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Bidston and St James Children's Centre

Inspection Summary

Overall summary & rating

Updated 7 April 2017

Bidston and St James Children’s Centre is operated by One to One (North West) Limited. The North West registered location is situated in the Bidston and St James Children’s Centre, Birkenhead.

There are also three-satellite community Hubs or Patient Advisory Centre’s (PAC), situated in Crewe, Warrington and Ellesmere Port.

The service provides maternity care.

We inspected this service using our comprehensive inspection methodology. We carried out the inspection on 16 and 17 January 2017. We interviewed 25 members of staff and four service users.

To get to the heart of women’s’ 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.

Strategy for the service was underpinned by the service five core values: excellence, safety, women centred, integrity and professionalism. These also underpinned midwifery practice and organisational systems.

An established leadership team, were both visible and accessible in the North West service. Staff, we interviewed as part of the inspection, were positive about the visibility and support from senior team. In addition, there were regular opportunities for midwives to meet with their line managers to discuss cases related to risks and suitable plans of care.

For long-term sustainability of the service, One to One envisaged the ongoing provision of the midwifery caseloading continuity of carer model. Caseload midwifery offers continuity of care by a primary midwife during the antenatal, intrapartum and postpartum periods.

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

We found the following areas of good practice:

  • There was risk assessment guidance in place and an escalation policy to ensure women received safe care. Risk assessments were reviewed regularly, and when there were any concerns about the health of the woman or her baby, referrals were made to other providers.

  • The service had internal and one external supervisor of midwives (SoM) to support staff and women.

  • Ninety eight percent of staff had completed safeguarding training in line with best practice guidance. Staff had an awareness of issues relating to domestic violence and female genital mutilation.

  • Caseloads were planned based on midwife availability, staff experience and women’s complex care needs. The service monitored the number of women on its caseload to ensure there was sufficient staff to provide the level of care required.

  • Care and treatment was provided in line with One to One policies and Practice Points (similar to standard operating procedures), which reflected guidance from the National Institute of Health and Care Excellence (NICE) and Royal Colleges.

  • Women received education about choices for feeding their babies and they were supported by staff to feed their baby by their chosen method.

  • Some staff had completed the NHS New born and Infant Physical Examination Programme (NIPE).

  • Twenty-one of the 47 midwives were trained in hypnobirthing.

  • One to One (North West) Limited worked closely with a number of external agencies and third party providers and were working towards improvements in communication to increase shared working pathways with other providers in an effective way.

  • Staff were kind, caring and sensitive in the way they communicated. They spent time speaking with women, addressing any worries or concerns. Care was individualised and women valued the close relationships they built with the midwives.

  • Staff took time to discuss previous birth experiences, worries, and fears about the current pregnancy. Women spoke very positively about the high level of emotional support provided and told us they felt confident and reassured by the support they were given.

  • Staff spoke with women about their mental and physical well-being. They had access to formal assessment tools to use where there were concerns about depression or anxiety.

  • Appointments were tailored around the needs of the women. Midwives provided care in the PACs and women’s homes.

  • Staff had access to a telephone translation service if required.

  • There was access to advice from a midwife 24 hours a day. Appointments could be arranged at mutually convenient times with women. Midwives were able to visit women on the same day if requested and considered necessary.

  • Complaints were managed in a timely manner and communication with families were undertaken by telephone or a home visit and followed up with a letter addressing concerns with an action plan. We saw evidence of lessons learnt from complaints displayed.

  • Quality of care, incidents, risks and lessons learnt were reviewed and discussed at regular 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 women.

  • There was a vision and strategy for the service that had been developed by the registered manager.

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

  • The service did not follow best practice guidance in relation to infection prevention and control.

  • The environment was not always visibly clean.

  • Clinical risk assessments were completed for women. These were documented well on the electronic records system but not always clearly or concisely in women’s handheld maternity notes.

  • Electronic records were maintained to a high standard, however, these were not contemporaneous with the women’s handheld notes, which were difficult to follow, information was not clearly or concisely recorded and copies of screening results and hospital discharge letters were not filed in a timely manner.

  • Staff supported women to make decisions and choices about their care and treatment. However, this was not always fully and concisely documented in the women’s handheld records.

  • Seventy nine per cent of staff had received an annual appraisal. However, specific personal development objectives were set and discussed as part of the “consolidation” passport.

  • Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with five requirement notices that affected maternity and midwifery services. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals North Region

Inspection areas


Updated 7 April 2017

  • We observed a good incident reporting culture within the One to One service (North West). All the midwives we spoke to were clear about reporting an incident through their online incident reporting system. The online reporting system automatically flagged incidents to senior managers and staff.

  • Incident reporting policies and procedures were in place for staff to follow. Senior staff informed us that they encouraged an open reporting culture and following review would often down grade some of the incidents.

  • From January 2016 to December 2016, one serious incident occurred in the North West. An independent external review has been commissioned. This was under way at the time of our inspection.

  • Governance and risk managers discussed, reviewed and monitored actions from incidents at monthly Quality Assurance (QA) meetings. Information was cascaded to different levels of staff through regular co-ordinators meetings, team leader meetings, teams and individual staff meetings. Lessons learnt were also shared through the One to One shared drive intranet pages. The service used root cause analysis (RCA) processes to investigate serious incidents.

  • A Midwives Mitigating Risk (MMR) pathway was introduced as a guide, in conjunction with the One to One practice points and other relevant national guidance, to assist staff to create a detailed plan of care for women.

  • A Fresh Eyes Review was undertaken monthly by staff to review and ensure that women were on the correct pathway as per the MMR guidance and that the correct assessments and documentation, including information sharing with the wider MDT were in place.

  • Complex Care logs were available online. These were reviewed and updated on a monthly basis by the team leaders. The logs were used to assist in the escalation process to other staff, local trusts, relevant external agencies and risk midwife. The log was also discussed and reviewed at the QA meeting.

  • An Intrapartum “Time Out” online checklist was implemented in December 2016 following lessons learnt and discussions of incidents. Staff at a homebirth completed the checklist. The checklist provided a summary of all staff attending the birth, review of care, assisted in a staff member clinically challenging another staff member andprovided a clear and concise summary if a woman was transferred into an acute trust. A separate checklist sheet was completed for every four hourly review. This was also a tool used to provide feedback to team leaders in order to monitor care and provide support in the management of care.

  • One to One had introduced “variance” sheets and (SBAR) handover forms to ensure an

  • A Modified Early Obstetric Warning Score (MEOWS) Prompt Chart for the immediate postnatal period following birth was available for all staff, to assist in their detection of a seriously ill and deteriorating woman.

  • A safety thermometer was completed but senior staff informed us that the response was low as data was only recorded for their homebirth women, which consisted of 25% of their overall numbers.

  • The Safeguarding Lead had regular meetings with the designated nurse for safeguarding at local CCGs to ensure the department met all legal and contractual requirements.

  • A safeguarding adult and children’s policy were in place. Information and guidance included working with sexually active less than 18 years old, looked after children, disabled children, missing children and children missing from education, female genital mutilation (FGM)forced marriages.

  • Staff were to be allocated a new “Safeguarding Passport” document from February 2017. The safeguarding team designed this three-year “passport”, to ensure all midwives met their statutory and mandatory requirements within safeguarding.

  • Midwives had access to an extensive resource area on the internal internet system, which detailed internal policies and guidance and links to local services, forms and pathways to link into external services.

  • Staffing numbers was adequate at the time of inspection. However, staff informed us that previous months had been difficult due to staffing levels and recruitment and retention of midwives. The service had introduced a new model of care to improve work life balance for staff and had employed new senior roles to support clinical staff.
  • There was a service level agreement was in place for the disposal of placentas and removal of clinical waste with an external company.


  • Written documentation in the handheld notes, we reviewed, was poor. Information was not always clear and concise and documents were not always fully completed.

  • Poorly written documentation and lack of contemporaneous record keeping observed in the antenatal handheld notes and the lack of postnatal handheld notes informed us that documentation did not meet the needs of the service, therefore providing limited assurance in the management of and escalation of risk We were not provided with assurance that all information was easily available, especially for external agencies who could not access the One to One EHR for full online details.

  • From our observations, a time lag of up to two weeks was evident between the management and filing of the paper blood results in the women's hand held notes.

  • A One to One hand written birth observation record was used rather than a standardised NHS partogram (partogramis a record used to monitor the progress oflabour) to record labour details and observations. They informed us that from the summer 2017, they planned to electronically record all labour details on staff portable electronic devises and discontinue using the handheld birth observation records. This did not assure us that all essential information to manage safe care was easily available to external care providers, especially for women who are transferred in an emergency in labour to an acute hospital.

