that meet the relevant specialty guidelines, either on-site or through formally agreed networked arrangements with clear protocols, such as:

• Critical care

• Interventional radiology

• Emergency obstetric surgery

• To maximise continuity of care consultants should be working multiple day blocks.

• Once transferred from an acute area of the hospital to a ante natal or post natal ward patients should be reviewed during a consultant-delivered ward round at least once every 24 hours, seven days a week, unless it has been determined that this would not affect the patient’s care pathway.

• https://www.england.nhs.uk/wp-content/uploads/2015/07/7ds-baseline-letter.pdf

• NCEPOD (2007): Emergency Admissions: A journey in the right direction? http://www.ncepod.org.uk/2007ea.html

➢ How do they access triage, and escalate

out of hours?

➢ What are the staffing arrangements for the FMUs and sustainability of home birth services if delivered by a separate team?

• Do you attempt to provide continuity of

carer? How successful has this been?

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• RCS (2011): Emergency Surgery, Standards for unscheduled surgical care https://www.rcseng.ac.uk/library-and-publications/college-publications/docs/emergency-surgery-standards-for-unscheduled-care/

➢ Safer Childbirth: Outside consultant hours, there should be a minimum of physical twice daily ward rounds, including bank holidays and weekends.

➢ AAGBI Obstetric Anaesthetic Guidance: An anaesthetist must be immediately available for emergency work on the delivery suite 24/7.

Key line of enquiry: E5

E5. How are people supported to live healthier lives and where the service is responsible, how does it improve the health of its population?

Prompts Professional standard Sector specific guidance

Report sub-heading: Health promotion

➢ E5.1 Are people identified who may need extra support? This includes:

• people in the last 12 months of their lives

• people at risk of developing a long-term condition

• carers

• Do the midwives participate with others to jointly facilitate classes with health visitors or practice nurses on health promotion initiatives such as smoking cessation or lifestyle programmes?

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• E5.2 How are people involved in regularly monitoring their health, including health assessments and checks, where appropriate and necessary

• E5.3 Are people who use services empowered and supported to manage their own health, care and wellbeing and to maximise their independence?

• E5.4 Where abnormalities or risk factors are identified that may require additional support or intervention, are changes to people’s care or treatment discussed and followed up between staff, people and their carers where necessary?

• E5.5 How are national priorities to improve the population’s health supported? (For example, smoking cessation, obesity, drug and alcohol dependency, dementia and cancer.)

• How do staff keep up-to-date with the latest messages from research evidence relating to safer pregnancies? How is this information communicated to parents?

• What classes, groups or activities does the service hold or promote for women in pregnancy?

• What classes, groups or activities does the service hold or promote for women following pregnancy complication, loss or still birth?

• Pregnant women at any stage of pregnancy should be offered the influenza vaccination. Pregnant women should also be offered the Pertussis vaccination. What local arrangements are in place for women to receive vaccinations?

• Are people using the service screened for C-diff / MRSA?

Key line of enquiry: E6

E6. Is consent to care and treatment always sought in line with legislation and guidance?

Prompts Professional standard Sector specific guidance

Report sub-heading: Consent, Mental Capacity Act and DOLs

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• E6.1 Do staff understand the relevant consent and decision making requirements of legislation and guidance, including the Mental Capacity Act 2005 and the Children’s Acts 1989 and 2004 and other relevant national standards and guidance?

• E6.2 How are people supported to make decisions in line with relevant legislation and guidance?

• E6.3 How and when is possible lack of mental capacity to make a particular decision assessed and recorded?

• E6.4 How is the process for seeking consent monitored and reviewed to ensure it meets legal requirements and follows relevant national guidance?

• E6.5 When people lack the mental capacity to make a decision, do staff ensure that best interests decisions are made in accordance with legislation?

• E6.6 How does the service promote supportive practice that avoids the need for physical restraint? Where physical restraint may be necessary, how does the service ensure that it is used in a safe, proportionate, and monitored way as part of a wider person centred support plan?

• E6.7 Do staff recognise when people aged 16 and over and who lack mental capacity are being deprived of their liberty, and do

• Consent: patients and doctors making decisions together (GMC)

• Consent - The basics (Medical Protection)

• Department of Health reference guide to consent for examination or treatment

• BMA Consent Toolkit

• BMA Children and young people tool kit

• Gillick competence

• MHA Code of Practice (including children and young people - chapter 19)

• Montgomery and informed consent

• How does the service ensure that consent is sought appropriately for women undergoing procedures including caesarean section, instrumental delivery, episiotomy or suturing?

(This is particularly relevant in women who speak a different language, women who are controlled by their partner or have diminished mental capacity).

• Are midwives and doctors able to demonstrate understanding of ‘best interests ‘decision making and when this is applicable?

• Are women given opportunities to understand their options and give informed consent (Montgomery)

• Are any patients detained under the Mental Health Act? If so, are staff aware there are additional steps to consider if the woman does not consent to treatment? Do they know where to get advice on this?

In addition if you are inspecting a community, independent midwifery or maternity service it is also important to ask the following:

• Do midwives and doctors working with young mothers understand the law relating to Fraser Guidelines?

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they seek authorisation to do so when they consider it necessary and proportionate?

• What is done locally within the service or community to support and enable women with learning disabilities and /or poor reading skills to make informed decisions and take an active role in their planned care- e.g. with screening tests?

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Caring

By caring, we mean that the service involves and treats people with compassion, kindness, dignity and respect.

Key line of enquiry: C1, C2 & C3

C1. How does the service ensure that people are treated with kindness, dignity, respect and compassion, and that they are given emotional support when needed?

