SASH progress against the CNST incentive scheme maternity safety actions

SASH progress against the CNST incentive scheme maternity safety actions Trust Board in public Date: 28 th June 2018 Agenda item: Executive sponsor Report author(s) Des Holden Medical Director Bill Kilvington AD WACH Michelle Cudjoe DCN and Head of Midwifery WACH Report discussed previously: (name of subcommittee/group and date) WACH Divisional Board 8 th June 2018 Executive Committee 13 th June 2018 Action required: Approval ( ) Discussion ( ) Assurance ( ) Purpose of report: For 2018/19 the Clinical Negligence Scheme for Trusts (CNST) introduced an Incentive Scheme for Maternity Safety Actions. The scheme offers a financial rebate of up to 10% of the maternity premium for Trusts that are able to demonstrate progress against a list of ten safety actions. The annual CNST Premium for maternity services at SASH is 4m. The attached Board Report and supporting evidence is presented to the Board to demonstrate the Trust s progress against the ten safety actions Page 1 of 19

The report template requires sign-off by the Board that it is satisfied that the evidence provided to demonstrate compliance/achievement of the maternity safety actions meets the required standard and that the self-certification is accurate The Board agrees that any reimbursement of CNST funds will be used to deliver the actions referred to in Section B of the report. Summary of key issues The maternity service is unable to declare compliance with two of the ten required actions. Action six; Savings Babies Lives care bundle. One of the 4 elements requires the use of CO Monitoring to aid smoking cessation and this is not yet in place. The 4 th element relates to effective fetal monitoring during labour and the service has not achieved more than 75% compliance with CTG training. Action eight; 90% of each maternity unit staff group to attend multiprofessional maternity emergencies training in the last year. Current compliance is 74% for Midwives and 63% for obstetric doctors. Anaesthetic and theatre staff must also be included and compliance among this group is low. The report details the areas of non-compliance, together with the action plan to achieve compliance in the current financial year. Recommendation: That the Board reviews the evidence included with this report and signs-off the Board Report as an accurate representation of the Trust s level of compliance with the ten CNST incentive scheme maternity safety actions. The signed report will be submitted to NHS Resolution on the 29 th June, being the deadline. Relationship to Trust strategic objectives and assurance framework: SO1: Safe Deliver safe, high quality care and improving services which pursue Page 2 of 19

perfection and be in the top 25% of our peers SO3: Caring Work with compassion in partnership with patients, staff, families, carers and community partners SO4: Responsive To continue to be the secondary care provider of choice for the people of our community SO5: Well led To be a high quality employer of choice and deliver financial and clinical sustainability around a patient centred, clinically led leadership model Corporate impact assessment Legal and regulatory impact Compliance with NHS Resolution CNST incentive scheme maternity safety actions. NHS Resolution expect trust Boards to selfcertify the Trust s declarations following consideration of the evidence provided. Where subsequent verification checks demonstrate an incorrect declaration has been made, this may indicate a failure of board governance which the Steering group escalate to the appropriate arm s length body/nhs System leader Financial impact The Trust does not comply with two of the ten actions so will not achieve the maximum rebate ~ 400k. The value of rebate that will be achieved to be determined by NHS Resolution, on the understanding that this is reinvested into the maternity safety action plan, as required by the declaration. Patient experience/engagement Compliant with Standard seven patient feedback mechanisms in place. Risk and performance management NHS Constitution/equality and diversity/communication Full compliance with eight of the ten safety actions and action plans in place for the remaining two actions. N/A Page 3 of 19

Attachments Evidential appendices 1-19 as listed in Section D of the report Page 4 of 19

