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Archived: Abbey Field Medical Centre

Inspection Summary


Overall summary & rating

Updated 12 April 2017

Abbey Field Medical Centre is a location base operated by One to One (North West) Limited in Essex. The service provides community midwifery services to women and their babies in the North East Essex region

We carried out announced inspections on 19 January and 06 February 2017.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate. We have not rated the service because we do not have sufficient evidence to rate the service of this type at this time.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

  • Training records showed only 33% of maternity assistants (MAMAs) were compliant with their mandatory training requirements.
  • There were no audits carried out to check the cleanliness of the environment or hand hygiene.
  • A birthing pool audit had been carried out; however, this did not cover visual inspection of the pools or whether midwives were cleaning the pool correctly.
  • No record of cleaning was maintained for the medicines fridge nor the fridge used to store placentas.
  • Midwives were not transporting Entonox (Nitrous Oxide) securely in their cars during transport. This was not compliant with national safety recommendations.
  • There was no system in place to track what visits each member of staff had planned for each day. Our concerns were heightened given there was no local manager in post. This meant there was no record of where lone workers were at any time, and no one had oversight of staff whereabouts.
  • The provider was not registered to supply and administer controlled medicines (such as pethidine), however, two midwives told us that they administered and disposed of Pethidine for homebirth women, because the local GP prescribes the medicine for the women as required. There was no record of Pethidine waste kept. Whilst senior managers told us that this practice was not in line with the provider’s protocol,  the ‘Medicine’s management’ policy in place however did not make this clear. The provider informed us that this practice would be stopped immediately.
  • Midwives were inconsistent in the medicines they offered women for the management of the third stage of labour. We also found the provider’s “Management of the third stage of labour” policy did not reflect evidence-based practice in relation to these medicines.
  • Women and babies electronic and paper healthcare records did not reflect one another, often containing conflicting information in terms or pregnancy risk.
  • Although women were on the correct pathway for their pregnancy in correlation with risk, we saw that the pathway title, such as low or high risk, where often missing or incorrect from their records.
  • Of the healthcare records we checked, we saw that there was no paper record of postnatal care for women and babies. However, the provider had recently introduced new paperwork to ensure this. Although because this system was new we were unable to check if these paper postnatal records were being completed.
  • Maternal Early Obstetric Warning (MEOWS) charts were not in use and scores were not calculated.
  • Where care had deviated from evidence-based practice recommendations, such as if a vaginal examination was not performed in labour, we saw that the reasons for this were not recorded in women’s healthcare records.
  • Staff did not have regular one-to-one meetings with a manager.
  • Staff did not demonstrate they understood the Fraser guidelines sufficiently.
  • Midwives had not received additional training in complex conditions in pregnancy, such as diabetes.
  • Of the twelve midwives employed in the Essex area, seven midwives were newly qualified or had been qualified for approximately a year. There was also no clinical manager for the area. This meant that the majority of staff were junior without adequate local supervision in terms of management.
  • The service had not carried out a needs assessment of the local community it provided a service to.
  • There had not been a registered manager in post since July 2015. There had also been no clinical manager based at the Essex service since November 2016 since the previous manager resigned from their post. This meant that 12 midwives, three midwifery support assistants (MAMAs) and an operations manager worked without clinical management presence. Staff told us that there was one clinical manager in the North West location; who line managed them and was accessible via telephone as required. However two senior managers also confirmed that this clinical manager only visited the Essex service bi-monthly.
  • The provider’s risk register did not mention who was accountable for each presented risk, and correlating action plans to the risk register were not updated following risk register review.

We also found areas of good practice.

  • The provider had made significant improvements since our last inspection in February 2016. This included improvements to incident reporting, risk assessments, policies and procedures and safeguarding.
  • All new starters received a six week induction training programme and a preceptorship programme was also in place for midwives. Competency framework were also in used.
  • Hypnobirthing and water (birthing pool) services were available to women for pain relief in labour.
  • Breastfeeding rates were good. 86.5% of women who delivered breastfed their babies within 48 hours of birth and 51.4% of women were still breastfeeding their babies at 10-14 days postnatal.These rates were above the national average.
  • There were arrangements to review guidance from national bodies such as the National Institute for Health and Care Excellence (NICE).
  • Two midwives were trained to carry out the examination of the newborn check (NIPE) required with 48 hours of delivery.
  • Staff had access to an abundance of up-to-date policies and procedures electronically via their work tablet device.
  • The Supervisor to Midwife (SoM) to midwife ratio was 1:12, which was better than the current Nursing Midwifery Council (2012) guidelines.
  • Staffing levels for midwife to women ratio were safe.
  • Women, babies and their families were treated with dignity and respect, and staff were offered appropriate emotional support tailored to individual need.
  • Feedback from people who used the service was consistently good.
  • There were no waiting lists for people accessing the service or for appointments. Antenatal and postnatal contacts were flexible in terms of amount and length, and appointments were offered at a convenient time and location to the women.
  • All staff we spoke with knew the provider’s vision and set of values.
  • There was a clear governance process in place including a risk register, monthly “Quality Assurance Groups” and a clinical dashboard, which was well monitored.
  • Staff spoke highly of their seniors within the organisation, saying they were encouraging, supportive and friendly.

