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Bidston and St James Children's Centre

Inspection Summary


Overall summary & rating

Updated 27 June 2016

One to One (North West) Limited is a private community based maternity service that provides antenatal, intrapartum and postnatal care to expectant mothers. The service is based in the Bidston and St James Children’s centre. The service was set up in 2011. The company aims to provide a single midwife to support expectant mothers aged 14 years and older through antenatal care, birth and postnatal care. Midwives working for the company were allowed to go into NHS hospitals to act as advocates or support if the woman chose a hospital birth. One to one midwives were not allowed to deliver babies in NHS hospitals but they could stay with women on their case load if the woman made this request. The midwives employed by the trust were responsible for all maternity care once a woman was admitted to hospital.

This service was previously inspected on 13 April 2015 as part of an unannounced focused inspection and we found that there were concerns related to medicines management, the use of Cardiotocography (CTGs) in a community setting and the management of risk and governance. At that inspection we were not given the assurance that risk was being managed effectively across the organisation to provide a safe environment for high risk pregnancies. At that inspection we also found no evidence of joint pathways in place with local providers and agreed processes for flagging up or considering additional needs of the mother were not in place. We asked the provider to make improvements in these areas.

We carried out a further comprehensive inspection on the 30 November and 1 December 2015. We have not published a rating for this service. CQC does not currently have a legal duty to award ratings for those services that provide solely or mainly community maternity services.

We found that incidents were not being reported to CQC under the statutory notifications’ regulation.  The incidents the staff were required to report to CQC was limited to “serious incidents which has potential to threaten registration status”. The clinical incident policy did not require staff to report clinical incidents to CQC. Regulation 18 of the CQC (Registration) Regulations 2009 requires providers to notify CQC of certain defined incidents. This would include incidents of patients experiencing prolonged pain or prolonged psychological harm or certain types of injury to a service user.

The North West service reported 788 births during this period and reported one intrauterine death, one intrapartum death and one neonatal death which involved joint care with an NHS trust. Two serious incidents were reported to the Care Quality Commission between April 2015 and December 2015. Our records indicated that the CCG informed the Care Quality Commission about two of these occurrences. We had to seek additional information from the One to One services. This meant the service was fulfilling their obligation to provide CQC with notifications of incidents required under the Act.

Staff we spoke to was confident in the use of the incident reporting systems; however, they were unclear about the breadth of events that should be reported. Staff said they were given feedback from their manager about the incidents they reported.

Managers responsible for running the service undertook the root cause analysis (RCA) of incidents and feedback from incidents was provided. Staff directly involved in incidents received individual feedback and any lessons learned were disseminated throughout the organisation in order to improve the care delivered to women and babies.

Action had been taken to provide the appropriate skill mix of midwifery staff for low risk pregnancies throughout pregnancy. This included changing the notice period for permanent midwives who wanted to leave the service. This was to ensure a handover period during which new recruits could become confident in carrying out their roles.

The provider did not present evidence of specific training about underlying conditions which made a pregnancy high risk. As midwives did not encounter these conditions very often they accessed best practice guidance available at the time the information was needed.

Birth records indicated that midwives took the correct actions during labour and used their skills to deal with complications during childbirth such as shoulder dystocia. This is when women need extra help to allow the shoulders of the baby to be born.

Concerns remained about how well high risk pregnancies were monitored during pregnancy because staff stated they had not received specialist training to support women with underlying conditions such as epilepsy and diabetes. Concerns were also raised about action taken for women who may develop unforeseen complications who then refused to seek medical intervention and/or hospital support when midwives identified that this was needed.

Schedule 2 Controlled Drugs were no longer used by the service and women were well informed about the pain relief the service could provide.

Processes were established to ensure medication was appropriately stored and accounted for.

There were plentiful stocks of personal protective equipment, such as disposable gloves and aprons.

Midwives carried hand gel for use when hand washing facilities were not available.

Midwives held a maximum caseload of 32 women.

Risks within the organisation were identified and included safeguarding training rates for midwives, potential gaps in the handover process between midwives when the lead midwife was unavailable and; women who chose to deviate from NICE guidance who also had complex needs with a risk of overall poor outcomes. A gap in integrated working with other providers was also identified as a risk.

The service continued to work with partner agencies to develop single care pathways for women who would opt for joint care with One to One North West Ltd and the acute trust obstetrician-led service.

The service needed to develop clear pathways for women with high risk pregnancies who refused to accept care based on best practice guidance.

We visited the One to One North West office and clinic at the Bidston and St James children centre and the Warrington Pregnancy Advice Centre in the Golden Square shopping centre.