C2. How does the service support people to express their views and be actively involved in making decisions about their care, support and treatment as far as possible?

C3. How is people’s privacy and dignity respected and promoted?

Generic prompts Professional Standard Additional prompts

Report sub-heading: Compassionate care

• C1.1 Do staff understand and respect the personal, cultural, social and religious needs of people and how these may relate to care needs, and do they take these into account in the way they deliver services? Is this information recorded and shared with other services or providers?

• C1.2 Do staff take the time to interact with people who use the service and those close to them in a respectful and considerate way?

• NICE QS15 Statement 1: Patients are treated with dignity, kindness, compassion, courtesy, respect, understanding and honesty.

• NICE QS15 statement 2: Patients experience effective interactions with staff who have demonstrated competency in relevant communication skills.

• NICE QS15 Statement 3: Patients are introduced to all healthcare professionals involved in their care,

If you are inspecting acute, community or independent midwifery or maternity services it is important to consider the following:

• Is appropriate help and support provided for mothers in labour before arrival at the acute setting? E.g. when a woman contacts the hospital/ service for advice?

• How does the service ensure that it maintains the privacy and dignity of

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• C1.3 Do staff show an encouraging, sensitive and supportive attitude to people who use services and those close to them?

• C1.4 Do staff raise concerns about disrespectful, discriminatory or abusive behaviour or attitudes?

• C3.1 How does the service and staff make sure that people’s privacy and dignity needs are understood and always respected, including during physical or intimate care and examinations?

• C3.2 Do staff respond in a compassionate, timely and appropriate way when people experience physical pain, discomfort or emotional distress?

and are made aware of the roles and responsibilities of the members of the healthcare team.

• NICE QS15 statement 13: Patients’ preferences for sharing information with their partner, family members and/or carers are established, respected and reviewed throughout their care

women and families especially at those times when women may be more vulnerable?

• Do staff members display understanding and a non-judgemental attitude towards (or when talking about) women who have

• mental health,

• learning disability,

• autism diagnoses?

• How do staff respond to women who might be

• frightened

• confused

• phobic about medical procedures or any aspect of their care?

• How are women cared for in a subsequent pregnancy if they have previously experienced a bereavement?

• Can the service provide you with any examples of how they ensure they provide good care?

• Are there any examples of surveys they undertake locally on care and experience?

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Report sub-heading: Emotional support

• C1.5 Do staff understand the impact that a person’s care, treatment or condition will have on their wellbeing and on those close to them, both emotionally and socially?

• C1.6 Are people given appropriate and timely support and information to cope emotionally with their care, treatment or condition? Are they advised how to find other support services?

• C2.7 What emotional support and information is provided to those close to people who use services, including carers, family and dependants?

• NICE QS15 Statement 10: Patients have their physical and psychological needs regularly assessed and addressed, including nutrition, hydration, pain relief, personal hygiene and anxiety.

• Sands Guidelines - Pregnancy loss and death of a baby

• Human Tissue Authority (HTA) Guidance on the disposal of pregnancy remains following pregnancy loss or termination. March 2015

• Maternal mental health: Improving emotional wellbeing in postnatal care, Royal College of Midwives

• Antenatal and postnatal mental health (QS115). Statement 4. Women are asked about their emotional wellbeing at each routine antenatal and postnatal contact.

• Caesarean section (CG132) Statement 4.4 Maternal request for CS.

• Multiple pregnancy: twin and triplet pregnancies (QS46)

• How are the appropriate assessments of perinatal mental health provided, including assessment for post natal anxiety and depression?

• How is good and consistent support provided during and after stillbirth/unexpected death/unexpected abnormality/ neonatal death?

• When there is an unexpected death or anomalies found prenatally? What support is provided for women and their families?

• What does the service have in place for emotional support following bereavement for the woman and their family? Does the service regularly signpost or refer women to outside agencies or organisations for support?

• How is support provided following maternal death?

• How is appropriate specialist bereavement support provided that meets the individual circumstances of the women?

• How do staff ensure that they deliver parent-led care, tailored to their

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individual needs and wishes? How are these wishes recorded, and other staff made aware of this?

• Does the woman/family have time with the baby they have lost? What procedures are in place to facilitate this?

• Do they have cooled cots to allow the family to have time with their baby in their home? Does the service have a clear procedure in place to enable this, which is understood by all staff? Are all bereaved families informed that this is an option for them?

• How does the trust make sure that bereavement support includes appropriate support with funeral, burial or sensitive disposal of pregnancy remains in the case of early pregnancy loss?

• Are bereaved families informed of all of their available options in line with HTA guidelines, and supported to make a choice which is right for them?

• What training have staff had regarding bereavement? How are they able to demonstrate this knowledge? Does this training cover losses from both single and multiple pregnancies?

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• Are there bereavement specialist leads for medical and midwifery staff? What does their job role include, and what working hours do they have?

• What emotional support does the service offer for a women planning to give a baby up for adoption, or a surrogate mother during and post-delivery?

In addition if you are inspecting a community, independent midwifery or maternity service it is also important to ask the following:

• How is the transition between hospital care and community care for women managed?

• Are all relevant healthcare staff in primary and community settings informed of a bereavement? What mechanism is in place to do this?

• How do midwives support bereaved women at home? For example, are bereavement services made available to women within their own home; are women referred to counselling services or signposted appropriately?

• In an independent or community service what involvement do the doctors have in bereavement?

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• How do midwives provide support when a baby has been diagnosed with a deformity or genetic condition or where a stillbirth is suspected?

