SandwellandWest BirminghamNHS Hospitals Trust

Children,YoungPeopleandFamiliesServices

CQCRegisteredLocation / CQC Location ID
SandwellGeneralHospital / RXK

Tel:01215543801Dateofinspectionvisit:

29- 30June 2015

Dateofpublication:

Thisreportdescribesour judgement ofthequality ofcareprovidedwithinthiscoreservicebySandwellandWest BirminghamNHS HospitalsTrust.Whererelevantweprovidedetailofeachlocation orareaofservicevisited.

Our judgementisbased on a combinationofwhatwe found whenweinspected, informationfrom our‘Intelligent Monitoring’system,andinformation given to usfrompeoplewho use services, the publicandother organisations.

Whereapplicable,wehave reportedon eachcoreserviceprovided bySandwellandWest BirminghamNHSHospitalsTrustandtheseare brought together to inform our overalljudgement ofSandwell andWestBirminghamNHSHospitalsTrust.

Summary of findings

Contents

Page

Overallsummaryx

Thefivequestions we askaboutcore servicesandwhatwe foundx

What peoplewho use theservicesayx

Our inspectionteamx

Why wecarriedout thisinspectionx

How wecarriedout thisinspectionx

Goodpracticex

Areasfor improvementx

Actionwehavetold theprovidertotakex

Overallsummary

Overall rating for thiscoreservice

Outstanding

Childrenandyoungpeople(CYP)serviceswas ratedoutstandingoverall. During theinspectionwemetwithmanagers, staff, childrenandparentsinarange ofcommunitysettings.Weobserved carebeingdeliveredinmainstream and special schools, clinicsand inchildren’sownhomes.Wesawexcellentinnovations in practicetoimprovecare andtreatment for childrenandyoungpeopleforexample a‘tactilecue’called‘TaSSeLs’and acomputer‘app’to helpchildrenlearnanddevelop.CYPStaffworkedwithotherprofessionalsandexternal organisationssuch asCAMHs(child and adolescent mental healthservices)andsocial services.

Therewasevidencethat theservicesfor childrenandyoungpeopleweredeliveredinlinewith bestpracticeguidanceandlocalagreement.Staffwerededicated, professional andwellsupported.WesawstronglocalleadershipacrossallcommunityCYPservices. Staff told us that theywere avaluedmemberof theirrespectiveteams.Wesaw thatcarewaschildcentredandindividualisedacrossallCYPservices.

Therewas aneffectivesysteminplacetoreportandlearnfromadverseincidents, errors,near missesandcomplaints.Wesawcarewasdelivered topromotedignityandrespect,and foundstaffwere veryresponsive to children andtheirfamilies’ needs.

Therewas a robust safeguardingprocessinplaceandinfectioncontrolauditsdemonstratedthatinfectioncontrolguidance waseffective.Wesawinfectioncontrol practicesacrossCYPserviceswas good.

Environmental observationsand reviewsofrecordsshowedthere was ahighlevel ofcleanlinessacrossthe sitesandtheavailabilityofsafe, cleanequipmentwas generallygood.

Generally,staffinglevelsacrossCYPservicesweregood,we sawthetrusthadongoingchallenges withrecruitment ofhealthvisitors,and noassessment of‘finemotor skills’for childrenwithcomplexneedsbyoccupational therapists due toa capacityissue.However,thisdidnot adverselyaffectpatient satisfactionand thetrust had arobust recruitmentplaninplace.

Managementof medicineswereinlinewithtrust policy.Thetrust supportedstaff toensurethat theirmandatorytrainingneedsweremetandindividualtrainingneedsidentified.Staffweregivensupervisionandannual appraisals. Staffexpressedsatisfactionwith the levelsofsupportfrom their localmanagers. TheleadershipofCYPserviceswassupportive and nurturing, senior managerswerevisible and wellliked.Staff told us theythought theexecutive team“didagoodjob” inleadingthetrust andthere wasstrongcommunicationnetworksthroughout CYPserviceswithstaff feelingwellinformed.

Wesawlocalandseniormanagersencouragedandsupportedstaff tobecreativewithinnovationsinpractice.CYPservicesreceived fewcomplaints, andpeoplewespoketoduring theinspectionwereverycomplimentaryabout thestaff andthequality oftheservice theyreceived.

Background to theservice

Communityservicesforchildren,youngpeopleandfamiliesunder theageof20 yearsmakeup 26.8% ofthe population ofSandwell.47.3% ofschoolchildrenarefromaminorityethnicgroupcomparedtotheEnglandaverageof27%.

SandwellChildren’sCommunityServicesprovided arangeofservicesforchildrenandyoungpeopleacross threelocalities inSandwell:Wednesbury andWestBromwich,SmethwickandOldbury,andRowleyRegisandTiptontoinclude:

  • Communitychildren’snursingservice
  • Childdevelopmentcentre
  • Healthvisitingservice
  • Special school nursingservice
  • FamilyNursePartnership, to support youngparents
  • Children’soccupational therapy
  • Children’sphysiotherapy
  • Children’sspeechandlanguagetherapy

Servicesincludeuniversalhealthservicesfor childrenandyoungpeople0–19yearstoensuretheystayhealthy,safe,enjoyandachieve,make apositivecontributionandachieveeconomic well-beingfrom thenationalGovernment Initiative‘Every ChildMatters’. Services such ashealthvisitingaredesignedtopromotepublichealth. Delivery andcoordinationofspecialistorenhanced careandtreatment includedspecialistnursingservices, therapyservices and communitypaediatricservices. Together, theyprovidedcoordinatedcareandtreatment for childrenandyoungpeoplewithlong-term conditions, disabilities,multiple or complexneedsandchildrenandfamilies in vulnerablecircumstances.

Carewasdelivered froma variety ofsettings: mainstream schools, special schools, childrencentres,communityhealthcentresandthechildren’sown home.

Thelevel ofchildpovertyisworsethantheEnglandaverageof28% with 29.9% ofchildrenagedless than16 yearslivinginpoverty andtherate of familyhomelessnessisworsethan theEnglandaverage.

