Southern Health NHS Foundation Trust

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1 Southern Health NHS Foundation Trust Perinatalal services Quality Report Headquarters Tatchbury Mount Calmore Southampton Hampshire SO40 2RZ Tel: Website: Date of inspection visit: 7-10 October 2014 Date of publication: 25 February 2015 Locations inspected Name of CQC registered location Location ID Name of service (e.g. ward/ unit/team) Postcode of service (ward/ unit/ team) Melbury Lodge RW119 Mother and baby unit and perinatal community team SO22 5DG This report describes our judgement of the quality of care provided within this core service by Southern Health NHS Foundation Trust. Where relevant we provide detail of each location or area of service visited. Our judgement is based on a combination of what we found when we inspected, information from our Intelligent Monitoring system, and information given to us from people who use services, the public and other organisations. Where applicable, we have reported on each core service provided by Southern Health NHS Foundation Trust and these are brought together to inform our overall judgement of Southern Health NHS Foundation Trust. 1 Perinatal services Quality Report 25 February 2015

2 Summary of findings Ratings We are introducing ratings as an important element of our new approach to inspection and regulation. Our ratings will always be based on a combination of what we find at inspection, what people tell us, our Intelligent Monitoring data and local information from the provider and other organisations. We will award them on a four-point scale: outstanding; good; requires improvement; or inadequate. Overall rating for Perinatal services Are Perinatal services safe? Are Perinatal services effective? Are Perinatal services caring? Are Perinatal services responsive? Are Perinatal services well-led? Mental Health Act responsibilities and Mental Capacity Act / Deprivation of Liberty Safeguards We include our assessment of the provider s compliance with the Mental Health Act and Mental Capacity Act in our overall inspection of the core service. We do not give a rating for Mental Health Act or Mental Capacity Act; however we do use our findings to determine the overall rating for the service. Further information about findings in relation to the Mental Health Act and Mental Capacity Act can be found later in this report. 2 Perinatal services Quality Report 25 February 2015

3 Summary of findings Contents Summary of this inspection Overall summary 4 The five questions we ask about the service and what we found 6 Background to the service 7 Our inspection team 7 Why we carried out this inspection 7 How we carried out this inspection 7 What people who use the provider's services say 7 Good practice 8 Detailed findings from this inspection Locations inspected 9 Mental Health Act responsibilities 9 Mental Capacity Act and Deprivation of Liberty Safeguards 9 Findings by our five questions 10 Page 3 Perinatal services Quality Report 25 February 2015

4 Summary of findings Overall summary We gave an overall rating for perinatal services of outstanding because: There were excellent processes in place to ensure that women and their children were safeguarded from possible abuse. There were sufficient staff available to ensure that women were cared for safely and their needs could be met. There was a very low turnover of staff on the ward and few vacancies arose. Staff at all levels told us how learning from incidents had occurred in the service and described how lessons had been learned from these. Action plans had been put in place following investigations of incidents and implementation had brought about improvements in care and treatment. Infection prevention and control measures and the safe management of medicines helped ensure that women and babies were protected from the risk of harm. The needs of women and their babies were assessed and care and treatment planned and delivered in accordance with their needs and identified risks. Wellness recovery action plans (WRAP) had been developed especially for mothers and also for their babies. Women told us they had been involved in the development of care and WRAP plans as well as crisis and contingency plans. The service was accredited by the Royal College of Psychiatrist s Quality Network for Perinatal Mental Health Services and had been named psychiatric team of the year at the national Royal College of Psychiatrists (RCPsych) Awards in Staff told us there were good opportunities to improve their knowledge and skills and senior managers were supportive of further professional development. There was excellent multi-disciplinary team working as well as joint working with other external agencies and services that enabled effective holistic care for people. The perinatal service offered specialist support and advice to other teams, for example, GP s and community mental health teams. Women were treated with dignity and respect and their privacy was maintained by staff. During the shift handover we observed that staff talked about people using the service respectfully and showed genuine compassion. Women said they had been encouraged to help develop their own care plans and everyone we spoke with said they had been given a copy. They all said they felt involved in their care and treatment and in the care provided to their baby. Excellent support was provided for fathers, families and other people significant to women. The service was committed to increasing awareness of perinatal mental illness and the support available from the service. The community team was involved in preventative work and provided training to a range of health professionals and voluntary sector groups. A telephone clinic had been developed as a way of meeting the needs of more women as referrals to the community service had risen considerably in recent years. The co-location of the in-patient unit and the community perinatal team was beneficial and encouraged a seamless transfer of care of women between the teams. Women were enabled to remain in contact with staff who supported them in the community and this helped provide continuity of care. The service was responsive to the needs of the local community and had analysed population data in order to identify groups within who were underrepresented in the patient population. Plans were in place to advertise the service and raise awareness of perinatal mental health issues in these groups. Referrals to the service were prioritised according to needs and risks and responded to promptly. The service was very well led. There was an effective system in place in place to assess and monitor risks. Governance arrangements supported the delivery of high quality safe, effective, caring and responsive services to women and their babies. Staff were supported to be creative and innovative in their approach to meeting women s needs and 4 Perinatal services Quality Report 25 February 2015