• What support is provided to women following an ultrasound and a referral to a consultant unit for further tests?

• What information is provided to the women and what are they told they are being referred for? Is this pathway easy to follow for staff?

• Are women informed and understand what to expect on this pathway?

• Are women (and their families) who receive life-changing diagnoses given appropriate emotional support, including help to access further support services?

(Life-changing conditions include, cerebral palsy, downs syndrome, Patau’s syndrome, Edward’s syndrome).

• For the women – what emotional support are they provided should they be diagnosed with a heart condition, pre-eclampsia or other serious condition?

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• What support is provided to women who require an emergency hysterectomy after childbirth?

• If a women becomes distressed in an open environment, how do staff assist them to maintain their privacy and dignity?

• How are women with a fear of vaginal delivery supported?

• What support is available for women with transient psychological symptoms ('baby blues') or infant attachment problems?

• When twins or multiple births are expected/ delivered is advice on mental health and wellbeing routinely given?

Report sub-heading: Understanding and involvement of patients and those close to them

• C2.1 Do staff communicate with people so that they understand their care, treatment and condition and any advice given?

• C2.2 Do staff seek accessible ways to communicate with people when their protected and other characteristics make this necessary to reduce or remove barriers?

• C2.3 How do staff make sure that people who use services and those close to them are able to find further information, including community and advocacy services, or ask

• NICE QS15 Statement 2: Patients experience effective interactions with staff who have demonstrated competency in relevant communication skills.

• NICE QS15 Statement 4: Patients have opportunities to discuss their health beliefs, concerns and preferences to inform their individualised care.

If you are inspecting acute, community or independent midwifery or maternity services it is important to consider the following:

• Do discussions include advice and explanation tailored to women’s needs about the benefits and risks of each location for birth (including home birth) without bias?

• Are women given the opportunity of making an informed choice about all

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questions about their care and treatment? How are they supported to access these?

• C2.4 Are people empowered and supported, where necessary, to use and link with support networks and advocacy, so that it will have a positive impact on their health, care and wellbeing?

• C2.5 Do staff routinely involve people who use services and those close to them (including carers and dependants) in planning and making shared decisions about their care and treatment? Do people feel listened to, respected and have their views considered?

• C2.6 Are people’s carers, advocates and representatives including family members and friends, identified, welcomed, and treated as important partners in the delivery of their care?

• C3.3 How are people assured that information about them is treated confidentially in a way that complies with the Data Protection Act and that staff support people to make and review choices about sharing their information?

• NICE QS15 Statement 5: Patients are supported by healthcare professionals to understand relevant treatment options, including benefits, risks and potential consequences.

• NICE QS15 Statement 13: Patients’ preferences for sharing information with their partner, family members and/or carers are established, respected and reviewed throughout their care.

• GMC Guidance and resources for people with communication difficulties

available birth settings that are appropriate and safe for their clinical need and risk? Is the information of risk and safety clearly given without bias.

• How is feedback from women who use the services (as well as their partners/ family) obtained?

• What are the results of the friends and family test, surveys or feedback forms in respect of midwifery or maternity services?

• Are women empowered to have individualised care plans for the birth of their child? How is this undertaken if the women have complex needs or learning disabilities? Can the women have a doula?

• Are the birth partners/ families involved in the planning for the delivery and after care? Are they sufficiently informed of what to expect?

• How does the service provide information to women and receive feedback through this route? i.e. social media platforms.

• Do staff have access to communication aids to help women

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become a partner in their care and treatment? For example is there evidence that the service uses the woman’s preferred method of communication?

• Do women understand their choices for them following pregnancy loss, still birth and do families know what to expect next following a maternal death? What are the processes?

• Are bereaved families provided with information and support to make informed choices about their care which are right for them? Are they provided options and choices about how to make memories with their baby, if they wish to?

Responsive

By responsive, we mean that services meet people’s needs

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Key line of enquiry: R1 & R2

R1. How do people receive personalised care that is responsive to their needs?

R2. Do services take account of the particular needs and choices of different people?

Prompts Professional standard Sector specific guidance

Report sub-heading: Service delivery to meet the needs of local people

• R1.1 Do the services provided reflect the needs of the population served and do they ensure flexibility, choice and continuity of care?

• R1.2 Where people’s needs and choices are not being met, is this identified and used to inform how services are improved and developed?

• R1.3 Are the facilities and premises appropriate for the services that are delivered?

• NICE QS22 statement 2: Pregnant

women are cared for by a named midwife throughout their pregnancy.

• NICE CG 62: Midwife- and GP-led models of care should be offered to women with an uncomplicated pregnancy.

• NICE CG 62: Antenatal care should be readily and easily accessible to all pregnant women and should be sensitive to the needs of individual women and the local community.

NICE CG 62: Information should be given in a form that is easy to understand and accessible to pregnant women with additional needs, such as physical, sensory or learning disabilities, and to pregnant women who do not speak or read English.

• How well does the service provided reflect the local community – i.e. specific service users such as travellers, women with disabilities?

• What facilities are there for relatives/ partners to stay/ visit?

• Where applicable: Is there help with parking? Or public transport arrangements? How does the service work with the Maternity Voices or its local equivalent to design services that meet the needs of women and their families? Who attends these meetings? Do they attend regularly.

• How does the service ensure continuity of care and support on transition between antenatal, labour and birth and postnatal care during hospital stay? what handover method is used SBAR? Is this meeting women’s needs?