Thehealth and wellbeingofchildreninSandwell isgenerallyworsethantheEnglandaverageandtheinfantmortalityrateisthe worse than theEnglandaverage. The childmortalityissimilar totheEnglandaverage.

Therewasa better rateofimmunisationsforchildrenincare and lowerratesofsexuallytransmittedinfectionsthanthe national average.

Childrenaged4-5years inSandwellhavebetter thanaverage levelsofobesity at10.9%. TheEnglandaverage is 13% . However, 24.3%ofchildrenaged 10-11yearsareclassifiedasobesethisisworsethanthe Englandaverageof19%.During the inspectionwevisited avariety ofservices for children,youngpeopleandfamilies. Thisincludedthreechildren’scentresofferingroutineservices such asimmunisationsandspecialistadvice toyoungexpectant mothers.Wedidthreehomevisits,visitedtwospecial schools, onemainstreamschoolandfourhealthcentres. Weconductedinterviewswithcommunitypaediatricians,nurses, physiotherapists, occupationaltherapists,speechandlanguagetherapists,healthvisitors, managers andserviceleads.We interviewed membersoftheexecutive boardandheldtwocommunitystafffocusgroups.Staff focusgroupsarea plannedmeetingwithspecificstaff memberssuch asnurses,healthvisitorsandtherapiststolisten totheir viewsabout theirworkandhowtheirservices arerun.

Duringtheinspection,wespokewith22parentsandchildrenandwereviewed12individualcareplansforchildren,riskassessmentsandavarietyofteamspecificandservicebaseddocumentsandplans.Wealsosought feedbackfrom external partnerorganisations,and reviewedonlinefeedback.

LAC(Lookedafter children)servicewas notinspectedduringthisvisitasthisservicewasincludedatthecomprehensiveinspectionunder acuteCYPinOctober 2014.Wedidnot inspect children’sschoolservicesas thisservice is provided byanother trust.

Thefivequestionsweaskaboutcoreservices andwhatwefound

Areservices safe? / Good
Summary
Theoverall safetyoftheChildrenandyoungpeopleservicewas good.
Incident reportingandrecordingwasencouragedandembeddedacross allservices. There was arobustprocessinplacefor staffto learnfrom lessonstominimisefuturerisksto children,youngpeopleandfamilies.
Infectioncontrolguidancewas in placeandpracticed bystaff. Equipmentwaschecked,servicedandcleanedinlinewithtrust policyand ingood supply.
Therewereeffectivesafeguardingprocesses inplace to protect childrenfrom the riskofabuseand parentstold us they were providedwith goodadvice,support andtreatmentandfelttheirchildwasin‘safehands’.
Wesawquality ofcareandserviceperformancewasmonitoredandmeasuredacrossCYPservices.
Wesawarobustrecruitmentplaninplaceforhealthvisitorpostswhichwasan item onthe riskregister,howeverthisdidnotadverselyaffectpatient outcomesoroverallpatientsatisfaction.
Mandatory trainingattendancewasgenerally good.Wesawareas oflowtrainingattendance duetostaffvacancies for some healthvisitorteams.Riskstopatientswereeffectivelyassessedandmanagedinmostareasandclinical practicewasreviewedregularlytoimprovecare.
Wesawfinemotor skillsfor childreninspecial schoolswasnotroutinelyassessedduetocapacityissues.
Incidentreporting, learningandimprovement
  • NeverEventsareserious,wholly preventablepatientsafetyincidents thatshould notoccur iftheavailablepreventative measureshave beenimplemented. There werezeroNeverEventsregisteredacrosscommunity CYPservices.
  • StaffacrossCYPserviceswereencouragedtoreport incidentsandwereable to accessthetrust’selectronicincident-reportingsystem.
  • Within a12monthperiod2014to 2015therewere352incidents reported by staffacrossCYPservices,213werereported as noharm,80were reportedas lowharm and14asmoderateharm.Six ofthoseweredirectlyrelatedtochildren. Threemedicationincidents ,twoofwhichwereeducationstaffincidentsandthreewerefalls. Themajority ofincidents werestaff related.
  • Staffweremadeawareof trust wideincidentsinvariousforms,forexample,throughweeklyteammeetings, monthlygovernancemeetingsand emails fromlinemanagers to sharelessonslearned.
  • Wespoke withsenior managersandsawthat seriousincidents weremanagedswiftly.Forexample,weweretold howa child injuredtheirheadduring a therapysessionduetoinsufficientquantity offloormatsinthecorrectposition. Thetherapyteamcarriedout a root causeanalysisinvestigationwhichincludedrecommendations.Lessonslearnedwereshared withtherapystaffacrossspecial and

mainstreamschoolsandfurthersafetymats wereprovided ateachtherapysession toreducetheriskofarepeat.Staff toldus theywereconfident about reportingincidents andwereawaretheyneeded tobe openandtransparent withpatientsandtheir relatives ifanythingwent wrongwiththeir care.

  • Duringtwostaff focusgroupsnot allstaffwere awareofthenew‘duty ofcandour’regulations2014.Weweretoldbystaff theyhad noformalduty ofcandour training,howeverthetrust hadaDuty ofCandourPolicyinplaceand thetrust hadninepromisestheymadetopatientsto include: “Iwill…keepyouinformedand explainwhatishappeningandIwilladmittomistakesand doall Icanto putthem right”.Wesawthis wasimbedded across CYPthroughposters displayedinschoolsandclinicsandstaff’sgeneral awareness.