  • One to One were running a pilot project for the “GROW” package. GROW provides standardised procedures, training and tools for assessment of baby growth and birthweight. This pilot was due for completion in June 2017. Only 60% of midwives had completed the GROW training and the service had still not implemented the full package since the last inspection in November 2015. The GROW package was to be implemented because of the outcome of a Root Cause Analysis (RCA) investigation by One to One in 2015.

  • Not all staff had completed their annual mandatory training.

  • Some medicine fridges were visibly dirty on inspection. Clinical procedures rooms contained carpets and cloth covered chairs. We observed one chair soiled with bloodstains. These were highlighted to staff at the time of inspection.

  • There were no visible cleaning rotas.

  • Staff did not consistently follow the cleaning and use of the pool guidance.

  • Staff offered both syntoncinon and syntometrine for the delivery of the placenta. National guidance recommends syntoncinon as this has less side effects.

  • Entonox cylinders were not secured in transport bags in community midwives cars.

  • There was no daily equipment maintenance checklist by staff and there no annual service maintenance sticker visible on the cardiotocography (CTG) machine we inspected.


Updated 7 April 2017

  • There was a yearly audit plan in place to monitor care, to ensure healthcare was being provided in line with national standards and let care providers and women know where their service is doing well and where there could be improvements.

  • All new staff received a six-week induction training programme and a preceptorship programme, including

  • Staff attended “Keeping in Touch” (KIT) meetings with their team leaders to discuss

  • Hypnobirthing and water was used as relaxation techniques during labour.

  • Between July 2015 and June 2016, breastfeeding statistics for homebirths showed that between 81% and 86% of women were breastfeeding after delivery. This was within the national rates (Infant feeding Survey 2010).

    Staff monitored postnatal baby weight loss and jaundice.

  • The One to One (North West) maternity dashboard recorded information that was divided under three main subheadings: Key Performance IndicatorsKPIs) and Activity, Morbidity and Risk and Patient care. The dashboard did not currently record any service or national targets.

  • There was one midwife trained in the Frenulotomy procedure (to correct tongue-tie in babies.)

  • Five midwives had completed the NIPE programme, therefore able to complete the examination of the newborn soon after delivery.

  • One to One worked closely with a number of third party providers. Providers included nutritional experts, a private ultrasound scanning company and complementary therapists.

  • Staff accessed policies, guidelines and other information through the services intranet and all staff had access to computers and individual electronic devices.

  • Staff told us that they did not use a specific standardised mental health assessment tool but each individual midwives used a tool of her own preference, for example the Edinburgh Mental Well-being scale or
  • Whooley assessment tool. Staff informed us they were aware how to make and who to contact to make a referral if required.

  • The SoM to midwife ratio of 1:12, which was within the current NMC (2012) guidelines.


  • Midwives did not offer Pethidine or any other form of opioid drugs as a form of pain relief at homebirths in the North West.

  • Service level agreements (SLA) to provide shared pathways and shared care for high-risk pregnancies were not yet in place with commissioners of services. At the time of inspection, we were informed that there were eight shared pathways in draft.Staff informed us that multidisciplinary working with local acute trust maternity services could be problematic but some positive and productive meetings had recently taken place.

  • Staff told us that clinical staff from some NHS trusts were supportive and welcoming; however, they reported that they also faced negativity in some areas towards their service, which led to difficult working relationships. Staff had taken steps to improve working relationships with other providers including formal and informal meetings and invitations to training or social events.

  • External care providers had limited access to information, as they could not access the electronic information system used by One to One.

  • One to One did not use any specific postnatal handheld notes to document observations and procedures. This was all documented electronically.

  • Informed consent was not always clearly and concisely documented in the women’s handheld notes.

  • The reason why women refused or declined treatment was not clearly visibly documented in the women’s handheld notes that we observed during the inspection.

  • Midwives mandatory training covered some medical condition such as high blood pressure, infection, severely ill women and complex care planning.


  • Only 79% of staff had completed a yearly appraisal interview.

  • Midwives mandatory training covered some medical condition such as high blood pressure, infection, severely ill women and complex care planning. However, staff informed us that they did not receive specific training in obstetric or medical complex conditions but supported each other and referred to national guidelines online.