Board report on Surrey & Sussex Healthcare NHS Trust progress against the Clinical Negligence Scheme for Trusts (CNST) incentive scheme maternity safety actions Date: 28 th June 2018 SECTION A: of Trust s progress against 10 safety actions: Please note that trusts with multiple sites will need to provide evidence of each individual site s performance against the required standard. Safety action please see the guidance for the detail required for each action 1). Are you using the National Perinatal Mortality Review Tool (NPMRT) to review perinatal deaths? of Trust s progress Please refer/ append all relevant evidence to demonstrate the Trust s progress against this action as per the guidance document. NHS Resolution will also use data from MBRRACE to verify the Trust s progress against this action. The aim of the PMRT programme is introduce the PMRT to support standardised perinatal mortality reviews across NHS maternity and neonatal units in England, Scotland and Wales. The department has registered to use the NPMRT tool and has uploaded the review of perinatal deaths which have occurred in May and June 2018 PMRT are completed as part of an MDT process. Action met? (Y/N) Yes Page 5 of 19

2). Are you submitting data to the Maternity Services Data Set (MSDS) to the required standard? 3). Can you demonstrate that you have transitional care facilities that are in place and operational to support the implementation of the ATAIN Programme? PMRT information Appendix Please refer/ append all relevant evidence to demonstrate the Trust s progress against this action as per the guidance document. The Trust meets this Standard of a minimum of 8 out of the 10 criteria. Confirmation of compliance from NHS Digital is appended as evidence. Please refer/ append all relevant evidence to demonstrate the Trust s progress against this action as per the guidance document. NHS Resolution will cross-check trusts self-reporting with Neonatal Operational Delivery Networks to verify the Trust s progress against this action. The Neonatal Unit has a three bedded Transitional Care Unit that is separate from the main unit. The unit has a separate milk kitchen and small kitchen area for mothers to make drinks and snacks. Mothers and babies are supported by a Band 4 Nursery Nurse and the Nurse in Charge of the Neonatal Unit. Additionally the Neonatal Unit has two side rooms for the exclusive use of parents and babies rooming in. Transitional Care is also provided in the postnatal clinical setting for babies requiring intravenous antibiotics as additional care requirements. This is a Yes Yes Page 6 of 19

4). Can you demonstrate an effective system of medical workforce planning? multidisciplinary approach whereby the mother and baby are cared for by maternity staff and a neonatal nurse attends to deliver intravenous antibiotics. The Neonatal Unit also provides a Community Outreach Service for those babies who identify for this care as specified in the Neonatal Outreach Service visits policy/guidelines. Occupancy data for 2017/2018 extracted from the BadgerNet Database Policy for early discharge to neonatal outreach care Please refer/ append all relevant evidence to demonstrate the Trust s progress against this action as per the guidance document. This should include reference to the Royal College of Obstetricians and Gynaecologists (RCOG) workforce monitoring tool template The Trust actively monitors demand and capacity across obstetrics and gynaecology. In 2017/18 the Trust funded an additional 2 wte Consultant Obstetricians and Gynaecologists in response to rising demand. The Trust completed the RCOG workforce monitoring tool and submitted this in April 2018. It is very rare for consultants to have to act down into the registrar role, normally as a result of short notice sickness absence. Completed workforce template The confirmation email from the RCOG Yes Page 7 of 19

5). Can you demonstrate an effective system of midwifery workforce planning? Please refer/ append all relevant evidence to demonstrate the Trust s progress against this action as per the guidance slides. Midwifery In 2016 /17 The Head of Midwifery conducted a midwifery workforce review based on a previous Birthrate + desktop review and incorporating NICE Standards and recommendations. The 2016/17 review indicated that the then current midwifery establishment did not consistently allow for supernumerary status of the Labour Ward Shift Leader and as such the unit was non-compliant with NICE Guideline 4 in this respect. The Trust acknowledged that the ratio of midwives to births is lower than benchmarks and agreed actions to improve the position. The local review resulted in executive approval for a 3 year plan to improve the ratio of midwives to births to the then national average of 1:30 from the Trust ratio of 1:33 at that time. In year one the Head of Midwifery prioritised expanding the midwifery triage hours as this was deemed to be the greatest area of risk. Year two (18/19) has prioritised improving compliance with a supernumerary labour ward shift leader. Next year s allocation has been earmarked for improving the home birthing team. The workforce review has subsequently been refreshed in 17/18 and again in 18/19 against activity levels. As a full Birthrate + analysis had not been undertaken in recent years and given the changes in complexity of women being cared for locally, the Head of Yes Page 8 of 19