Safeguarding

  • Staffdemonstratedagoodknowledgeofthetrust’ssafeguardingpolicyand theprocessesinvolvedfor raising analert.
  • Staff knewthename ofthetrust safeguardinglead andtheytold ustheywerewell-supportedandwould seek adviceiftheyhadsafeguardingconcerns.
  • Wesawsafeguardingposters on displayinclinical baseswhich meant that staff hadaccesstotherelevantinformation andphonenumberstoraisesafeguardingconcerns.
  • Staffreceivedsafeguardingtraininguponinduction andatthreeyearlyintervals,thiswaswell-attended.Wesawsafeguardingtrainingfiguresforlevel one,which is abasicawarenesstraining was100%,exceptforhealthvisitorsatVictoriaandWarley medical centrewhichwas 98%.Safeguardinglevel threetrainingwhich is advancedtraining to includechildprotectionandidentificationofchildrenat risk. Figuresacross community CYPserviceswasabove83%,SpeechandLanguageserviceachieved93%.However,HealthVisitors at MaceStreet andWhite Heathclinicachieved78%.Weweretoldstaffvacancies atthisclinicwas acontributoryfactorforlowtrainingattendance.
  • WesawthatSafeguardingalertswerecompletedwithin the recommended24-hourtimeframeandwerediscussedduringstaffhandovertimesto ensurethat allstaffwere awareofpatients’safeguardingissues.
  • Therewasevidenceofrobustsafeguardingproceduresinplace toprotectvulnerablechildren,safeguardingalertswereinvestigated with amulti-disciplinary,multi-agencyapproachwithtrust widegovernancesupportandreview.Local andseriouscase reviewswereheld in atimelymannerand wesawactionplanssupportingthese reviews.
  • CYPserviceswereawareofchildsexualexploitationand hadrobust systems toraiseconcerns.safeguardingreferralsfed into‘MASH’ (MultiAgencySafeguardingHub)where theywerereviewedbyhealth,domesticabuseadvisors,police, mentalhealthservices and thelocalauthority.
  • Wesawstaff fromtheFamily NursePartnership(FNP)andHealthVisitorservicesinvolvedwithsafeguardingcaseshadreceivedsafeguardingsupervision sessions, this rangedbetweentwo and sixweeklydependingonthecomplexity ofthe cases.
  • Staff told usand we sawthat bothroutineandurgentsafeguardingmulti-agencyplanningmeetings

tookplace.Multi-agencyprofessionalssuchas, teachers, police, social workers andhealthcareprofessionalsattendedthesemeetings. Individual caseswerereviewed,risksidentified,careplansagreed andactionsplansput inplaceto protect thechild and support thefamily.

  • Staff told usduringfocusgroupsthatif theywitnessedpoor practicetheywouldhave no reservationtoescalateconcernstotheirlinemanagersand ifnecessarywhistle blowtheirconcernsto either theseniormanager, the safeguardinglead, thesocialworkerortheCareQualityCommission.
  • Themajority ofCYPstaff hadreceivedlevel three safeguardingtraining,whichincludedallrelevantsubjectsincluding, childsexualexploitation,trafficking andfemalegenitalmutilation(FGM). Therewas areferralmechanism toreferanypatientwith FGMtothetrust tobeseen bya consultant andidentifyachild at risk.

Medicines

  • CYPstaffwhoadministeredmedicationsuch asthechildren’snursestransportedmedicationincoolbagstomaintain theintegrity ofthemedicationinlinewithNMCStandardsforMedicinesManagement2010.
  • Wesawchildrenwhorequiredpainrelief forexamplebeforeintensetherapysessionswereadministered prescribedmedicationsandinaccordancewith the trust medicationpolicy.Wesawthatemergencydrugswereavailable and ‘in date’ intheclinicsandstaffdemonstrated agoodunderstandingofthemanagement ofcontrolleddrugsacrossCYPservices.
  • Thecommunitypharmacistbasedatthehospitalprovidedprescribinganddispensingofmedication tochildrenwithcomplexneedsin the community.The communitypharmacistensured children’smedicationwasavailable and supported the children’s communitynurseswith advice and supportwhen required.

Environmentand equipment

  • Welookedatthestorage, maintenanceandavailability ofequipment usedinclinics,schoolsandequipmentused by staffinchildren’sown homesandwe sawelectrical ‘safetytest’stickers wereinplace on equipmentandwithin therecommendedtestdate and staff toldusequipmentwas ingoodsupply.
  • TheHeathVisitorservicecarriedout anenvironmental audit, theresultsshowedinNovember201463%ofbabyclinicswerechildfriendly,the area’sthat wereassessednot to be childfriendlycontainedhazardssuchas adarkroom, stackedchairsandopenplugsockets.Tenrecommendationsweremadeto addressareasforimprovement.Staffwereawareoftherecommendationswhich had been highlightedat team meetingsandwereworkingthroughtheiractionpoints toreducehazards.
  • Staff knewthelocationof first aidboxesinclinicsandschools, andwesawboxescontainedin-datefirst aiditems.
  • Staffdisposed ofclinical wasteappropriatelyand we sawtherewas a goodsystem inplaceforcollectionofclinical waste and sharpsbinsacrosscommunityCYP.

Qualityofrecords

  • Welookedatthemanagement ofchildren’srecordsacrossCYPservicesand sawrecordswerewell

maintained.Paper recordsweresecurelystoredinlockedcabinetsandwereonly accessible to staffwhohad the authoritytoviewthem.

  • Wesawstaffwhoworked in thecommunitysuchasthespeechandlanguage therapist,thefamilynursepartnershipnurse andthetherapistshaddifficultyaccessingelectronicrecordsandupdatedrecordson paper thentransferred therecordsontothe computer backatbase. Thiswastimeconsuming.Weweretold thetrust wasawareofthisand hadbeguntorollouthandhelddevices tocommunitystaff toresolvethisproblem as part ofthetrusts‘paperlight’initiative.
  • Wesawthat recordswerecompletedinaccordancewithtrustrecordspolicy,werelegible and auditedat regularintervals.
  • The HealthVisitorservicecarriedouta careplanauditin2015.76recordswerereviewed.The resultsshowed82%ofrecordshadcareplansinplaceand54%oftherecordshadsafeguardingconcernsraised.Wesawtheauditcontainedeightlearningpoints,forexample,notallcareplanswereindividualisedorcontainedfrequencyofcontactsandreviewdates.Therewasalearningactionplanto addressareasforimprovement.Staff told ustheywereawareofthe auditandactionpoints.
  • The paediatricqualitymanagement frameworkauditlookedathealthcare recordsfromMarch2015 toJune2015andshowed100%offolderswereinsatisfactorycondition.Theauditlookedat‘dailyentries made’and‘contemporaneousentries’in recordswas100%inMay,JuneandJulyand‘basicsin recordkeeping’scored on average92.3%.
  • Therewasevidenceofwrittenconsentandfamilyinvolvementinrecordsaswellasdemonstratingcarecontinuityand multidisciplinaryapproach tothe caredelivered.