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• Change can disorientate people with these conditions, and sometimes triggers behaviour that challenges, for example: NICE CG142 Autism: recognition, referral, diagnosis and management of adults on the autism spectrum

• What information leaflets and website information are available? Are they available in multiple languages and in easy read where required?

• Is there sufficient information available on the website and in the service for overseas or paying women? Is this discussed prior to the women booking in the service? if the women turn up and are not booked, is this followed up post delivery?

• Are there any systems or staff members in place to aid the delivery of care to women in need of additional support? Are their specialist staff within the service who are trained in subjects including teenage pregnancy, mental health, bereavement, learning disabilities, obesity in pregnancy, drug and alcohol dependency etc.

• Are their markers/ stickers or flags on the woman’s records to identify the support they require?

• Are the needs of patients with

• mental health conditions

• learning disability

• autism Are needs routinely considered when any changes are made to the service? For example, through use of an impact assessment.

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Report sub-heading: Meeting people’s individual needs

• R1.4 How does the service identify and meet the information and communication needs of people with a disability or sensory loss. How does it record, highlight and share this information with others when required, and gain people’s consent to do so?

• R2.1 How are services delivered, made accessible and coordinated to take account of the needs of different people, including those with protected characteristics under the Equality Act and those in vulnerable circumstances?

• R2.2 How are services delivered and co-ordinated to be accessible and responsive to people with complex needs?1

• R2.3 How are people, supported during referral, transfer between services and discharge?

• R2.4 Are reasonable adjustments made so that people with a disability can access and use services on an equal basis to others?

• R2.5 Do key staff work across services to coordinate people's involvement with families and carers, particularly for those with multiple long-term conditions?

• NICE QS15 Statement 9: Patients experience care that is tailored to their needs and personal preferences, taking into account their circumstances, their ability to access services and their coexisting conditions

• Accessible Information Standard

• Dementia Charter

• NICE QS32 statement 3:. Pregnant women who request a caesarean section because of anxiety about childbirth are referred to a healthcare professional with expertise in perinatal mental health support.

• NICE CG 110: Recommendations for pregnant women who have complex social factors such as:

o Substance misuse o Migrants, asylum seekers,

refuges. o Women aged under 20

• Do hand-held records show that women’s antenatal, fetal medicine, labour, birth and postnatal needs have been assessed and provided according to their individual needs? (e.g. English not being their first language)

• Are there arrangements in place for people who need translation services? Are these available out of hours or on weekends?

• Are there suitable arrangements in place for people with a learning disability? Mental health condition? Complex pregnancy support?

• Does the provider comply with Accessible Information standard by identifying, recording, flagging, sharing and meeting the information and communication needs of people with a disability/sensory loss?

• How well does the service care for people with other complex needs, e.g. substance misuse deaf/blind/wheelchair access?

1. For example, people living with dementia or people with a learning disability or autism.

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o Women who experience domestic abuse.

• NICE CG 192: Antenatal and postnatal mental health: clinical management and service guidance.

• NICE QS46: statement 4 care planning for women with a multiple pregnancy.

• NICE QS46: statement 7 Advice and preparation for pre-term birth women with a multiple pregnancy

• NICE QS46: statement 8 preparation for birth for women with a multiple pregnancy

• Recommendation 4 of the the MBRRACE UK findings (published on 10th June 2015) sets out that units should ensure that a post-mortem examination is offered in all cases of stillbirth and neonatal death in order to improve future pregnancy counselling of parents

• Human Tissue Authority (HTA) Guidance on the disposal of pregnancy remains following pregnancy loss or termination. March

• How well does the service meet women’s antenatal, labour, birth and postnatal mental health needs?

• Is there a system in place to signal to healthcare professionals that a parent has experienced a bereavement (such as a marker for medical notes)?

• How do staff ensure that there are local arrangements to ensure that women with a multiple pregnancy have a care plan that specifies the timing of antenatal care appointments with the multidisciplinary core team appropriate for the chronicity and amnionicity of their pregnancy?

• How do staff ensure that there is local arrangements to ensure that women with a multiple pregnancy have a discussion by 24 weeks with one or more members of the multidisciplinary core team about the risks, signs and symptoms of preterm labour and possible outcomes of preterm birth?

• Are there local arrangements to ensure that women with a multiple pregnancy have a discussion by 32 weeks about the timing of birth and possible modes of delivery so that a birth plan can be agreed?

• What about other medical problems – diabetes, renal disease, placenta

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2015

• RCN guidance about managing disposal of pregnancy remains October 2015

• NICE NG27 Transition between inpatient hospital settings and community or care home settings for adults with social care needs. Of particular relevance to Looked After Children and Young People – see NICE QS31

• Antenatal and postnatal mental health (QS115)

• NICE CG62 Antenatal care for uncomplicated pregnancies

• HTA Code B Post-mortem Examination Standards and Guidance

• HTA Guidance on the disposal of pregnancy remains following pregnancy loss or termination

accreta etc? how are their needs with these complex conditions met?

• Does the service ensure that a post-mortem examination or CT scan is offered in all cases of stillbirth and neonatal death in order to improve future pregnancy counselling of parents?

• Is placental histology made available?

Is this offer made by a senior member of staff trained in obtaining informed consent for post mortem examinations?

• In respect of maternity, how do staff ensure that women are given the opportunity of making informed individual choice about disposal of pregnancy remains or burial or cremation following pregnancy loss?

• Are they provided with information about their full range of choices, in line with HTA guidance?

• For people with - a mental health condition - learning disability - autism

What reasonable adjustment, extra support or supervision is available to them on the ward or in the clinic?

• Are appropriate discharge arrangements in place for people with

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complex health and social care needs? This may mean taking account of chaotic lifestyles.