Following this inspection, we told the provider that it must take some actions to comply with the regulations to help the service improve. Details are at the end of the report.

Professor Edward Baker

Deputy Chief Inspector of Hospitals

Inspection areas

Safe

Updated 12 April 2017

We have not rated the safe domain. We found:

  • Only 33% of maternity assistants (MAMAs) were compliant with all their mandatory training requirements.
  • There were no audits carried out to check the cleanliness of the environment or hand hygiene.
  • A birthing pool audit had been carried out; however, this did not cover visual inspection of the pools nor whether midwives were cleaning the pools correctly.
  • No record of cleaning was maintained for the medicines fridge nor the fridge used to store placentas.
  • Midwives were not transporting Entonox (Nitrous Oxide) securely in their cars during transport. This was not compliant with national safety recommendations.
  • There was no system in place to track what visits each member of staff had planned for the day. Our concerns were heightened given there was no local manager in post. This meant there was no record of where lone workers were at any time, and no one had oversight of staff whereabouts.
  • The provider was not registered to supply and administer controlled medicines (such as pethidine), however, two midwives told us that they administered and disposed of Pethidine for homebirth women, because the local GP prescribes the medicine for the women as required. There was no record of Pethidine waste kept. Whilst senior managers told us that this practice was not in line with the provider’s protocol, we however saw that the ‘Medicine’s management’ policy in place did not make this clear.
  • Midwives were inconsistent in the medicines they offered women for the management of the third stage of labour. We also found the provider’s “Management of the third stage of labour” policy did not reflect evidence-based practice in relation to these medicines.
  • Women and babies electronic and paper healthcare records did not reflect one another, often containing conflicting information in terms or pregnancy risk.
  • Although women were on the correct pathway for their pregnancy in correlation with risk, we saw that the pathway title, such as low or high risk, where often missing or incorrect from their records.
  • Of the healthcare records we checked, we saw that there was no paper record of postnatal care for women and babies. However, the provider had recently introduced new paperwork to ensure this. Although because this system was new we were unable to check if these paper postnatal records were being completed.
  • Maternal Early Obstetric Warning (MEOWS) charts were not in use and scores were not calculated.

However we also found:

  • There was an incident report process in place, and learning from incidents occurred.
  • Sufficient safeguarding processes existed, and staff acted appropriately to safeguarding women, babies and their families, whilst supporting them.
  • Risk management systems and processes had been implemented to ensure the safeguarding team and clinical lead had oversight of the risk present in relation to midwives caseloads.
  • Staffing levels were very good and appropriate for the service.

Effective

Updated 12 April 2017

We have not rated the effective domain. We found:

  • Evidence based practice, such as undertaking a vaginal examination was not always performed in labour, we saw that the reasons for this were not recorded in women’s healthcare records.
  • Staff did not have regular one-to-one meetings with a manager.
  • Staff did not have sufficient knowledge of Fraser guidelines.
  • Of the twelve midwives employed in the Essex area, seven midwives were newly qualified or had been qualified for approximately a year. There was also no clinical manager for the area. This meant that the majority of staff were junior without adequate local supervision in terms of management.

However we also found:

  • There was an annual audit programme in place.
  • All new starters received a six week induction training programme and a preceptorship programme was in place for midwives. Competency framework was also in place.
  • Hypnobirthing and water (birthing pool) services were available to women for pain relief in labour.
  • Breastfeeding rates were good. 86.5% of women delivered breastfed their babies within 48 hours of birth and 51.4% of women were still breastfeeding their babies at 10-14 days postnatal. These rates were above the national average.
  • We found there were arrangements to review guidance from national bodies such as the National Institute for Health and Care Excellence (NICE) and that care was delivered in line with best practice.
  • Two midwives were trained to carry out the examination of the newborn check (NIPE) required with 48 hours of delivery.
  • The provider worked hard to develop and build good relationships with third party providers.
  • Staff had access to an abundance of up-to-date policies and procedures electronically via their work electronic tablet device.
  • The Supervisor to Midwife (SoM) to midwife ratio was 1:12, which was better than the current Nursing Midwifery Council (2012) guidelines.

Caring

Updated 12 April 2017

We have not rated the caring domain. We found:

  • Women, babies and their families were treated with dignity and respect.
  • Staff were offered appropriate emotional support tailored to individual need to people who used the service.
  • We spoke with four women who had used the service, and reviewed patient feedback which showed caring was excellent.
  • Friends and Family Test (FFT) results consistently showed that people who used the service would recommend One to One midwives to others.
  • Additional surveys also showed consistently good feedback from people who used the service.