Cleanliness, infectioncontrol andhygiene

  • Wesawclinical areas at babyclinics,childrencentresandspecial schoolsmaintainedcleaninglogsforfurnishingsandtoys, andfoundthem tobe satisfactory.
  • Wesawstaffwashingtheirhandsandusinghandgel inbetween eachintervention.Thepaediatricteam whichincludedtherapistsandchildren’snursescompleted amonthlyqualitymanagementframeworkauditwhich lookedat severalareas,forexample resultsforMay 2015showed the handhygieneauditachieved100%inApril2015andscored onaverage 99.6% betweenApril and June2015.
  • Infectioncontrol auditswerecarriedoutannually acrossallCYPservices. In 2014/2015we sawtheHealthVisitor service onaveragescored85%. TheFamily NursePartnershipservicescored83%,Speechandlanguage service scored 93%andthechildren’snursingservice scored 95%.
  • StaffadheredtothetrustsInfectionPreventionControl policy,staffwerebarebelowthe elbows,andhad accesstopersonal protectiveequipment(PPE )if required.Staff didnotwear gloves orapronswheninteractingwithchildrenunlesstherewasanidentifiedrisk.
  • Signsweredisplayedaroundclinical areasremindingstaff andvisitors towash theirhands. Footoperatedwastebinswereavailable and in goodworkingorder.
  • AllCYPteamshadinfectioncontrolchampions whoattendedinfectioncontrolmeetings. Thechampionssharedany actionsto localteamsto improveinfectioncontrolpractices.
  • Wesawappropriatecleaningschedulesforlarger piecesofequipment such ashoistsandprofilingbeds used inspecial schoolsandwe sawstaffcleaningsmalleritemssuchas babyscalesandtoysaftereachuseinchildren’scentres, clinicsandschools.

Mandatorytraining

  • Wesawon averageHealthvisitorsscored86% for mandatorytrainingattendance.Trainingincluded:firesafety awareness, resuscitation-basiclifesupport,infectioncontrolandmovingandhandling.Thehighest area of trainingattended wasinfectioncontrol andthelowestwasfiresafety awarenesswhichrangedbetween 48%at HatelyHeathClinicand85%atVictoria andWarley Medical centre.Weweretold acontributoryfactor for lowtrainingattendancewas due toHealthVisitorvacancies, staff toldustheyfound itdifficult to leavetheirworkloadtoattendtrainingdueto demandandcapacity.Seniormanagementwereawareofthisandtold usitwas an areafor improvementandtheyconsideredit apriority.
  • TheFamilyNursePartnershipservicescored atotal of83%acrossmandatory trainingandthespeechandlanguagetherapyserviceandthenursingandtherapy servicecombinedscoredonaverage94%.
  • Stafftold us theyweresupportedtoattendmandatorytrainingandwereactivelyencouragedto attendspecialisttrainingandrestorativesupervision.

Assessingandrespondingto patientrisk

  • A wide range ofriskassessmentswereusedacrossCYPservices to assess andmanageindividualrisksto children.Forexample, the Family Nurse Partnershipservice useda childsexualexploitationriskassessment, children’snursesassessedforpressureulcer risk.
  • Wesawjoint occupational therapyandphysiotherapy riskassessmentsfor manualhandlingandeachchildwhohadhydrotherapyand usedthe swimmingpool were riskassessedbeforeeachactivity.Healthvisitorsriskassessedchildrenandfamiliesforhomesafetysuch assafetygatesandsafesleeping.
  • Whereriskswereidentified,staffhadaccessto support, guidanceandequipment to helpmanagerisks.

Staffinglevelsandcaseload

  • TheFamilyNursePartnershipserviceprovidedcarefromonebase, The LyngCentreandthestaffinglevelsconsistedofone manager and oneseniornurse. Currently the service had commissioned165placesovera two and a halfyearperiodreaching 85%ofitscontract.
  • Wesawthat thetherapystaffinglevelsfor Physio and Occupationaltherapistscombinedwas32.5staffWTE(wholetimeequivalent)with 20 supportstaff. Speechandlanguageservices had 18staffwithtwosupportstaff.Thetherapyteam provided care inclinics,children’s own homes and across122special andmainstreamschools.
  • Staffinglevelsfor children’snursingservicesincluded 16 nursesand 12supportstaffwhoprovidedcareinchildren’sown homes andacross 122special andmainstreamschools.
  • Wesawgenerallytherewas adequatestaffinglevelsacrosschildren’snursingandtherapyservices tomeet themajority ofneedsofchildrenandfamilies. Thetherapyteamconsistedofaclinical leadwhowasresponsiblefor alltherapistsacrossCYPservices andfour monthsagohadtakenover themanagementofthechildren’snursingservice.However,weweretold therewereinsufficient OT’savailable to meetalltheneedsofchildreninspecial schools.Forexample, we saw‘finemotor skills’which are delicatemovements ofhandsfeetandlipswerenotbeingassessed byOT’sdueto

capacityissues. Thepaediatricleadtold usplanswereinplace torecruitanadditional OT tobridgethisgap

  • Twomonthsprevious,thetrust decidedto placenursingandtherapiestogether under a ‘paediatric

group’.Staff told usthisworkedwellreducingduplicationoffassessmentsandsharingbestpracticeamongclinicians