• When appropriate do Community Mental Health Teams (CMHTs), Community Learning Disabilities Teams (CLDTs), Child and Adolescent Mental Health Teams (CAMHS) or similar, get copied into discharge correspondence?

• Is there a quiet room, private room or bereavement room available for women and families to be cared for whilst grieving? Do these facilities meet the needs of bereaved parents?

In addition if you are inspecting a community, independent midwifery or maternity service it is also important to ask the following:

• What is the range of antenatal and postnatal services provided through the service?

• How is information provided about these services?

• Are there local community groups/networks that midwives and/or doctors routinely get invited to or attend?

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• Does the midwifery or maternity service provide any additional services for their clients e.g. Aqua aerobics.

• Does the service provide preparation for parenthood classes? Are these provided out of hours to support working parents and in accessible locations within the community?

• What framework is in place for mental health referrals and access to perinatal nurses?

• If women have pre-existing mental health issues (or develop them) is their mental and emotional wellbeing discussed at each contact and do staff respond appropriately to any changes?

• Are there regular opportunities while they are in contact with the service for women to discuss sensitive issues such as domestic violence, sexual abuse and recreational drug use?

Key line of enquiry: R3

R3. Can people access care and treatment in a timely way?

Prompts Professional standard Sector specific guidance

Report sub-heading: Access and flow

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• R3.1 Do people have timely access to initial assessment, test results, diagnosis, or treatment?

• R3.2 Can people access care and treatment at a time to suit them?

• R3.3 What action is taken to minimise the length of time people have to wait for care, treatment, or advice?

• R3.4 Do people with the most urgent needs have their care and treatment prioritised?

• R3.5 Are appointment systems easy to use and do they support people to access appointments?

• R3.6 Are appointments care and treatment only cancelled or delayed when absolutely necessary? Are delays or cancellations explained to people, and are people supported to access care and treatment again as soon as possible?

• R3.7 Do services run on time, and are people kept informed about any disruption?

• R3.8 How is technology used to support timely access to care and treatment? Is the technology (including telephone systems and online/digital services) easy to use?

• NICE QS22 statement 1: Pregnant women are supported to access antenatal care, ideally by 10 weeks 0 days.

• NICE CG 62 :A schedule of antenatal appointments should be determined by the function of the appointments. For a woman who is nulliparous with an uncomplicated pregnancy, a schedule of 10 appointments should be adequate. For a woman who is parous with an uncomplicated pregnancy, a schedule of 7 appointments should be adequate

• How does the service ensure women are not in labour and giving birth in areas not designated for birth (e.g. in antenatal care, triage)?

• How does the service ensure patients are regularly seen through their pregnancy? Is attendance for high risk patients monitored?

• How does the service monitor women who do not attend their appointments (DNAs)?

• How are women triaged to appropriate areas? E.g. to prevent labour wards getting overcrowded?

• Is there a maternity assessment centre? or separate triage area? Who runs this? what medical input/support do they have?

• How many women have their planned induction delayed? Or is the process delayed? (it may start on time but there is a delay in getting into labour ward when ready).

• How does the provider ensure that women who present beyond 12 completed weeks or require abortion for urgent medical reasons, receive

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care promptly to minimise further risk to health?

• Are people with urgent mental health needs seen within one hour of referral by an appropriate mental health clinician and assessed in a timely manner?

In addition if you are inspecting a community, independent midwifery or maternity service it is also important to ask the following:

• Do women know how to access the service directly or are they still required to access services via the GP? What is the proportion of women who access midwifery services directly?

• How does the service ensure patients are regularly seen throughout their pregnancy?

• Is attendance for low risk/high risk women monitored and followed up e.g. missed community midwifery appointments?

• Is there a Do Not Attend Policy in place for antenatal or follow up services?

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• When a visit to a woman at home has to be cancelled or rescheduled how is the risk to the woman assessed?

• When a womanpresents at triage how is this information relayed back to the community midwifes, how effective is the process in practice?

• How does the service’s escalation policy impact on access and flow issues e.g. visits to women in their home? Are any identified issues on the maternity risk register?

Key line of enquiry: R4

R4. How are people’s concerns and complaints listened and responded to and used to improve the quality of care?

Prompts Professional standard Sector specific guidance

Report sub-heading: Learning from complaints and concerns

• R4.1 How well do people who use the service know how to make a complaint or raise concerns and how comfortable do they feel doing so in their own way? How are people encouraged to make a complaint, and how confident are they to speak up?

• R4.2 How easy is it for people to use the system to make a complaint or raise concerns? Are people treated

• The NHS constitution gives people the right to

➢ Have complaints dealt with efficiently and be investigated.

➢ Know the outcome of the investigation.

• How many maternity specific complaints have been referred to the Parliamentary and Health Service Ombudsman?

• Does the main provider analyse community complaints? Is there evidence of how this links to service improvements?

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compassionately and given the help and support, through use of accessible information or protection measures if they need to make a complaint?

• R4.3 How effectively are complaints handled, including to ensure openness and transparency, confidentially, regular updates for the complainant, a timely response and explanation of the outcome, and a formal record?

• R4.4 How are people who raise concerns or complaints protected from discrimination, harassment or disadvantage?

• R4.5 To what extent are concerns and complaints used as an opportunity to learn and drive improvement?

➢ Take their complaint to an independent Parliamentary and Health Service Ombudsman.

Receive compensation if they have been harmed.

Independent services and private patients only

• ISCAS: Patient complaints adjudication service for independent healthcare

• How are complaints triangulated across teams and where is this done e.g. trust wide, within teams etc?