5 Summary of findings extending the reach of the service. The service engaged in national initiatives in order to drive forward improvements. There was a strong culture of innovation and continuous improvement. 5 Perinatal services Quality Report 25 February 2015

6 Summary of findings The five questions we ask about the service and what we found Are services safe? There were excellent processes in place to ensure that women and their children were safeguarded against possible harm. Staff at all levels told us how learning from incidents had been incorporated into ensuring safe care was provided. There were sufficient staff available to ensure that women were cared for safely and their needs could be met. Are services effective? The needs of women and their babies were assessed and care and treatment planned and delivered in accordance with identified needs and risks. Staff had the skills necessary to deliver effective delivery of care and treatment. There was excellent multidisciplinary team work in evidence and effective working with external partners. Are services caring? Women were treated with dignity and respect and their privacy was maintained by staff. Staff talked about people using the service respectfully and showed genuine compassion. Women were actively involved in their care. Excellent support was offered to fathers, families and friends. Are services responsive to people's needs? The service was committed to increasing the awareness of all health professionals of perinatal mental health problems. The service was actively involved in preventative work and was responsive to the needs of the local community. There was a seamless transfer of care of women between the in-patient and community teams that enabled women to remain in contact with staff who supported them and helped provide continuity of care. Referrals to the service were prioritised according to needs and risks and responded to promptly. Are services well-led? The service was very well led. Governance arrangements supported the delivery of high quality safe, effective, caring and responsive services to women and their babies. Staff were supported to be creative and innovative in their approach to meeting women s needs and extending the reach of the service. The service engaged in national initiatives in order to drive forward improvements. There was a strong culture of innovation and continuous improvement. 6 Perinatal services Quality Report 25 February 2015

7 Summary of findings Background to the service The mother and baby unit provides 10 in-patient beds for mothers and their babies under one year of age. It is located at the Trust s Melbury Lodge location in Winchester. The unit provides a national service in terms of admissions. The perinatal community team is located on the same site adjacent to the in-patient unit. The team provides a service to women in Hampshire and the Southampton city area. The perinatal services had not been inspected since registration by the Care Quality Commission. Our inspection team Our inspection team was led by: Chair: Shaun Clee, Chief Executive, 2gether NHS Foundation Trust, Gloucestershire Team Leader: Karen Wilson, Head of Inspection for Mental Health, Learning Disabilities and Substance Misuse, Care Quality Commission The team included CQC inspection managers, inspectors, Mental Health Act reviewers, pharmacy inspectors, CQCs national professional advisor for learning disabilities, analysts and inspection planners. There were also over 100 specialist advisors, which included consultant psychiatrists, psychologists, senior nurses, student nurses, social workers GPs, district nurses, health visitors, school nurses and an occupational therapist. In addition, the team included Experts by Experience who had personal experience of using or caring for someone using the types of services that we inspected. Five Experts by Experience were involved in the inspection of mental health and learning disability services and two were involved in inspecting community health services. Why we carried out this inspection We inspected this core service as part of our ongoing comprehensive mental health inspection programme. How we carried out this inspection To get to the heart of people who use services experience of care, we always ask the following five questions of every service and provider: Is it safe? Is it effective? Is it caring? Is it responsive to people s needs? Is it well-led? Before visiting, we reviewed a range of information we hold about perinatal services and asked other organisations to share what they knew. We carried out an announced visit on 10 October During the visit we spoke with a range of staff who worked within the service, such as nurses, child care practitioners, social worker and a consultant psychiatrist. We talked with women who use services. We observed how women and babies were being cared for and reviewed service records. What people who use the provider's services say Women we spoke with during the inspection all told us how much they valued the perinatal services. Staff were described as supportive and professional. Women felt very safe on the unit and were pleased with the way their 7 Perinatal services Quality Report 25 February 2015