  • Suturing the perineum was part of an outline agenda for mandatory training. However, three programme timetables we reviewed did not have suturing listed. Not all staff were competent in suturing. This could affect the transfer of women into an acute hospital for perineal repair.

  • We observed that not all national guidance was strictly followed, for example the use of syntometrine drug, the safe transport of Entonox and a woman who had a home delivery after previously having a  caesarean section delivery. The inclusion criteria checklist also stated that women with a history of previous stillbirth or neonatal death, hepatitis B or C, HIV positive and haematological disease were suitable for homebirths. However, this was not in line with the NICE Intrapartum Care guideline 190, which recommend births at an obstetric unit for these conditions.

    Staff informed us that homebirth inclusion and exclusion criteria were set by the local Clinical Commissioning Groups.


Updated 7 April 2017

  • We observed sensitive interaction and discussions between staff and women.

  • Staff allocated individual appointments in the women’s home or PAC and ensured adequate time was allotted to discuss all the woman’s needs.

  • Women felt very supported and reported that midwives responded in a timely manner when they were contacted.


Updated 7 April 2017

  • The Warrington Patient Advisory Centre (PAC) was located in a central suite in a busy shopping precinct. This innovative service enabled and encouraged women to seek advice and access antenatal care as frequently as they wanted.

  • Senior staff attended the Clinical Commissioning Group (CCG) maternity network meetings and contributed to discussions and planning for local maternity services.

  • There was no waiting list for appointments with One to One.

  • Women were able to access midwives and maternity care 24 hours a day, seven days a week.

  • Complaints we reviewed were all managed in a timely manner and communication with families were undertaken by telephone or a home visit and followed up with a letter addressing concerns with an action plan. Complaints were discussed at the clinical meetings and the QA meetings on a monthly basis.

  • Lessons learnt were used to share learning from complaints throughout the organisation. Monthly lessons learnt were disseminated via the shared drive, displayed on staff notice boards, discussed at locality team meetings, and were a standing agenda on the locality team meetings.

  • Parent education classes were offered in a group setting in various locations or on an individual basis if requested.

  • The service had a service level agreement with a private scanning company to perform scans at Bidston and St James children centre, Crewe, Ellesmere Port and Warrington PAC’s]. Women were also referred to their local trust scan departments if concerns or deviations from the normal were seen.

  • Hypnobirthing classes were offered to women.


  • The service continued to promote and encourage continuity of carer, however, staff informed us that at times this was difficult to achieve. The service target was 80% for continuity of carer; however, data from the provider showed that across both locations, between April 2015 and March 2016, this target was only achieved six of the 12 months.

  • Staff informed us that the service aimed to establish good working relationships with local CCG and local NHS trusts to ensure that women received the best care and birth experience possible. However, in some instances, this had been challenging and difficult.


Updated 7 April 2017

  • Risk was reviewed and managed through an online reporting system, executive board review, QA meeting reviews and shared lessons learnt.

  • The QA panel met monthly to review and discuss the performance dashboard, risk register, RCAs and incidents, lessons learnt, complaints and claims and the complex care log.

  • Team leaders meet monthly with the Operational lead and Head of Clinical Services to discuss complex cases and feedback board level information.

  • Team meetings and Hub meetings were held monthly.

  • Introduction of Variance sheets, SBAR, MMR, Complex Care Plans, Time Out sheets, MEOWS and the Fresh Eyes system were all elements of the One to One quality assurance framework.

  • All staff informed us that they felt well supported from within their teams, team leaders and senior management staff. They told us that there was an open, honest and helpful culture within the service in the North West.


  • An up to date risk register for the service was provided during the inspection, with nine risks recorded. This was reduced from 14 risks on the previous register provided. All risks were reviewed and action plans in place. However, the register did not state a named lead for each risk. Five of the nine risks remained static, with the same information carried over from the previous register review. The impact and control rating for the retention of midwives risk had increased from moderate to high. However, the action plan remained unchanged from the previous register review. Two of the three new risks identified did not have an action plan documented. However, one risk was rated as high.

  • The service informed us that they did not refuse care for any women but referred to their inclusion and exclusion criteria to categorize “low” and “high” risk pregnancies and whether women were suitable for homebirths. However, we observed that this criteria list was not always strictly adhered to for all women. Staff informed us that if a woman declined to birth in a trust, the CCG were informed and a shared care plan was put in place with an obstetrician.

Checks on specific services


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.