• Are trends, learning and changes to practice monitored and reviewed as part of the complaints process and is this shared across teams?

• How does the service complaints relate to incidents, are they compared/combined? Can they demonstrate learning from trends.

Independent services and private patients only • What arrangements are in place for the

independent review of complaints (e.g. ISCAS, of which membership is voluntary)

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Well-led

By well-led, we mean that the leadership, management and governance of the organisation assures the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture.

Key line of enquiry: W1

W1. Is there the leadership capacity and capability to deliver high-quality, sustainable care?

Prompts Professional standard Sector specific guidance

Report sub-heading: Leadership

• W1.1 Do leaders have the skills, knowledge, experience and integrity that they need – both when they are appointed and on an ongoing basis?

• W1.2 Do leaders understand the challenges to quality and sustainability, and can they identify the actions needed to address them?

• W1.3 Are leaders visible and approachable?

• W1.4 Are there clear priorities for ensuring sustainable, compassionate, inclusive and effective leadership, and is there a leadership strategy or development programme, which includes succession planning?

• Safer Childbirth: o To ensure 24-hour managerial

cover, each labour ward must have a rota of experienced senior midwives as labour ward shift coordinators, supernumerary to the staffing numbers required for one- to-one care.

o There should be one supervisor of midwives to every 15 midwives.

o Every unit should have a consultant obstetrician as clinical lead, a consultant midwife and a labour ward manager.

• Since the supervisor of midwives (SOM) role has been removed by the RCM and replaced with A-Equip. What processes does the service have in place now to ensure midwives are adequately supervised and receive an annual review?

• Does the Head of Midwifery have access to the Trust Board? Does the Head of Midwifery feel supported by the board?

• What is the management structure of the service? does this flow and work based on all elements of the maternity framework? i.e. antenatal, fetal medicine, intra partum care, post partum care, community? Etc.

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• Do equal parts of the maternity service get represented in the governance meeting minutes and reviews?

• Who sits on the committees for the service? is it just the Head of Midwifery and clinicians? Or are other parts of the service represented by local leaders?

• How are decisions taken at these meetings? How are actions and learning points disseminated throughout the service?

• Are there processes to enable staff to pass areas of good practice or report concerns up to the committee meetings for the service?

• How do leaders ensure that employees who are involved in the performance of invasive procedures develop shared understanding be educated in good safety practice, as set out in the national standards.

• Has the organisation designated a board member as the board level lead for maternity services? And does the Board routinely monitor information about quality, including safety and take necessary action to improve quality?

• Does the Head of Midwifery (HOM) have a presence in the work area? can the staff talk to them?.

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• What about the area leads? i.e. labour ward matron, ante natal matron, post natal matron, fetal medicine matron, community services matron etc? Are these approachable, visible and accessible?. Do these senior staff have a good understanding of the day to day pressures and risk?

In addition if you are inspecting a community, independent midwifery or maternity service it is also important to ask the following

• What is the leadership structure for community services?

• How is the service linked to the leadership and governance of the acute trust? Is there leadership at all levels?

• Do the community team feel part of the acute trust? Are leaders visible to the community staff?

• Are lead champions encouraged within the service?

• Is innovation encouraged?

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Key line of enquiry: W2

W2. Is there a clear vision and credible strategy to deliver high-quality sustainable care to people who use services, and robust plans to deliver?

Prompts Professional standard Sector specific guidance

Report sub-heading: Vision and strategy for this service

• W2.1 Is there a clear vision and a set of values, with quality and sustainability as the top priorities?

• W2.2 Is there a robust, realistic strategy for achieving the priorities and delivering good quality sustainable care?

• W2.3 Have the vision, values and strategy been developed using a structured planning process in collaboration with staff, people who use services, and external partners?

• W2.4 Do staff know and understand what the vision, values and strategy are, and their role in achieving them?

• W2.5 Is the strategy aligned to local plans in the wider health and social care economy, and how have services been planned to meet the needs of the relevant population?

• Is there a Non-Executive Director with responsibility for Maternity Services?

• Does the HOM have direct access to the trust board when maternity is under considerations?

• Is there involvement if the midwifery and medical staff in innovation and change?

• How are staff kept involved and motivated?

• How does the vision look at the services in the wider community?

• How does the vision and/or strategy link to the local health economy?

• How does the vision and strategy link to commissioning in the area? What about the STP working?

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• W2.6 Is progress against delivery of the strategy and local plans monitored and reviewed, and is there evidence to show this?

In addition if you are inspecting a community, independent midwifery or maternity service it is also important to ask the following:

• Is there a clear vision and set of values specific to independent midwifery and maternity services, with quality and safety the top priority? How is this embedded?

• Do the functions in each area of the service feel they an important part of the future of the service?

• How does the community service link to the broader maternity services within the region?

• Are independent services working with providers and acute services to deliver a wider strategy to increase women’s choice on birth?

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Key line of enquiry: W3

W3. Is there a culture of high-quality, sustainable care?

Generic prompts Professional Standard Additional prompts

Report sub-heading: Culture

• W3.1 Do staff feel supported, respected and valued?

• W3.2 Is the culture centred on the needs and experience of people who use services?

• W3.3 Do staff feel positive and proud to work in the organisation?

• W3.4 Is action taken to address behaviour and performance that is inconsistent with the vison and values, regardless of seniority?

• W3.5 Does the culture encourage, openness and honesty at all levels within the organisation, including with people who use services, in response to incidents? Do leaders and staff understand the importance of staff being able to raise concerns without fear of retribution, and is appropriate learning and action taken as a result of concerns raised?