8 Summary of findings babies were cared for. They said there was good support for and liaison with families and local community mental health services. Fathers and relatives received good levels of support from staff and women said they felt they were at the centre of their care. Women told us they believed staff genuinely wanted to do their best for the mothers on the unit and showed great kindness. Good practice The service provided support to a range of health professionals, via a telephone advisory service, responding to requests for clinical advice from those working with women at risk. The service was proactive and engaged in considerable preventative work and awareness raising in respect of the needs of women with perinatal mental health needs. The service used a range of creative methods to engage and support women using the service. This included the effective use of video recording both as a diagnostic and therapeutic tool and use of information technology to reach more women at risk of perinatal mental ill-health. The service had analysed the patient population and compared this with the make up of the local community population in order to identify underrepresented groups of women in terms of use of the service. Plans were in place to raise awareness of perinatal mental health issues and the perinatal service, targeted at the groups/communities identified. The service was exceptionally well-led at a local level and there was a strong culture of innovation and continuous improvement. 8 Perinatal services Quality Report 25 February 2015

9 Southern Health NHS Foundation Trust Perinatalal services Detailed findings Locations inspected Name of service (e.g. ward/unit/team) Melbury Lodge mother and baby unit and perinatal community team Name of CQC registered location Melbury Lodge Mental Health Act responsibilities There were no women detained under the Mental Health Act 1983 at the time of our visit to the service. Mental Capacity Act and Deprivation of Liberty Safeguards Staff understood the Mental Capacity Act 2005 and how it applied to their day to day work. There had been no applications made in respect of Deprivation of Liberty Safeguards. All women on the unit on the day of the inspection were admitted informally. Women we spoke with understood their rights, including their right to leave the unit. Some restrictions were in place in respect of some of the babies on the ward in line with their child protection plan. Staff were aware of these restrictions as were mothers to whom this applied. 9 Perinatal services Quality Report 25 February 2015