We carried out 10 telephone interviews with midwives chosen at random and a number midwives attended a focus group. We interviewed two locality co-ordinators and met three midwives working at the pregnancy advice centre. Three women who used the service were interviewed face to face and seven were interviewed over the telephone.

Inspection areas

Safe

Updated 27 June 2016

The service did not always measure safety issues against quality targets and so could not be sure the processes were protecting women and babies from abuse and avoidable harm were as effective as possible. Care pathway risk assessments for antenatal care and protocols for dealing with emergencies were unclear and did not provide a firm basis on which to support home births for high risk pregnancies. Protocols were needed to ensure girls aged 18 and under were protected if they contacted the service.

The service had processes to ensure there were sufficient numbers of midwives and monitored this against the number of referrals into the service.

Women who were identified as high risk in pregnancy, who required care under a consultant obstetrician were seen by local NHS Providers if the women agreed to receive the service.

Women who were identified as high risk in pregnancy, who required care under a consultant obstetrician were seen by local NHS providers if the women agreed to receive the service.

Staff were clear about how to complete incident reports, however guidelines and policies for reporting and reviewing incidents lacked rigour and the implementation of change was not timely.

The service had just moved to an electronic reporting incident system in order to manage incidents more effectively.

Effective

Updated 27 June 2016

Care and treatment for low risk women was based on best practice evidence. Pain control was well managed by the service. The service was effective at supporting women to breast feed their babies. Service provision was flexible and available 24 hours a day, seven days a week.

An audit programme was in place, however it was difficult to measure comparative success for this service as national data was not always comparable with a community based midwifery led service providing care for low and high risk pregnancies.

The service had developed operational procedures for joint working with their partner agencies, in particular the maternity services at district general hospitals. Pathways into partner trusts were not consistent.

Caring

Updated 27 June 2016

The service provided compassionate care to expectant mothers which was individualised to fit their individual preferences. The management systems and philosophy of the service encouraged midwives to work flexibly and collaboratively with women and their families.

The service had completed a comprehensive customer satisfaction survey 2014/2015 which provided positive feedback which indicated the service operated in a caring, compassionate and person- centred manner. The service also participated in the friends and family test which also provided information which indicated the service was caring.

Women had access to antenatal and post-natal groups run by One to One midwives.

Responsive

Updated 27 June 2016

The service actively sought to work in partnership with commissioners and GPs to promote the service to all women who fit the referral criteria. This was sometimes challenging, due to different contracts in place with different commissioners.

The service was planned and provided services to meet the needs of current and potential women who wanted to use the service in a timely way, for example, the parents’ advice centre in a busy shopping precinct was innovative and enabled and encouraged women to seek advice and access antenatal care as frequently as they wanted.

The service accepted women with low and high risk needs, however specialist midwives for epilepsy, diabetes, mental health or substance misuse were not employed and women were not automatically referred to NHS trust specialist services

Concerns were listened to and acted on however all concerns were not recorded for the purpose of audit.

Well-led

Updated 27 June 2016

Policies and procedures included a statement about auditing the quality of the service and clinical outcomes; however no target dates for audits were included and the service did not include updating policies and procedures to support good practice in their audit plan.

Monthly quality assurance and board meeting records did not provide detailed and comprehensive information about what plans were been made in response to information received.

The service had a clear philosophy of care and a clear management structure. Leaders were visible and accessible to staff, and staff were clear on the values and philosophy of the service.

The culture was open and staff and people who used the service had a voice, and were able to contribute to service developments.

Quality and performance monitoring was in place and there was evidence of some improvements since the last inspection and the risk register was reviewed monthly at the quality assurance group, which was evidenced through the standard agenda item and minutes.

Checks on specific services

Maternity

Updated 7 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.

Clinical risk assessments were completed but documentation was not always accurate, complete or contemporaneous. There were policies and procedures in place to ensure staff escalated care to other providers if required. Electronic records were completed to a high standard; however, maternity handheld notes were not clear or concise.

The majority of care was provided by staff that followed evidence-based guidelines and policies. However, some national guidelines were not adhered to fully.

Ninety eight percent of midwives had completed safeguarding level three training. Not all staff had completed their mandatory training or received specific complex obstetric needs training, pool birth or suturing training. Not all had had received an annual appraisal review.

Staff provided advice and support in feeding their babies.

Staff provided care in an individualised way, supported women to make informed choices and respected their decisions. However, this was not always documented in full. Women told us staff provided a high level of emotional support and feedback was consistently positive.

Women 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 women might have additional needs and there were facilities in place to support this for example, access to translation services.

There had been 18 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 grow the service into a company that was seen as the preferred choice for women and their families for their maternity care and to deliver this care to the safest and highest standards.

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.