  • HealthVisitors provided care andsupportfrom12teamsacrosssixareas ofthetrust.Weweretold in2014 thetrust employed 21 healthvisitors inresponse totheNational HealthVisitor ImplementationPlan‘Acall to action’whichaimedtoexpandandstrengthenHealthVisitingservices.However,sevenHealthVisitors hadleft thetrust whichresultedinvacancies acrosstheteams.WesawVictoriaHealthcentrestaffhad12 healthvisitorsinpostwith fouradditional vacancies. Thetrust continuedwiththeirrecruitment drive tofillhealthvisitorvacancies.
  • WesawtheHealthvisitor’sworkforcetargetwas 85.6%, thetrusthadachieved78%. Theworkforcetargetisbased onthe national target toincreasetheamountofhealthvisitors tomeetthe needs ofchildrenandtheir families. Thecollective case loadacrossall 12teamswas28,000andwe sawtheservice had 11 HealthVisitorvacancies.
  • Despite thenumber ofvacanciesweweretoldby staffand we sawthroughobservations inclinics,children’scentresandhomevisits,thisdidnot affect the outcomesfor children, youngpeopleandfamilies and overallsatisfactionwasgood.Wesawthe HealthVisitor leadhadimplementedseveralstrategiestoretainstaffin post andto attractnewHealthVisitorsintothetrust.Forexample, apreceptorshipprogramme fornewly qualifiedHealthVisitors,introduction ofrestorativesupervision toaddressworklifebalance and aHealthVisitor teachingandtrainingprogramme.
  • Staff told usand we sawtherewereadequatestaff tomeet theneeds ofnewmothersontheir caseload.EachFamily NursePartnershipstaff memberwasresponsiblefor25 newparentsontheircaseload. Thiswastherecommendedcaseload sizeforafulltimenurseandinlinewith theDepartment ofHealthFNPprogramme2011.Howevertomeetthe needs ofthe widerpopulationandoffersupport tomoreyoungparentsfurther staff wererequired.Thisissuewasbeingaddressed asfurtherfundinghadbeenagreedforanewmanagerandthreesenior nurses from August 2015.
  • Staftoldus and we sawagencyusageacrosscommunityCYPserviceswasminimal. Senior stafftold us children’sagencynursesandtherapistswereinshort supplyandthetrust wasconcentratingitseffortsinto recruitmentpermanentstaff.
  • Wesawtherewas a goodinductionprocessfornewstartersacrossallservices.

Managinganticipatedrisks

  • Therewas adedicatedChildrenandyoungpeopleriskregister.The HealthVisitor riskregisteridentifiedfour risks.Threewereratedasamber relatingto:

1.inadequatechildprotectionandsafeguardingsupervision.

2.fromSeptember2015somefamilieswereto betransferredtootherareas, thiswas inlinewith GP areas, thismayresult inconfusionfor families astheywererequiredtochangetheirGP’s.

3.10HealthVisitorsplanstoretireovernext year2015/2016.

  • Thefourth riskwas ratedasred andrelatedtotheinabilityto deliveragainstsomekeyperformanceindicators.WesawallfourriskshadbeenreviewedinMay 2015and each containedan actionplan tomitigatetherisks.Followingthisreviewallfouractionshadbeendowngradedfromredandambertoyellow,whichindicatedtheriskhadreducedsignificantly.

Majorincidentawarenessandtraining

  • Thetrust had amajorincidentandunforeseenadverseweatherpolicyinplaceandstaffwereabletotell us whatwasexpectedofthemduringamajorincidentin the community.
  • Wesawtherewas aMajor IncidentPolicyinplaceandstaffwereawarehowto accessitwhenrequired.

Areserviceseffective? / Good
Summary
TheeffectivenessofChildrenandyoungpeople serviceswas good.
Caredeliverywasunderpinned by evidence-basedpractice andfollowedrecognisedandapprovednationalguidance.WesawCYPservicesparticipatedandcompletedclinical auditsandperformance ofserviceswasmonitoredandmeasuredat regular intervalsto achievethe best possibleoutcomes.
Pain,nutritionandhydrationassessmentswerecarriedoutfor eachchildattendingclinics, childrencentres,schoolsand intheir own homes. Careplanswereevaluated at timelyintervalsandreflectedindividual needs.
Therewas a multi-disciplinary approachto careandtreatment and aproactiveengagement withotherhealthandsocial careproviderstoachieve bestoutcomes.
TransfersandtransitionsbetweenCYPserviceswereplanned in advance. Therewasanassessment ofthechild’sindividualneeds;thisincludedworkingwithotheragenciestoassess,planandcoordinatecare.
Wesawplanswereinplace tostreamline I.T. access. Byimplementinghandhelddevices acrossCYPservices toreduceduplicationofinformationandspeedupinformationaccesswhilstworkingincommunitysettings.
Wesawstaff gainedverbal orwrittenconsentfor eachnursingand therapy intervention.
Evidencebased care andtreatment
  • AllChildrenandyoungpeopleservicesdeliveredevidence-basedpracticeandfollowedrecognisedandapprovednationalguidanceinaccordancewiththeirgoverningbodies. Thisincluded the NMC(NursingandMidwiferyCouncil),the RCPCH(Royal CollegeofPaediatricsandChildHealth)andtheHCPC(Health and CareProfessional Council)
  • WesawCYPservicestookpartinthenational Epilepsy auditfor children. InNovember2014,6%ofnewreferralstoepilepsyclinicwereseenwithin 2weeksbya specialistwithexpertise in epilepsy.66%of referralswereviaGP,with 10%consultant -to-consultant inhousereferral andtheremainder wereatthe pointofa child’sdischargefromhospital.Findingsfrom thisaudit showedonlya minority ofchildren with a first seizureepisodewereseen bya specialistinepilepsy,within2 weeksofreferral. Majority ofthesereferralswerethroughaGP. Inpatients with a first seizureepisodewereassessed bytheon-callpaediatricmedical team.Followingtheaudit,we sawtherewerefiverecommendationsmade, oneofwhichwas to recruittoa specialistEpilepsyNurse.WetalkedtothecommunityPaediatricianwhotold us fundinghadbeenagreedforafulltime nurseandthe post wasbeingadvertised.
  • TheCYPserviceparticipatedannuallyin the NationalPaediatricDiabetesAudit.Wesawin2013/14the audit lookedatchildrenin thecommunity whoattendedthe PDU(paediatricdiabeticunit) andwas