10 Are services safe? By safe, we mean that people are protected from abuse* and avoidable harm * People are protected from physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse Summary of findings There were excellent processes in place to ensure that women and their children were safeguarded against possible harm. Staff at all levels told us how learning from incidents had been incorporated into ensuring safe care was provided. There were sufficient staff available to ensure that women were cared for safely and their needs could be met. Our findings Track record on safety Perinatal service had a good record on safety. Safety issues affecting mothers and babies were clearly discussed in the handover between shifts on the unit. Community and inpatient staff knew how to recognise and report incidents. Learning from incidents Staff at all levels told us about learning from incidents that had occurred in the service and described how lessons had been learned from these. Action plans had been put in place following investigations of incidents and these had been implemented to bring about improvements in care and treatment and to prevent a reoccurrence. Staff received information from the Trust about incidents that occurred in other services and these were discussed with the perinatal team. The outcomes of serious case reviews related to other mother and baby units and perinatal services nationally were used to identify learning for the service. The unit social worker had attended a serious case review forum the day before our visit and there were plans to share learning from this meeting with the whole team. All incidents and complaints were reviewed by the service manager who considered whether and/or what changes needed to be made to the service to increase safety and effectiveness. Safeguarding There were excellent processes in place to ensure that women and their children were safeguarded. There was a safeguarding lead based in the community team who could 10 Perinatal services Quality Report 25 February 2015 be contacted for advice. Staff knew who they were and how to contact them. Staff understood how to recognise and report safeguarding concerns. There was a flow chart on display which supported staff in the event they needed to make a safeguarding referral. We observed that safeguarding issues were discussed in detail during the handover from one shift team to another. Staff were made aware of concerns and knew about restrictions in place in respect of babies and possible visitors to the unit. This helped keep women and babies safe. Senior staff in the service and the safeguarding lead had completed safeguarding training at level 5. The safeguarding lead provided supervision to staff once a month which allowed them to raise concerns and questions and ensured that safeguarding remained a priority for staff throughout all aspects of their work. Mothers we spoke with told us they felt very safe on the unit and were confident in the care provided to their babies. Staff carried out 15 minute checks on all babies at night to ensure they remained safe and well. Medicines were managed safely. We saw they were securely stored on the ward and medicines requiring cold storage were kept in the drugs fridge. Fridge temperatures were checked regularly to ensure medicines were kept at the correct temperature and remained fit for use. We noted that when a refrigerator had given a higher than normal temperature reading this had been promptly referred to the pharmacist who checked that the medicines affected were safe to use. Prescribing and administration records were held electronically and were accurate and up to date. All allergies had been recorded. Up to date information on medicines was available to staff on the ward including information on children s medicines and breast feeding guidance. All prescriptions for babies, excluding common medicines, were completed by a consultant paediatrician. This ensured that medicines prescribed and administered to babies on the ward were appropriate and safe. Women told us that their medicines had been explained to them, including possible side-effects. Leaflets about medicines were also provided for women to refer to when they wished.

11 Are services safe? By safe, we mean that people are protected from abuse* and avoidable harm Staff knew and understood the ligature risks in the environment. For example, there was a bedroom that was equipped for women with disabilities that had known ligature risks. As a result women were risk assessed before being allocated to the room. One to one observations of women were used when the level of risk was judged to be high. The service had infection prevention and control policies in place and a senior manager explained how a recent outbreak of diarrhoea and vomiting had been managed safely and effectively. The ward had been closed to new admissions during the outbreak. After investigating the cause of the outbreak an action plan was developed and implemented in order to improve procedures and reduce the likelihood of a reoccurrence. Assessing and monitoring safety and risk There were sufficient staff available to ensure that women were cared for safely and their needs could be met. There was a very low turnover of staff on the ward and few vacancies arose. Babies were cared for by trained child care practitioners. There were individual risk assessments in place for all women and babies which were discussed at the handover. Any known risks were clearly handed over to the on-coming team. Potential risks Senior managers were aware of potential risks to the service and planned ahead to address these. For example, increasing numbers of women were being referred to the community service as awareness of the service and risks of perinatal mental illness to women grew. In order to address this the service was exploring new and creative ways to meet their needs. 11 Perinatal services Quality Report 25 February 2015