• W3.6 Are there mechanisms for providing all staff at every level with the development they need, including

• NMC Openness and honesty when things go wrong: the professional duty of candour

• NRLS - Being Open Communicating patient safety incidents with patients, their families and carers

• Duty of Candour – CQC guidance

• Eight high impact actions to improve the working environment for junior doctors

• Do staff feel wanted and involved in the service development?.

• What is the staff turnover ?

• What are the staff sickness rates?

• What processes and procedures does the provider have in place to ensure they meet the duty of candour? For example, training, support for staff, policy and audits. How do Boards promote a culture of learning and continuous improvement to maximise quality and outcomes from their services, including multi-professional training?

• Do staff engage in incident reporting and review. Do they feel there is a blame culture?

• Is the culture within the service open and transparent? What so the staff surveys say? What do staff say about culture?

• Does the service have a freedom to speak up guardian? Do they

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high-quality appraisal and career development conversations?

• W3.7 Is there a strong emphasis on the safety and well-being of staff?

• W3.8 Are equality and diversity promoted within and beyond the organisation? Do all staff, including those with particular protected characteristics under the Equality Act, feel they are treated equitably?

• W3.9 Are there cooperative, supportive and appreciative relationships among staff? Do staff and teams work collaboratively, share responsibility and resolve conflict quickly and constructively?

know who the freedom to speak up guardian is?

• Do staff know how to raise concerns if they are unhappy about anything within the service? do they feel comfortable and able to use this system without fear of repercussions?

• What is the working relationship and culture like between community midwives, hospital midwives and Doctors/ consultants?

In addition if you are inspecting a community, independent midwifery or maternity service it is also important to ask the following

• If midwives are remote working, how is open is the relationship between them and local services such as the CCG, health visitors, acute and ambulance trust?

• Are transfers made easy and welcome with good communication?

• Are the service’s staff encouraged to go with the woman to offer support?

• Do the community staff feel part of the overall maternity service, do they feel respected and valued?

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• Are staff rewarded for example submitted for local, regional or national award schemes?

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Key line of enquiry: W4

W4. Are there clear responsibilities, roles and systems of accountability to support good governance and management?

Generic prompts Professional Standard Additional prompts

Report sub-heading: Governance

• W4.1 Are there effective structures, processes and systems of accountability to support the delivery of the strategy and good quality, sustainable services? Are these regularly reviewed and improved?

• W4.2 Do all levels of governance and management function effectively and interact with each other appropriately?

• W4.3 Are staff at all levels clear about their roles and do they understand what they are accountable for, and to whom?

• W4.4 Are arrangements with partners and third-party providers governed and managed effectively to encourage appropriate interaction and promote coordinated, person-centred care?

• NICE QS61 Statement 2: Organisations that provide healthcare have a strategy for continuous improvement in infection prevention and control, including accountable leadership, multi-agency working and the use of surveillance systems.

• NICE QS121 Statement 5: Individuals and teams responsible for antimicrobial stewardship monitor data and provide feedback on prescribing practice at prescriber, team, organisation and commissioner level.

• NICE QS 66 statement 1: Hospitals have an intravenous (IV) fluids lead who has overall responsibility for training, clinical governance, adult and review of IV fluid prescribing, and patient outcomes.

• Does the service have a strategy for continuous improvement in infection prevention and control, including accountable leadership, multi-agency working and the use of surveillance systems?

• What are the governance procedures for managing and monitoring any SLAs the provider has with third parties?

• What arrangements are in place in case of suspension of maternity services?

• Is there effective trust board oversight of performance regarding antimicrobial prescribing and stewardship? What action is taken when issues are identified?

• What are the things that concern the HOM, CD, area leads?

• Do the midwives and doctors look

forward to coming into work each

day?

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• Have they experienced bullying either physically or emotionally ?

In addition if you are inspecting a community, independent midwifery or maternity service it is also important to ask the following:

• Are senior community staff assured they have an overview of the current issues/concerns within the community service; and there are appropriate processes in place to mitigate against identified concerns?

• Is there a specific governance dashboard for community services which monitors risk, safety and performance issues?

• Do the community services participate in the overall acute trust audits, if so, which ones and what are the outcomes for community services?

• Do they conduct their own audits, what are they; and how are these acted upon?

• If guidelines are modified or tailored to the community setting, are staff able to explain why they have been modified for the community setting, is this documented clearly and justified

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e.g. responding to specific local circumstances?

Key line of enquiry: W5

W5. Are there clear and effective processes for managing risks, issues and performance?

Generic prompts Professional Standard Additional prompts

Report sub-heading: Managing risks, issues and performance

• W5.1 Are there comprehensive assurance systems, and are performance issues escalated appropriately through clear structures and processes? Are these regularly reviewed and improved?

• W5.2 Are there processes to manage current and future performance? Are these regularly reviewed and improved?

• W5.3 Is there a systematic programme of clinical and internal audit to monitor quality, operational and financial processes, and systems to identify where action should be taken?

• W5.4 Are there robust arrangements for identifying, recording and managing risks, issues and mitigating actions? Is there alignment between

• Safer Childbirth: A maternity risk management group meets at least every 6 months.

• Safer Childbirth: There is a written risk management policy, including trigger incidents for risk and adverse incident reporting.

• https://www.gov.uk/government/publications/safer-maternity-care

• Is there a maternity dashboard and how is it used. Do you bench mark with other in the region? What actions have been taken because of thing learnt from the dashboard.