Midwifery has commissioned a full Birthrate + review and commenced the w/b 18 th June 2018. The outcome of this review will inform the Head of Midwifery s annual workforce report. The 16/17 Midwifery Workforce Review Annually validated midwifery workforce calculations Executive team report May 2017 midwifery ratios Neonatal Nursing Neonatal nursing workforce requirements are calculated annually using the DH Toolkit for High Quality Neonatal Services. This provides the wte required to meet service demand based upon the daily levels of care. This is added to a locally produced workforce calculator that takes into consideration the ratio of registered to unregistered staff and the percentage of registered staff that are Qualified in Speciality, in line with the Toolkit Standards. The 2017 Toolkit calculation NNU Nursing Plan for Annual Report- BAPM 2011 Numbers Page 9 of 19

6). Can you demonstrate compliance with all 4 elements of the Saving Babies' Lives (SBL) care bundle? Please refer/ append all relevant evidence to demonstrate the Trust s progress against this action as per the guidance document. NHS Resolution will cross-check trusts self-reporting with NHS England. The 4 elements and level of compliance are; 1. Reducing smoking in pregnancy Not compliant at this time but procurement of CO Monitors is taking place in June 18 to achieve full compliance. 2. Risk assessment and surveillance for fetal growth restriction Compliant and personalised growth charts are embedded in practice. 3. Raising awareness of reduced fetal movement Compliant 4. Effective fetal monitoring during labour Not Compliant. Currently only 75% compliance with CTG training and competency assessment rates need to improve. SBL self reporting tool submitted to NHS England Surveillance audit of FGR No Page 10 of 19

7). Can you demonstrate that you have a patient feedback mechanism for maternity services, such as the Maternity Voices Partnership Forum, and that you regularly act on feedback? Please refer/ append all relevant evidence to demonstrate the Trust s progress against this action as per the guidance document. The department holds bi-monthly meetings with an established MVP forum (previously the Maternity Services Liaison Committee). Prior to each meeting the MVP collates feedback from service users using a structured questionnaire. This is fedback to the wider forum. Trust Midwifery Managers represent the Trust on Positive Birth Movements (PBM), and actively engage with service users via Facebook page and twitter. The service provide a listening service known as Birth Reflections providing women and their families with an opportunity to feedback and discuss their birth experience. A midwifery matron is available on a daily basis to address live concerns and promote the Don t take your troubles home service Actions logs from complaints are reviewed and monitored at Divisional Board meetings. In addition, the Lay Chair of the MVP is a member of the Divisional Governance Board and attends Governance Meetings. The Lay Chair also fulfils the role of Patient Representative on the Neonatal Unit Capital Expansion Project Group which is responsible for the design and delivery of the Neonatal Unit Expansion capital project. The Matron for Neonatal Services and AD updated the MVP on the plans at their meeting on the 29 th May 2018. Yes Page 11 of 19

8). Can you evidence that 90% of each maternity unit staff group have attended an 'inhouse' multi-professional maternity emergencies training session within the last training year? Minutes of the MVP (MSLC) Meeting Neonatal Expansion Project Working Group Structure Please refer/ append all relevant evidence to demonstrate the Trust s progress against this action as per the guidance document. This should include completion of a local training record form. The maternity department runs a mandatory and statutory training week on a monthly basis 11 months of the year (no training in August), held in our training room in the maternity department. This training week includes a full multi-professional training day comprising simulated emergencies, fetal monitoring, skills workshops, human factors training and integrated group work. The simulation obstetric anaesthetic leads are part of the faculty for the simulations and debriefs. The content of this training day is continually reviewed in relation to the latest evidence and recommendations, feedback from the patient safety team and the participants evaluation of the training. The programme is reviewed and changed on an annual basis to ensure equitable training is made available to all staff throughout the training year and that we are using case scenarios relevant to local audit findings and risk issues. No The maternity department is committed to running regular in-situ maternity simulations which include all maternity unit staff groups. At present midwives and obstetric doctors (including consultants and trainees ST3 and above) attend our multi-professional day. Page 12 of 19