12 Are services effective? By effective, we mean that people s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. Summary of findings The needs of women and their babies were assessed and care and treatment planned and delivered in accordance with identified needs and risks. Staff had the skills necessary to deliver effective delivery of care and treatment. There was excellent multi-disciplinary team work in evidence and effective working with external partners. Our findings Assessment and delivery of care and treatment Women we spoke with were very happy with the care provided to their babies. For example, one woman said, staff have really got to know my baby well too and she is very happy. Another woman told us staff seem to know exactly what to do for my baby. She was relieved that her baby was being well cared for. Staff were aware of and implemented evidence based care and treatment. Staff told us that about 30% of women were breastfeeding their babies. Breastfeeding was actively supported by staff. In addition staff would ensure babies were bottle-fed when it was considered particularly important for the mother to sleep undisturbed. Women told us that planned activities usually took place although there were times when they were cancelled because staff were very busy. One woman described it as disheartening when the activities did not run as planned. Several women described taking part in sewing activities in the evenings which they particularly enjoyed. Attempts were made to provide activities that were fun for the babies too. The needs of women and their babies were assessed and care and treatment planned and delivered in accordance with their assessed needs and identified risks. Wellness recovery action plans (WRAP) had been developed especially for mothers and also for their babies. Women told us they had been involved in the development of care and WRAP plans as well as crisis and contingency plans. There was an intensive support programme in place which included a number of short courses such as emotional coping skills and being a compassionate friend. Women could continue to attend and complete a course after they had been discharged to the perinatal community team. Staff and women using the service described the intensive support programme as very helpful. The delivery of care included the use of video cameras to give visual feedback to women on their interactions with their baby. One woman who had used this method told us it had been a very valuable experience and had enabled her to feel more positive about her own skills as a mother and her ability to bond with her baby. She said she had been able to recognise the connection between herself and her baby when watching a replay of their interaction and this had increased her confidence as a mother. Staff told us this was a powerful and effective approach which had led to better diagnoses and treatment as well as providing a useful therapeutic tool. Women described feeling more able to care confidently for their babies because of the support and input from staff. Outcomes for people using services The service was accredited by the Royal College of Psychiatrist s Quality Network for Perinatal Mental Health Services. A review of the community team had been carried out in July Although the report of the review was still in draft staff told us it had been very positive and had provided useful suggestions for improvements to the service, some of which were already being acted upon. In February 2013 the mother and baby unit had scored 100% in all but one area assessed (environment and facilities 98%) following a review by the Quality Network for Perinatal Mental Health Services. The perinatal service had been named psychiatric team of the year at the national Royal College of Psychiatrists (RCPsych) Awards The consultant psychiatrist was involved in developing standards of care at a national level and leading international conferences on perinatal mental health care and treatment. The service was piloting perinatal patient reported outcomes measures (PROMs) as part of a national initiative. The pilot had been running for a year and results were being reviewed to enable changes in the perinatal PROMs to make them more effective. It was hoped that the introduction of the PROMs would allow benchmarking of perinatal services nationally. Feedback questionnaires were given to women, their partners and to other professionals to complete in order to 12 Perinatal services Quality Report 25 February 2015

13 Are services effective? By effective, we mean that people s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. develop any understanding of how the service was experienced by people. Analysis of responses helped identify where improvements could be made to service delivery. Staff skill Staff had the necessaty skills to provide safe care to women and babies. Staff in both the in-patient service and community team told us good opportunities were available to improve their knowledge and skills. Senior managers were supportive of further professional development. All nursing and support staff completed a two day breastfeeding course to enable them to support women to breast feed their babies. Staff told us they had been on a range of training courses including in Wellness and Recovery Action Plans (WRAP) and dialectical behaviour therapy (DBT), a therapy designed to help people change patterns of behaviour that are not effective. All staff received training in basic life support or intermediate life support as well as baby resuscitation and the early signs of labour and delivery. Staff had undertaken specialist training in the field of perinatal mental health. Most specialist training was sourced outside the Trust. Staff said they were generously funded for conferences. The consultant psychiatrist was supported to attend meetings with their peer group and keep abreast of recent innovations and developments in the field. There were effective systems in place to support one to one and group staff supervision. Staff could request additional supervision at any time and this was responded to promptly. Staff confirmed they received regular one to one clinical and managerial supervision, and took part in regular reflective practice groups. Women told us that staff appeared very well trained and they felt very confident in their skills. Child care practitioners in particular were described as very skilled and knowledgeable. Multi-disciplinary working Services were provided by a multi-disciplinary team including nurses, psychologist, social worker, child care practitioners and medical staff. Although there was not an occupational therapist (OT) attached to the team, an OT could be brought in to conduct specific assessments as required. The psychologist had trained in family therapy and provided therapy on the unit where appropriate. There were plans in place to recruit a dedicated perinatal OT. Staff told us that team members were respectful of each other s different roles. There was a full time child care practitioner in the community team. They particularly helped women who were experiencing difficulties in parenting and in bonding with their child. The child care practitioner worked closely with the in-patient perinatal service and followed up women at home after discharge. There was effective communication and working between the ward and the community team. The service had access to a breast-feeding counsellor from the local maternity service. Women told us they appreciated being able to obtain information and reassurance on a range of topics including feeding and weaning their babies. In addition the service had close links with the paediatric ward at the local hospital, which was located next door to the unit. There was a service level agreement with a paediatrician who provided support and treatment for babies on the unit. There were also effective links with midwives and health visitors who came to see women on the unit. A health visitor came to the ward every week to see the babies on the unit. Contact was made with health visitors prior to high risk women giving birth to ensure they were alerted to their needs. The team had close links with social services. Women told us that health professionals involved in their care worked well together. One person told us everybody (professionals involved in her care) seems to work together. Staff told us that the perinatal in-patient and community service were the most integrated they had ever been. Joint working with other agencies and services was described as a real strength of the perinatal services. The perinatal team offered support and advice to other teams for example, substance misuse services, community mental health teams and GPs. The child care practitioner worked jointly with children s centres, developing support networks. Women felt involved in the discharge process and said this was discussed with them early in their admission and often throughout. Women said they knew what to expect on discharge and the follow-up care that had been arranged 13 Perinatal services Quality Report 25 February 2015