• Is there a maternity risk register and action plan? Does the board have oversight of this?

• Has the board appointed a maternity champion ( by January 2017 – see reference to safer maternity care action plan in standards)

• Has the trust appointed a designated obstetrician and midwife to joint champion maternity safety in their trust? (by February 2017) See reference to

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the recorded risks and what staff say is ‘on their worry list’?

• W5.5 Are potential risks taken into account when planning services, for example seasonal or other expected or unexpected fluctuations in demand, or disruption to staffing or facilities?

• W5.6 When considering developments to services or efficiency changes, how is the impact on quality and sustainability assessed and monitored? Are there examples of where financial pressures have compromised care?

safer maternity care action plan document.

In addition if you are inspecting a community, independent midwifery or maternity service it is also important to ask the following:

• How sustainable is the home birth service and if appropriate FMUs? Are the staff provided with the appropriate training and number of staff? Do they feel under threat?

• What arrangements are in pace in the case of suspension of homebirth services?

• What arrangements are in place in the case of suspension/closure of a free standing midwifery unit?

• What major incident awareness and training takes place in the community for example, EBOLA, pandemic flu episode?

• What plans are in place for severe weather conditions?

• How would community based services manage increased capacity if required by the acute trust? For example, if the hospital is closed temporarily? What about a flu pandemic?

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Key line of enquiry: W6

W6. Is appropriate and accurate information being effectively processed, challenged and acted upon?

Generic prompts Professional Standard

Additional prompts

Report sub-heading: Managing information

• W6.1 Is there a holistic understanding of performance, which sufficiently covers and integrates people’s views with information on quality, operations and finances? Is information used to measure for improvement, not just assurance?

• W6.2 Do quality and sustainability both receive sufficient coverage in relevant meetings at all levels? Do all staff have sufficient access to information, and do they challenge it appropriately?

• W6.3 Are there clear and robust service performance measures, which are reported and monitored?

• W6.4 Are there effective arrangements to ensure that the information used to monitor, manage and report on quality and performance is accurate, valid, reliable, timely and relevant? What action is taken when issues are identified?

• • Has the trust published and made public a bespoke Maternity Safety Improvement Plan ( by January 2017) See reference to safer maternity care action plan document

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• W6.5 Are information technology systems used effectively to monitor and improve the quality of care?

• W6.6 Are there effective arrangements to ensure that data or notifications are submitted to external bodies as required?

• W6.7 Are there robust arrangements (including internal and external validation) to ensure the availability, integrity and confidentiality of identifiable data, records and data management systems, in line with data security standards? Are lessons learned when there are data security breaches?

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Key line of enquiry: W7

Are the people who use services, the public, staff and external partners engaged and involved to support high-quality sustainable services?

Generic prompts Professional Standard Additional prompts

Report sub-heading: Public and staff engagement

• W7.1 Are people’s views and experiences gathered and acted on to shape and improve the services and culture? Does this include people in a range of equality groups?

• W7.2 Are people who use services, those close to them and their representatives actively engaged and involved in decision-making to shape services and culture? Does this include people in a range of equality groups?

• W7.3 Are staff actively engaged so that their views are reflected in the planning and delivery of services and in shaping the culture? Does this include those with a protected characteristic?

• W7.4 Are there positive and collaborative relationships with external partners to build a shared understanding of challenges within the system and the needs of the relevant

• Is there a friends and family or equivalent survey?

• How are the views of users of community services obtained? What does it tell you about the service?

• How does the leadership take an inclusive approach to involving community staff? Do staff feel involved?

In addition if you are inspecting a community, independent midwifery or maternity service it is also important to ask the following

• What are the opportunities for the public and staff to be engaged in the service?

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population, and to deliver services to meet those needs?

• W7.5 Is there transparency and openness with all stakeholders about performance?

Key line of enquiry: W8

W8. Are there robust systems and processes for learning, continuous improvement and innovation?

Prompts Professional standard Sector specific guidance

Report sub-heading: Innovation, improvement and sustainability

• W8.1 In what ways do leaders and staff strive for continuous learning, improvement and innovation? Does this include participating in appropriate research projects and recognised accreditation schemes?

• W8.2 Are there standardised improvement tools and methods, and do staff have the skills to use them?

• W8.3 How effective is participation in and learning from internal and external reviews, including those related to mortality or the death of a person using the service? Is learning shared effectively and used to make improvements?

• How has the service considered

and acted on the MBRRACE annual and perinatal reports and other reports?

• How has the service considered and acted on serious incident investigations and action plans? Are they followed up?

• How has the service considered and acted on the MBRRACE UK (Mothers and Babies Reducing Risk through Audits and Confidential Enquiries) report published December 2014? (about congenital diaphragmatic hernia (CDH))

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• W8.4 Do all staff regularly take time out to work together to resolve problems and to review individual and team objectives, processes and performance? Does this lead to improvements and innovation?

• W8.5 Are there systems to support improvement and innovation work, including objectives and rewards for staff, data systems, and processes for evaluating and sharing the results of improvement work?

• How has the service considered and acted on the MBRRACE UK findings (published on 10th June 2015) of the UK Perinatal Mortality Surveillance for 2013: Audits and Confidential Enquiries?

In addition if you are inspecting a community, independent midwifery or maternity service it is also important to ask the following

• What opportunities exist for learning from other trusts e.g. site visits

• Are they engaged in Sustainability Transformation Partnerships (STP)? This is relevant to the whole service.

• Do regional groups/clusters have a community input?

• Are staff encouraged to develop the service and not just provide the service are there good examples of development?Is innovation encouraged?