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Inspection Summary


Overall summary & rating

Updated 12 April 2017

The Birth Sanctuary is operated by The Birth Sanctuary Limited. The service provides care from the registered office in central Bolton, in the community in patients’ homes or in local NHS hospitals.

The service provides maternity care.

We inspected this service using our comprehensive inspection methodology. We carried out the inspection on 10 January 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.

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

We regulate and inspect this service but we do not currently rate single service providers. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

We found the following areas of good practice:

  • Staff were up to date with mandatory training and had completed emergency midwifery skills training within the previous 12 months.
  • The service followed best practice guidance in relation to infection prevention and control. The environment was visibly clean and staff had access to sufficient equipment which was serviced and calibrated regularly.

  • Clinical risk assessments were completed for each patient. There was clear guidance in place and an escalation policy to ensure patients received care in the most appropriate clinical setting. Risk assessments were reviewed regularly, and when there were any concerns about the health of the patient or her baby, referrals were made to other providers.
  • The service had an external supervisor of midwives (SoM) to support staff and patients.

  • All staff had completed safeguarding adults training in line with best practice guidance. Staff had an awareness of issues relating to domestic violence and female genital mutilation.
  • Records were maintained to a high standard and stored correctly. The service was registered with the Information Commissioners Officer.

  • Caseloads were planned based on midwife availability. The service monitored the number of patients on its caseload to ensure there were sufficient staff to provide the level of care required.
  • Care and treatment was provided in line with policies which reflected guidance from the National Institute of Health and Care Excellence (NICE) and Royal Colleges.

  • Patients received education about choices for feeding their babies and they were supported by staff to feed their baby by their chosen method. A recent audit showed that 90% of patients were exclusively breast feeding their babies at six weeks. This was better than the NHS average of 24%.

  • There were plans to work towards stage one accreditation of the Unicef Baby Friendly Initiative in 2017, a nationally recognised accreditation and mark of quality care designed to support breastfeeding and parent infant relationships.

  • Staff had received an appraisal and had specific personal development objectives. Staff were well trained and maintained their skills and competencies including completing the NHS New born and Infant Physical Examination Programme (NIPE).
  • The Birth Sanctuary worked closely with a number of third party providers and ensured they communicated with other providers in an effective way.
  • There was a 24 hour cooling off period following an initial free consultation before patients decided to sign the contract agreement. This was to ensure that each patient had the opportunity to consider the service and costs to ensure it was the right service for them.
  • Staff were kind, caring and sensitive in the way they communicated. They spent time speaking with patients; addressing any worries or concerns. Care was individualised and patients valued the close relationships they built with the midwives.
  • The service consistently received positive patient feedback. Patients described the care as “fantastic” and said they “couldn’t have been more satisfied with the care”. One patient described her midwife as her “voice during labour”.
  • Staff supported patients to make decisions and choices about their care and treatment. Patients told us they did this in an unbiased and non-judgemental way. Families and people close to the patient were involved in planning care.
  • Staff took time to discuss previous birth experiences and worries and fears about the current pregnancy. Women spoke very positively about the high level of emotional support provided and told us they felt more confident and reassured by the support they were given.
  • Staff spoke with patients about their mental and physical well-being. They had access to formal assessments to use where there were concerns about post-natal depression or anxiety.
  • Appointments were tailored around the needs of the patients and there was no limit to the number of appointments patients could access as part of the pregnancy care package.
  • Staff ensured they considered any specific individual or additional needs for each patient. They understood the need to make adjustments for patients with additional needs. There was access to a telephone translation service if required.
  • There was access to advice from a midwife 24 hours a day. Appointments could be arranged quickly and at mutually convenient times. Midwives were able to visit existing patients on the same day if requested and considered necessary.
  • There had been no complaints about the service in 2016. Staff were able to provide examples of learning from previous complaints.
  • There was a vision and strategy for the service that had been developed by the registered manager.
  • Quality of care and outcomes were discussed at regular meetings. There was also discussion of incidents and risks at these meetings.
  • There was a risk management policy in place that set out how risks should be monitored and mitigated and we saw examples of completed risk assessments.
  • There was a positive, open and enthusiastic culture within the service. Staff were committed to provide the best service possible to their patients.
  • The service gained feedback from patients via a feedback form. A patient user group met every three months where the service and new ideas for development were discussed.

However, we also found the following issues that the service provider needs to improve:

  • Staff reported incidents and discussed learning from them however, there was no formal monitoring of the number or themes and trends in incidents.
  • The consent policy did not reflect the Mental Capacity Act (2005) code of practice.
  • There was no policy or formal system in place to support the storage and disposal of medications at midwives homes in preparation for a home birth.