14 Are services effective? By effective, we mean that people s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. for them. One woman said, I don t feel rushed out the door, which was reflective of other women s comments. Women who lived locally could be supported at home by the perinatal community team. The transition between hospital and home for these women was usually smooth. Information and Records Systems There was an effective handover of information between staff teams. We observed the lunchtime handover on the unit. Pertinent information about the women was shared with on-coming staff. The handover included information about women s physical as well as mental health, any safeguarding concerns, risks affecting women and babies and with whom information could be shared based upon the woman s agreement and consent. A child care practitioner handed over information about all the babies staying on the unit in order to ensure their continuing needs were met. The child care practitioner had developed a resource folder to support all staff in the team locate support services for women and babies in the community. Consent to care and treatment Women were asked for their consent to any treatment provided. Women we spoke with told us they were encouraged to take part in activities and groups but were never bossed around. Assessment and treatment in line with Mental Health Act There were no women detained under the Mental Health Act 1983 on the unit on the day of our inspection. 14 Perinatal services Quality Report 25 February 2015

15 Are services caring? By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect. Summary of findings Women were treated with dignity and respect and their privacy was maintained by staff. Staff talked about people using the service respectfully and showed genuine compassion. Women were actively involved in their care. Excellent support was offered to fathers, families and friends. Our findings Dignity, respect and compassion We spoke with several women using the service. They told us they were treated with dignity and respect and their privacy was maintained by staff. During the shift handover we observed that staff talked about people using the service respectfully and showed genuine compassion. Women told us that the housekeeping staff were very much part of the team and that nothing was ever too much for them. They were described and kind and caring. Some women preferred not to have a male nurse assigned to them. Where this happened the service tried hard to accommodate the woman s wishes. Photographs of staff on duty on each shift kept women informed as to who was caring for them. We were told of many examples of the kindness and consideration of staff. One woman, who wrote to us during the inspection, told us they had turned up at the unit in the middle of the night as they did not know where else to go for help. She went on to describe her reception by staff: from the moment the staff opened the door I was so overwhelmed by their professionalism and kindness they immediately looked after me and were incredibly reassuring. Involvement of people using services Information leaflets were available for women using the service on a range of relevant topics such as advocacy, smoking cessation and immunisations for babies. There was a noticeboard on the unit dedicated to the provision of information to support fathers. Women said they had been encouraged to help develop their own care plans and everyone we spoke with said they had been given a copy. They all said they felt involved in their care and treatment and in the care provided to their baby. Emotional support for people Staff provided strong support for fathers, family members and friends. Visiting times could be flexible which helped visitors who travelled long distances. We observed that staff spoke compassionately about the needs of fathers during the lunchtime handover between shifts. Women said there was good support for and liaison with families. A woman who wrote to us about the service said, myself, my husband and other family were given lots of opportunity to discuss the care we were receiving and I was really impressed with how supported my family felt too. One woman who had been observed on a one to one basis for part of her stay told us that she had never felt judged by staff and staff assigned to be with her had tried to speak to her at a really horrible time, which she had really appreciated. Another woman told us that the support of staff had made a massive difference. Women felt that they were at the centre of their care. When on leave at home women said they had been reassured to have staff available to talk to over the telephone. Women believed that staff genuinely wanted to do their best for the mothers on the unit and provided good care to the babies. 15 Perinatal services Quality Report 25 February 2015