measuredagainst 170PDU’sacrossEngland andWales.Theresults showedoutofsevenareas,(25questionsintotal), SandwellCYPscored better than theregional andEngland andWalesaverage in22 out of25 areas. Completionofseven careprocesseswasmeasuredandincluded,eyescreening,cholesterol, bloodpressurerecordingandfoot examination.Theresults showedSandwellCYP scored20.4%,better thantheregionalaverageof15.7%andbetter thanEnglandandWales averageat16.1%.Parentsfeedbackwasmeasuredandtheresultsshowedthat theSandwellservice rated byparents wasbetter thanboth the National andRegional average.

  • TheFamilyNursePartnershipserviceprovidedevidencebased, preventativesupport for vulnerablefirst timeyoungmothers,from pregnancyto untilthechild is twoyearsofage.Family nursesdeliveredthe programme,within a defined andstructuredservicemodel.
  • Healthvisitorsandtheir teamsdelivered theHealthy ChildProgramme (HCP)toallchildrenandfamiliesduringpregnancyuntil 5 yearsofage. TheHealthy ChildProgramme isthekeyuniversalpublichealthserviceforimproving thehealth and wellbeingofchildrenthroughhealth anddevelopmentreviews,healthpromotion,parentingsupport, screeningandimmunisationprogrammes.For the early lifestagesthefocuswas on aprogressiveuniversalpreventativeservice. Theimmunisationauditcarried out between 24 and30November2014auditedthevaccinationstatusofchildrenbetween 2 months and 5yearsofage. Theauditcaptureddetailsofchildrenwhoattendedthe paediatricwardsbased on vaccinationadministeredinthe community.Wesaw93%ofchildrenwereup to date withtheirimmunisationsand97%hadplannedappointmentsbymidDecember2014.Across fivevaccinationprogrammes we sawtheEnglandaveragewas92%andSandwellCYP hadachieved 90.8%.
  • Wesawtheaudit carriedout inDecember2014ofdepressionscreeningofchildrenandyoungpeoplewhichshowed65%ofchildrenover12 yearshadthreescreeningquestionsaskedagainst atarget of100%. Onechildwhowasclassedas moderatetosevereriskwasreferredto CAMHs(child andadolescent mentalhealthservices) within 24 hours.Wesaw57% ofchildrenwhoansweredyes tooneofthequestionshada CAMHsreview.Thishelpedstaff toidentifychildrenearly withoverdose/depressionorself-harm risksandreferthem ontotheappropriateservice.
  • TheWeight Managementinchildren withobesityauditcarriedoutinJune2014identifiedhowmanychildrenwithobesitywere assessedusingweight management criteria.Theresultsshowed100%ofchildrenwithco-morbidities(morethanonehealthconditions)werefullyinvestigatedand17.6% ofchildrenwerereferredtosecondary carewithoutcomorbidities.Wesaw100%ofchildrenafter 2010hadreceivedinformationtoenrol ontotheweightmanagementprogramme.The programme wasdesignedtohelpparentsdevelop the confidenceandskillstomakehealthierchoicesfor themselvesandtheirfamiliesaboutfood and nutritionandphysical activity.

Painrelief

  • Therewereclearguidelinesforstafftofollowwhichreflectednationalguidance.
  • Children’spainlevelswereappropriatelyassessedaccording totheageofthechild.Wesawthatdifferent methodswereused,such aspicturesandassessment of facial andbodylanguage,whereverbal communicationwasnot possible.
  • Wesawstaff atmainstreamandspecial schoolsknewthechildrenvery wellandcouldidentify ifachildwasuncomfortableorinpain, basedontheir bodylanguage,noisesandfacial expressions.

Nutritionandhydration

  • Where appropriate,childrenhada nutritional andhydrationplaninplacewhichreflectednationalguidanceanddemonstrated amultidisciplinaryapproachtomeetingchildren’sdietaryneeds.
  • Wesawstaff followingthefeedingregimeas prescribed.For thosewherewerereceivingenteralfeeding,which is anutritionalcompletefeed usually throughatube directlyinto thestomachorviathenose, thiswascorrectlycompleted.
  • Childrenwhowereatriskofobesityhadaccessto aweight clinictomonitor theirprogress.The childandtheir parentshadaccessto adieticianwhoprovided aregular review oftheirdietaryrequirementandprovideddietarysupportforparents.
  • Wesawstaff met children’sindividual hydrationneeds,. For example,ontheday ofthe inspectionthetemperature reached28degreescentigrade,staff providedchildrenwithextradrinksand icecreams.