Following this inspection, we told the provider that it should make some improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals North Region

Inspection areas

Safe

Updated 12 April 2017

We regulate but do not currently rate this service.

We found the following areas of good practice:

  • All staff were up to date with mandatory training. They followed best practice guidance in relation to infection prevention and control. The environment was clean and staff had access to sufficient equipment which was serviced and calibrated regularly.

  • Clinical risk assessments were completed for each patient. There was clear guidance in place in the form of inclusion and exclusion criteria and an escalation policy to ensure patients received care in the most appropriate clinical setting. Risk assessments were reviewed regularly, and when there were any concerns about the health of the patient or her baby, referrals were made to other providers.
  • Staff had attended training in emergency midwifery skills within the previous 12 months. This included the management of post-partum haemorrhage, breech presentation and shoulder dystocia. This also included basic adult life support and neonatal life support.
  • The service had an external supervisor of midwives (SoM) to support staff and patients.

  • All staff had completed safeguarding adults training in line with best practice guidance. Patients were asked if they had experienced any domestic violence at their booking appointment. Staff had received training on female genital mutilation (FGM) and understood their responsibilities to report this to the local safeguarding authority.
  • Records were maintained to a high standard and stored correctly. The service was registered with the Information Commissioners Officer.
  • Caseloads were planned based on midwife availability. The service monitored the number of patients on its caseload to ensure there were sufficient staff to provide the level of care required.

However, we also found the following issues that the service provider needs to improve:

  • Staff had not completed safeguarding children Level 3 as set out in the Intercollegiate Guidance. The provider took immediate action and arranged the relevant training.
  • Staff were able to give examples of learning from incidents. However, they there was no mechanism for monitoring the number of these incidents or analysing themes and trends.
  • There was no clear guidance for midwives to use when storing medications at home including in their personal domestic fridges in advance of a home birth. There was no guidance about the disposal of unused or expired medications.

Effective

Updated 12 April 2017

We found the following areas of good practice:

  • Policies and procedures were based on evidence-based guidelines. Care and treatment was provided in line with these policies which reflected guidance from the National Institute of Health and Care Excellence (NICE) and Royal Colleges.

  • Patients received education about both breast and bottle feeding. They were supported by staff to feed their baby by their chosen method. A recent audit showed that 90% of patients were exclusively breast feeding their babies at six weeks. This was higher (better) than the NHS average of 24%.

  • There were plans to work towards stage one accreditation of the Unicef Baby Friendly Initiative in 2017. This is a nationally recognised accreditation and mark of quality care for mothers and babies and is designed to support breastfeeding and parent infant relationships.

  • Staff had received an appraisal within the preceding 12 months and had specific personal development objectives. Staff were well trained and maintained their skills and competencies. One member of staff had completed the NHS New born and Infant Physical Examination Programme (NIPE). This programme offersparents of new born babies the opportunity to have their child examined shortly after birth by a midwife.
  • Another member of staff was a part time lecturer at a local university and worked as a supervisor of midwives which involves working in an advisory role in the clinical environment at a local NHS trust.
  • The Birth Sanctuary worked closely with a number of third party providers.
  • Staff often accompanied patients to appointments at NHS hospitals and liaised directly with hospital staff. Staff told us that clinical staff from some NHS trusts were supportive and welcoming; however in others working relationships were more difficult. The registered manager had taken steps to improve working relationships with these providers.
  • The service offered a free 30 minute consultation with all patients. There was a 24 hour cooling off period following this appointment before patients decided to sign the contract agreement. This was to ensure that each patient had the opportunity to consider the service and costs to ensure it was the right service for them.

However, we also found the following issues that the service provider needs to improve:

  • Staff understood the principles of the Mental Capacity Act (MCA) (2005) however the consent policy did not reflect the MCA (2005) code of practice.

Caring

Updated 12 April 2017

  • Staff were kind, caring and sensitive in the way they communicated. They spent time speaking to patients; addressing any worries or concerns. Care was individualised.
  • The service consistently received positive patient feedback. Patients described the care as “fantastic” and said they “couldn’t have been more satisfied with the care”.
  • Patients valued the opportunity to build a close relationship with the midwives, and told us the familiarity reduced their fears and anxieties.
  • Staff supported patients to make decisions and choices about their care and treatment. Patients told us they did this in an unbiased and non-judgemental way.
  • Staff involved patient’s partners, children and the wider family unit within the patients care. Fathers told us staff considered their needs.
  • Staff took time to discuss previous birth experiences and worries and fears about the current pregnancy. Women spoke very positively about the high level of emotional support provided and told us they felt more confident and reassured by the support they were given.
  • Staff spoke with patients about their mental and physical well-being. They had access to formal assessments to use where there were concerns about post-natal depression or anxiety.
  • Patients told us that during labour staff were able to support them to express their birth preferences. One patient described her midwife as her “voice during labour”.