16 Are services responsive to people s needs? By responsive, we mean that services are organised so that they meet people s needs. Summary of findings The service was committed to increasing the awareness of all health professionals of perinatal mental health problems. The service was actively involved in preventative work and was responsive to the needs of the local community. There was a seamless transfer of care of women between the in-patient and community teams that enabled women to remain in contact with staff who supported them and helped provide continuity of care. Referrals to the service were prioritised according to needs and risks and responded to promptly. Our findings Planning and delivery of services The service was committed to increasing the awareness of all health professionals of perinatal mental health and illness and the support available from the service. The community team was involved in preventative work and provided training to a range of health professionals and voluntary sector groups. It was hoped that raising awareness amongst professionals would lead to increased early detection and prevention of relapse in high risk women. Staff delivered training on perinatal mental health to midwives and trainee midwives on a regular basis. Child care practitioners were actively involved in preventative work with women. The service was aware of the birth rate in the catchment area and estimated the number of women who may be affected by post natal mental ill-health based on known population prevalence. This made it possible to predict the future needs of the service in terms of resources. A telephone clinic had been developed as a way of meeting the needs of more women as referrals to the community service had risen considerably. All referrals to the team were triaged and if possible women were responded to over the telephone. Staff told us there was a lot of satisfaction from women receiving a service in this way. The co-location of the in-patient unit and the community perinatal team was beneficial and encouraged a seamless transfer of care of women between the teams and enabled women to remain in contact with staff who supported them in the community and helped provide continuity of care. The average length of stay in the unit for women was 30 days, although it was often much shorter particularly for local women who could be supported at home by the perinatal community team. Diversity of needs A pictorial version of the welcome pack for women admitted to the in-patient unit had been developed as a way of sharing information with women who may have had difficulty reading and concentrating or did not have English as a first language. Information could be translated into different languages when needed. We saw an example of information that had been translated into Slovakian to meet a woman s language needs. Interpreters were also available on the telephone and could attend ward rounds and other important meetings where assistance was need with communication. Staff described how they blended therapeutic groups and spirituality to provide a more holistic approach to working with some women. Some pilot groups had been running combining mindfulness and spirituality in the approach, which had gone well. The service had carried out a review of the ethnicity of people using the in-patient service and compared the breakdown with that of the local population, as reported in the 2011 census, and the ethnicity of people using the services of the community perinatal team. From the results the team identified that less women of south Asian origin and from the gypsy/traveller community were users of the perinatal services provided. The service had plans in place to contact a local Asian radio station to discuss ways of making people from the south Asian community aware of perinatal mental ill-health and perinatal services. In addition there were plans to link with a health visitor working with the gypsy/traveller community in order to explore ways of accessing women at risk. The service had recognised that the ethnicity of women using the service was not always being recorded by staff, particularly in the community team. The electronic records system used did not make it particularly easy to record some of the required information. Staff were being reminded of the importance of recording this information so that the service could identify any gaps in the service they were providing. 16 Perinatal services Quality Report 25 February 2015

17 Are services responsive to people s needs? By responsive, we mean that services are organised so that they meet people s needs. The service had a cultural considerations booklet that had been produced for staff that included information on the belief and practices of different faiths and provide staff with useful knowledge. Right care at the right time Referrals were prioritised according to needs and risks. The agreed response target time was seven weeks but the service tried to respond to people more quickly. Women who developed mental ill-health shortly after birth could be seen promptly in an emergency. Women were initially triaged by telephone and then prioritised on a case by case basis. Urgent needs were prioritised. Women we spoke with said they had had prompt access to the service and were admitted when they needed to be. The service responded to 100% of referrals to the community team. The manager and staff told us that referrals to the community team had doubled in the last two years. Some of the increase was as a result of effective awareness raising in respect of perinatal mental health issues with other health professionals and the increasing profile of the service. Staff were developing creative and innovative ways of responding to the increase in referrals such as the increasing use of telephone contact and development of on-line face to face contacts. Learning from concerns and complaints We saw that information on how to make a complaint was given to women on admission to the unit as part of the welcome pack. In addition there were complaints leaflets available on the ward and details of how to contact the Patient Advice and Liaison Service (PALS), who could support people to make a complaint. Staff provided examples of learning and improvements made following complaints. For example, changes had been made to the type of activities provided to women on the unit following complaints that there was not enough to do. Women we spoke with who had raised issues of concern with staff said they had been responded to promptly and to their satisfaction. Others told us they had no concerns about their care and treatment but would feel confident raising concerns if they wanted to. 17 Perinatal services Quality Report 25 February 2015