Responsive

Updated 12 April 2017

We have not rated the responsive domain. We found:

  • There were no waiting lists for people accessing the service or for appointments.
  • Antenatal and postnatal contacts were flexible in terms of amount and length, and appointments were offered at a convenient time and location to the women.
  • Additional services were also provided included parent preparation and labour classes, hypnobirthing, breastfeeding support groups and regular coffee mornings.
  • Complaints were minimal and were reviewed and actioned appropriately in a timely manner.
  • People who used the service told us that continuity of care from staff was excellent.

However we also found that:

  • The service had not carried out a needs assessment of the local community it provided a service to.
  • Leaflets and information sheets we looked at did not have review dates on so we could not be sure they were up-to-date.

Well-led

Updated 12 April 2017

We have not rated the well-led domain. We found:

  • There had not been a registered manager in post since July 2015, and at the time of our inspection, there was no ongoing action to employ one.
  • There had also been no clinical manager based at the Essex service since November 2016 since the previous manager resigned from their post. This meant that 12 midwives, three midwifery support assistants (MAMAs) and an operations manager worked without clinical management presence. Staff told us that there was one clinical manager in the North West location; who line managed them and was accessible via telephone as required. However two senior managers also confirmed that this clinical manager only visited the Essex service bi-monthly.
  • Our concerns about a lack of registered manager and clinical manager were heightened given the issues we have identified including; a lack of staff one-to-one meetings taking place, and numerous concerns we have reported under the “Safety” section of this report including lone working arrangements, medicine management, skill mix, lack of infection control audits, record keeping and staff were not using the MEOWS system.
  • The services risk register did not mention who was accountable for each presented risk, and correlating action plans to the risk register were not updated following risk register review.

However we also found:

  • All staff we spoke with knew the provider’s vision and set of values.
  • There was a clear governance process in place including a risk register, monthly “Quality Assurance Groups” and a clinical dashboard, which was well monitored.
  • Staff spoke highly of their seniors within the organisation, saying they were encouraging, supportive and friendly.
  • The service had processes in place for public and staff engagement.
Checks on specific services

Maternity

Updated 12 April 2017

  • Training records showed only 33% of maternity assistants (MAMAs) were compliant with their mandatory training requirements.
  • There were no audits carried out to check the cleanliness of the environment or hand hygiene.
  • A birthing pool audit had been carried out; however, this did not cover visual inspection of the pools or whether midwives were cleaning the pools correctly.
  • No record of cleaning was maintained for the medicines fridge nor the fridge used to store placentas.
  • Midwives were not transporting Entonox (Nitrous Oxide) securely in their cars during transport. This was not compliant with national safety recommendations.
  • There was no system in place to track what visits each member of staff had planned for the day. Our concerns were heightened given there was no local manager in post. This meant there was no record of where lone workers were at any time, and no one had oversight of staff whereabouts.
  • The provider was not registered to supply and administer controlled medicines (such as pethidine), however, two midwives told us that they administered and disposed of Pethidine for homebirth women, because the local GP prescribes the medicine for the women as required. There was no record of Pethidine waste kept. Whilst senior managers told us that this practice was not in line with the provider’s protocol, we however saw that the ‘Medicine’s management’ policy in place did not make this clear.
  • Midwives were inconsistent in the medicines they offered women for the management of the third stage of labour. We also found the provider’s “Management of the third stage of labour” policy did not reflect evidence-based practice in relation to these medicines.
  • Women and babies electronic and paper healthcare records did not reflect one another, often containing conflicting information in terms or pregnancy risk.
  • Although women were on the correct pathway for their pregnancy in correlation with risk, we saw that the pathway title, such as low or high risk, where often missing or incorrect from their records.
  • Of the healthcare records we checked, we saw that there was no paper record of postnatal care for women and babies. However, the provider had recently introduced new paperwork to ensure this. Although because this system was new we were unable to check if these paper postnatal records were being completed.
  • Maternal Early Obstetric Warning (MEOWS) charts were not in use and scores were not calculated.
  • Where care had deviated from evidence-based practice recommendations, such as if a vaginal examination was not performed in labour, we saw that the reasons for this were not recorded in women’s healthcare records.
  • Staff did not have regular one-to-one meetings with a manager.
  • Staff did not demonstrate they understood the Fraser guidelines sufficiently.
  • Midwives had not received additional training in complex conditions in pregnancy, such as diabetes.
  • Of the twelve midwives employed in the Essex area, seven midwives were newly qualified or had been qualified for approximately a year. There was also no clinical manager for the area. This meant that the majority of staff were junior without adequate local supervision in terms of management.
  • The service had not carried out a needs assessment of the local community it provided a service to.
  • There had not been a registered manager in post since July 2015. There had also been no clinical manager based at the Essex service since November 2016 since the previous manager resigned from their post. This meant that 12 midwives, three midwifery support assistants (MAMAs) and an operations manager worked without clinical management presence. Staff told us that there was one clinical manager in the North West location; who line managed them and was accessible via telephone as required. However two senior managers also confirmed that this clinical manager only visited the Essex service bi-monthly.
  • The provider’s risk register did not mention who was accountable for each presented risk, and correlating action plans to the risk register were not updated following risk register review.