Responsive

Updated 12 April 2017

We found the following areas of good practice:

  • There was a one off charge to patients to use of The Birth Sanctuary as part of the pregnancy care package. Appointments were tailored around the needs of the patients and there was no limit to the number of appointments patients could access.
  • The service aimed to maintain good working relationships with local NHS trusts to ensure that the patients received the best pregnancy and birth experience possible. In some instances this had been challenging, with some local trusts refusing the midwives access to their patients.
  • Staff ensured they considered any specific individual or additional needs for each patient. They told us of an example of working with a patient with complex needs where they had worked closely with other services involved in her care such as social care and physiotherapy. Staff understood the need to make adjustments for patients in some cases. There was access to a telephone translation service if required.
  • There was access to advice from a midwife 24 hours a day. Appointments could be arranged quickly and at mutually convenient times. Midwives were able to visit existing patients on the same day if requested and considered necessary.
  • There had been no complaints about the service in 2016. Staff were able to provide examples of learning from previous complaints.

However, we also found the following issue that the service provider needs to improve:

  • The complaints policy did not direct individuals who remain dissatisfied with the outcome of their complaint to the Independent Sector Complaints Adjudication Service.

Well-led

Updated 12 April 2017

We found the following examples of good practice:

  • The Birth Sanctuary vision was “to be recognised as the leading provider of maternity care in the UK, setting a new standard for quality whilst prioritising the needs of each and every individual”. There was a strategy which included establishing links with other providers including gaining practicing privileges to deliver babies at their hospitals, working with NHS England to provide student midwifery placements and developing a Doula training programme.
  • Monthly meetings were held where the quality of clinical care and outcomes were discussed. There was also discussion of incidents and risks at this meeting. There was a risk management policy in place that set out how risks should be monitored and mitigated and we saw examples of completed risk assessments.
  • There was a positive, open and enthusiastic culture within the service. Staff were committed to provide the best service possible to their patients.
  • Patient feedback forms were given to all patients on discharge from the service where patients were asked to rate the service provided and make comments about care and treatment. A patient user group met every three months where they discussed the service and provided feedback on new ideas about developing the service.
Checks on specific services

Maternity

Updated 12 April 2017

We regulate this service but we do not currently rate it. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

Appropriate clinical risk assessments were completed to ensure care and treatment was safe. There were policies and procedures in place to ensure staff escalated care to other providers if required. Staff followed best practice guidance in relation to infection prevention and control. All equipment was serviced and maintained as required. Records were completed to a high standard and stored securely. However, neither of the midwives had completed safeguarding children to the appropriate level. The registered manager took immediate steps to ensure this training would be completed. There was no formal monitoring or reviewing of the number of incidents in the service. There was no guidance in place to inform midwives who may be required to store medications at their homes in preparation for a home birth.

Care was provided by well-trained staff who followed evidence-based guidelines and policies. Staff provided advice and support in feeding their babies and a recent audit showed a high proportion of babies were being breast fed at six weeks. Staff liaised well with other providers. Staff understood the principles of informed consent and the Mental Capacity Act (MCA, 2005) however the consent policy was not in line with the MCA (2005) code of practice.

Staff provided care in an individualised way, supported patients to make informed choices and respected their decisions. Patients told us staff provided a high level of emotional support and feedback was consistently positive.

Patients were able to access advice 24 hours a day. There were no restrictions to the number of appointments they could receive to ensure they were fully supported throughout their pregnancy and for up to six weeks following the birth. Staff understood that some patients may have additional needs and there were facilities in place to support this for example, access to translation services. There had been no complaints about the service in 2016 and staff were able to give examples of learning from previous complaints.

The vision for the service was “to be recognised as the leading provider of maternity care in the UK, setting a new standard for quality whilst prioritising the needs of each and every individual”.  The culture in the service was positive and enthusiastic and staff were dedicated to providing the best care possible. Staff met monthly and discussed key information such as clinical quality, care outcomes and key incidents or risks. A risk management policy was in place and we saw this had been implemented appropriately. Patient feedback was sought from every patient and a quarterly user group met who were involved in developing the service for the future.