18 Are services well-led? By well-led, we mean that the leadership, management and governance of the organisation assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture. Summary of findings The service was very well led. Governance arrangements supported the delivery of high quality safe, effective, caring and responsive services to women and their babies. Staff were supported to be creative and innovative in their approach to meeting women s needs and extending the reach of the service. The service engaged in national initiatives in order to drive forward improvements. There was a strong culture of innovation and continuous improvement. Our findings Vision and strategy The service worked proactively with others both inside and outside the organisation to improve access to appropriate and effective care and treatment for women at risk of developing mental ill health after childbirth. Staff were clear about the vision and values of the service. Governance There was an effective system in place in place to assess and monitor current and future risks. Governance arrangements supported the delivery of high quality safe, effective, caring and responsive services to women and the babies. The service worked in an almost seamless way ensuring the safe transition of women from the community to in-patient unit and back home again. Senior staff felt supported by the Trust s governance structures. Being part of an integrated Trust was viewed as helpful to the service as it enabled better partnership working with other health professionals and teams across the Trust. The service carried out a range of audits of practice as a way of ensuring that Trust policies and procedures were being followed. Not all Trust audits were considered particularly relevant for the service but they were able to omit those that were not relevant. Where shortfalls were identified through audits these were addressed. Leadership and culture The service manager had the necessary skills, knowledge and experience to lead an effective team. All staff were knowledgeable about the needs of people using the service and looked more broadly at ways of meeting the 18 Perinatal services Quality Report 25 February 2015 needs of people who were not currently using the service. Staff were supported to be creative and innovative in their approach to meeting women s needs and extending the reach of the service. The service engaged in national initiatives in order to drive forward improvements. Women using the service told us that managers were highly visible on the unit and this was reassuring to them. Engagement with people and staff There were high levels of satisfaction across all staff working in the service. There was a low turnover of staff and low rates of sickness absence. Student nurses told us that the mother and baby unit was a highly popular placement. Staff we spoke with told us it was a brilliant place to work. A student nurse on placement with the team described the service as a good learning environment. They felt able to voice the opinions and said that alternative views of team members were actively encouraged and discussed. Letters were sent directly to women following assessments, explaining the outcome and any advice. GPs and other referrers were copied into the letters rather than being written to directly. Staff told us this had increased women s satisfaction with the service. There was evidence of learning from feedback received from people who used the service and professionals who referred women to the service via satisfaction questionnaires. Responses were analysed and areas for improvement identified and acted upon. The perinatal service had supported the formation of a support group of mothers who had experienced or were experiencing mental health problems during the perinatal period, called the Hampshire Lanterns. The women offered peer support to women experiencing similar problems. Continuous Improvement There was a strong focus on continually learning and improving the service at all levels. Staff on the in-patient unit told us there were regular discussions about quality improvement that included all of the team. The community team met monthly to discuss quality improvements. For example at a recent meeting staff discussed how they could improve their knowledge of medicines and keep up to date with recent developments.

19 Are services well-led? By well-led, we mean that the leadership, management and governance of the organisation assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture. There was a strong culture of innovation and continuous improvement. As a way of increasing the accessibility of the service and responding to women who were not comfortable in using the telephone the community team was looking into ways of communicating with women face to face via the computer. The women who wished to communicate with staff in this way would be able to download the particular package onto their own computer and communicate directly with perinatal staff. The service was proactive in thinking about new ways of working that would increase the quality of service provided to women. 19 Perinatal services Quality Report 25 February 2015