Patientoutcomes

  • Servicescarriedoutseveralauditstomeasurequalityandperformance.Forexample,healthvisitorslookedatskillmixtoprovideauniversalbestpracticestandardandprocedureinWellBabyclinics,tobabiesandchildrenaged0-5years.InNovember2014SandwellHealthVisitorservicedelivered30WellBaby clinicsovera fourweekperiod.93 sessionswereprovidedwitha total of165hoursofbabyclinic.
  • We sawthenumberofmotherswhoreceivedafirstfacetofaceantenatalcontacthadimprovedfrom28from October to December 2014to 56fromJanuary to March2015.
  • Againstatargetof60%wesawthepercentageofchildrenwhoreceiveda12monthreviewfromOctobertoDecember2015was44%,thisfiguredroppedto38%fromJanuarytoMarch2015.Thetrusthadtakenremedialaction and implementedadditional Saturdayclinicsto improveperformance.
  • Thepercentageofchildrenwhoreceivedatwototwoandhalfyearreviewwas67%fromOctobertoDecember2014andsawareductioninJanuarytoMarch2015to59%.Weweretoldthetrustwasreviewingthedatatoseeiftherewasanycorrelationtoworkingparents,theresultshadnotbeencompletedpriortothisreportbeingpublished.Atextmessageservicewasinplacetoremindfamiliesofappointments.
  • Thepaediatricteamwhichincludedtherapistsandchildren’snursescompleted amonthlyqualitymanagementframeworkauditwhich looked at several areas,forexample, asthmaaudit, paediatricindicatoraudit andhealthcarerecordsaudit.Wesaw100%wasachievedinMay 2015 forasthma/wheezepatients with anactionplangivenanddirectaccessarranged ifnecessary.Wesawsmokingcessationadvicegivenwas 62.5%. However,we sawa significantimprovement ofacrossallasthmaaudit areas,achieving100%inJune2015.Wesawthepaediatricindicator auditlookedatheight,weight andpainscorerecorded.Resultsshowedin June 2015 83.3%ofchildren’sheightwasrecorded,100%of children’sweightwasrecorded and 100%painscorewasrecorded.
  • Anauditwascarriedoutto lookatthenutritional status ofchildreninspecial schools. Theresultsshowed65%ofchildrenhaddysphagia (feedingproblems), 55% ofthemwereunderthedietician.Allchildrenwhoweresupported with NG (nasogastric) orPG (percutaneous) feedswereunder thedietician.71% ofchildrenhad afollowup planwith thedietician.
  • Wesawfiveactionpointstoaddressareasfor improvement,forexample,allchildren at OrchardandMeadowsspecial schoolshadannual height andweightdocumented intheirnotes,or staff todocument thereasonforabsence.Allchildrenforwhomheightestimation wasimpossible due tophysical disability had skinfoldmeasurement recordedinstead, thismeasuresachild’sbodyfatpercentage. Thetarget date for actions tobecompletedwas 31 July2015.
  • WesawtheFamilyNursepartnershipservicemonitoredthe effectiveness ofthe service bymeasuringthe number ofclientscompletingtoddlerhood, thisstageisthe physicalgrowthwithin the child’sfirsttwoyears. The auditshowed from April 2014to March2015figureshadsteadilyincreasedfrom fivewithin the previousyear, to 37recorded inthelast 12monthsto 65 within the last threemonths.

Competent staff

  • StaffacrossCYPservicesdemonstratedtheypossessedsufficientknowledge,andwerecompetent todelivercareandtreatment to childrenandtheir families.For examplewe sawtherapystaffhadacompetencyframework whichincludedhydrotherapyandrespiratory competencies.
  • Wesawchildren’snurseshadcompletedcentral lines,intravenouschemotherapyadministrationandenteralfeedingcompetencies.Family NursepartnershipserviceandHealthVisitors receivedspecialisedtraining toidentifysigns ofchildabuse and childsexualexploitation.
  • Staff trainingneedswereidentifiedat theirappraisalsandrestorativesupervisionmeetings.Wesawstaffwereencouragedtodeveloptheirclinical skillsandcompetenciesthroughattendingrolespecificcourses within the trust andwerefundedtodevelopfurtheratexternalcoursesatuniversity.
  • Managersidentifiedpoor performancequickly andwe sawstaffbeingsupportedthroughaperformancemanagementprocess withadditional trainingandregular onetomeetingstomeasuretheirprogress.

Multi-disciplinaryworking andcoordinatedcarepathways

  • Wesawtimelyreferralsbetween Familynursepartnership and HealthVisitor servicesandweweretoldthat children’snursing andtherapieshadbeenjoinedtogether andwereworkingunder thesamegroup. Staff told usthisnewtransitionhadreducedunnecessaryduplicationofassessmentsand hadimprovedcollaborativeworking.
  • WesawtheHealthVisitorservice had plansto implementNICE(National InstituteforClinicalExcellence) guidance‘Fever’pathwaysto improveserviceprovisionfor childrenunder5yearsofageandstrengthenintegratedworkingacrossacuteandcommunityservices.
  • OT’s, Physio andSpeech and languagetherapistsweremainlybasedinthe sameoffice inspecialschoolswhichimprovedcommunicationandassistedwithearlydetection ofproblems associatedwiththe child’sphysical andsocial situation.Workingincloseproximity meant nurses, therapistsandteacherscouldhandover informationquicklyandjointassessmentsfor examplemanualhandlingassessmentsbetweenthephysio and OTpromotedsharingof best practice andreducedduplicationofinformation.
  • Wesawan integratedchildren’spathwayprovided aseamlessservicewhichfollowed the child withcomplexneedswithadmissionanddischargetohospital. Thechildren’scommunitynurseserviceincludedpalliative care nurses, special schoolsnursesandcontinuinghealth carenurses.Theteamworkedtogether to provideindividualised carewhich followed the childinto and outofhospital andwassupported byspecialistnursesinareasofdiabetes andepilepsy. Thisapproachensuredthe childandtheirfamilyremainedcentral tothe advancedplanningandcaredelivery.

Referral, transfer,dischargeandtransition

  • Referral arrangementswereinplaceforchildrenandyoungpeopletransferringbetweenservices.
  • Eachyoungpersonhada namednurseortherapistwhocoordinatedtheirtransition,howeverstafftold ushaving atrust transitionleadwouldprove moreeffective in coordinatingpathwaysofcareasthistransitiontime wasusuallyintense and timeconsuming to support theyoungadult.
  • Therewerestronglinksbetween the Local Authority,BirminghamChildren’sHospital,paediatriciansandconditionspecificspecialistssuch asepilepsy anddiabeticnursespecialistto discussthechild’s/youngperson’scomplexneeds.Regularmeetingswereheld todiscuss andplanthechild’s/youngpersontransitionthroughschool andatthepointof discharge.
  • Wesawthetransitionof childrenmovingfrom infant tojuniorand secondary school wasseamless,howeverstaff told usthetransitionforyoungadultswhenleavingeducationneededto beimproved.
  • Thereweretransitionarrangementforchildren/youngpeoplewithcomplexhealthneedsfromchildrento adult services. Children/youngpeople withcomplexneedsweresupportedupto 19yearsofageandchildren/youngpeoplewith acute needsweresupported upto18yearsofage.Oncethe youngpersonhadreachedadulthoodprevioussupport andactivitiesofferedtothem, suchas nursingandtherapysessions,werevery limited.Childrenwithcomplexneedsweresupportedupto 19yearsofageandchildren with acute needsweresupported upto 18yearsofage.
  • Weweretoldbysenior management thatdiscussionswereunderwayto extend thesupport for youngpeoplewithcomplexneedsfrom19 yearsto25 years.

Access toinformation

  • Acrosschildren’scentres,babyclinics, mainstreamandspecial schoolswe sawinformationleafletsandbooklets available forparentsthatincludedclinictimes, supportnetworks, self-helpgroup andcontact details.
  • Informationleaflets wereavailablein manyformatsincludingpictorialandsimpletext.
  • HealthVisitors provideda range ofleaflets, thisincluded‘introducingsolidfood, ‘weeklytimetableofactivities’ and the callcentrecontact details.
  • Therapists,Children’snurses andHealthVisitors did nothave afullyintegratedITsystem. Planstobring amorejoined up servicewasunderwaywith theplannedintroductionofhandheld‘recordkeeping’devices.InthemeantimeCYPstaffusedpaper recordswhichwereupdatedduringvisits forexample atspecial schoolsand inthe child’shome andwereupdated andstoredbackat theirbases.
  • Wetalkedto22parents whotold ustheywere givencontact detailsofservices and accesstoinformationwas good.

MentalCapacityActandDeprivationof LibertySafeguards

  • AcrossCYPserviceswe saw that staff gainedconsentbeforeeachinterventionandparentstoldustheywereaskedfor verbal consent andsometimeswrittenconsent dependingon whatthetreatmentofcarewas.
  • Wesawconsentwasrecorded in school recordsandincludedin care pathwaysanddocumentation.
  • Toassesswhetherachildwasmatureenoughtomaketheir owndecisionsandgiveconsentstaffusedagreedprocessesandframeworks, including'Gillickcompetencies' and'Fraserguidelines'.
  • Duringoneto one interviewsandstaff focusgroups,staff demonstratedagoodunderstandingof theMental CapacityAct(MCA)and howtosupport youngpeoplewithdecisionmaking.Wesawstaff held
‘bestinterest meetings’tosupportyoungadults whowereunable tomakedecisionsfor themselves,thiswas in accordancewithlegislation. One exampleinvolved a youngpersonwithcomplexneedsmakingthetransitionfromchildhoodto adult.
Areservicescaring? / Outstanding
CommunityCYPserviceswererated asoutstanding for ‘caring’.
Wesawstaffinteractionwithchildrenandfamilieswereexceptionally caring andcompassionateandstaffengagement wasrespectful andprovided careina dignified way.
Children/youngpeopleandtheirfamilieswereactivepartnersintheir care. Staffwerefullycommitted toworkinginpartnershipwithpeople andmakingthisarealityfor eachperson.Staffalwaysempoweredchildren/youngpeoplewho usetheservice tohave avoice andtorealisetheir full potential.
Staffinvolvedchildrenandparentsthroughevery aspect ofcaredeliveredandwe sawstaff tooktimetoexplainoptionsandchoicesandansweredquestionsclearlyandpatiently.
Staffdemonstrateddeterminationand creativity to overcomeobstaclestodeliveringcare. Children/youngperson’sindividualpreferences andneedswere alwaysreflectedin howcarewasplanned and delivered.
Wesawmanyexamples ofstaffofferingemotionalsupport tochildrenandtheirparentsacrossallservicesandchildrenandyoungpeoplewereencouragedtobe asindependent astheir abilityallowedin asupportiveandnurturingenvironment.
CompassionateCare
  • Wesawthatchildren’sandyoungpeople’sassessmentsandtreatmentsacrossCYPserviceswerecarriedoutatappropriatestages of theirdevelopment andat significant timesof their liveswithin eachservice and betweenservices.Forexample, theFamilynursepartnership(FNP) serviceinvitedyoungexpectant mothersuptothe ages of19 yearsonto theprogrammeandsupportedthemwhen the childwas born and untiltwoyearsofage.Wevisited ayoungmother at homewhowaspregnantwithhersecondchild.Shetoldus”Icouldn’t havegot throughthisonmyown,theFNPprogrammecamejustattheright timeand I’ve been supportedallthe way along”.
  • Interactions weobservedacrossallCYPserviceswereundertakenin adignifiedandcompassionateway. WesawoneHealthvisitorlaughing and playingwith a toddlerduringtheirdevelopment check,tomakethe appointment morefun.Wesawa nursefrom the FNPservicedemonstrateacompassionateandgentleapproachwhendiscussingasensitiveissuetoayoungparentwhowas upsetabout theirabilityto cope withparenting as ayoungteenager.
  • Aswell as childrenwe talkedto 22parents whotold ustheywerealwaystreatedwithdignityandrespect.
  • Duringhome visitsandinteractionsbetweenstaff at clinicsandschools we sawstaffhelpedchildrenandtheirfamiliesunderstandthe caretreatmentand caresupport available tothem.
  • Wesawstaffinteractions withchildrenandtheirparentswerepositive,respectful andchildcentred. Forexample one childwithcomplexneedsrequiredatherapysession.Wesawthree staffpreparethechildbyhoistingthemfrom thewheelchairto abench.TheOT sat behindthe child to support themandthePhysio andhealth careassistantsangnurseryrhymes, whilstencouraging the childto stretchand reachfor toys.The child waslaughingandgigglingwhilstworkingthrougha therapysessionandexercisingthroughplay.
  • Wesawstaff using‘TaSSeLs’whichwas atactile cuefor childrenwithcomplexneeds. This was asystemwhich usedtouch topromote effectivecommunicationwithchildrenwhohadprofoundand