In the rolling 12 month period 74% midwives and 63% obstetric doctors attended the Multidisciplinary Emergency training day Multiprofessional Training Action Plan (Draft) 9). Can you demonstrate that the trust safety champions (obstetrician and midwife) are meeting bi-monthly with Board level champions to escalate locally identified issues? Please refer/ append all relevant evidence to demonstrate the Trust s progress against this action as per the guidance document. The Trust complies with this safety action in that at least bi-monthly meetings take place between Head of Midwifery, Lead Clinician for Obstetrics and Gynaecology and the Medical Director and Chief Nurse. The Trust s formal governance structure supports this action through Divisional Performance Review Meetings; the Clinical Effectiveness Committee; and the Safety and Quality Committee. At each of these, maternity service performance and safety and quality issues are regularly discussed and reviewed. Additionally, there are regular meetings with the Lead Clinician; Head of Midwifery; Medical Director and Chief Nurse. This review process has highlighted that the evidence or these individual meetings is weak in that the meetings do not follow a set agenda and are not minuted. The Medical Director and Chief Nurse will affirm compliance to the Board and commit to ensuring that going forward meetings are recorded. The first recorded meeting took place on the 15 th June. The record shows an Yes Page 13 of 19

10). Have you reported 100% of qualifying 2017/18 incidents under NHS Resolution's Early Notification scheme? example of the type of discussions that take place. Maternity Safety Champions Meeting Record Template 15 th June Please refer/ append all relevant evidence to demonstrate the Trust s progress against this action as per the guidance document. NHS Resolution will also use data from the National Neonatal Research Database to verify the Trust s progress against this action. All cases meeting the criteria have been reported to NHS Resolution s early notification scheme. NHS Resolution referral confirmations x 5 Yes Page 14 of 19

SECTION B: Further action required: If the Trust is unable to demonstrate the required progress against any of the 10 actions, please use this section to set out a detailed plan for how the Trust intends to achieve the required progress and over what time period. Where possible, please also include an estimate of the additional costs of delivering this. The National Maternity Safety Champions and Steering group will review these details and NHS Resolution, at its absolute discretion, will agree whether any reimbursement of CNST contributions is to be made to the Trust. Any such payments would be at a much lower level than for those trusts able to demonstrate the required progress against the 10 actions and the 10% of the maternity contribution used to create the fund. If made, any such reimbursement must be used by the Trust for making progress against one or more of the 10 actions. SAFETY ACTION ACTION PLAN COST 18/19 COST 19/20 5. Midwifery Workforce Planning Although the Trust is compliant with this action the midwifery workforce review in 16/17 highlighted that the ratio of midwives to births was below national benchmarks and a 3 year phased plan to improve the ratio was put in place. The last major workforce review against the Birthrate + standards was presented to the Board by the Head of Midwifery in 16/17. An external assessment has been commissioned this year. a) The Trust has 3 year strategy for improving the ratio of midwives to births to the national average. Will achieve 1:31 this year = 4 wte Band 6. Based upon current activity a further 4.25 wte will be required next year. b) The Trust has commissioned an external Birthrate + Assessment to take place in June 2018 c) Providing 24/7 domestic/housekeeping support to the maternity service to reduce the amount of cleaning being carried out by trained midwives and MSWs improving time to care provided out of hours = 4.1 wte Band 1 a) 184k b) 11.5k c) 82k a) 195.5k Page 15 of 19

6. Compliance with the Saving Babies Lives Care Bundle 8. Multiprofessional maternity emergencies training To improve compliance with smoking cessation programmes the Trust will equip the community midwifery teams with carbon monoxide monitors. The 19/20 cost is the revenue cost of mouthpieces, included in the 18/19 quote An action plan is being formulated to increase compliance in midwifery from 74% to 90% of all staff, with appropriate backfill to ensure training is ring-fenced as we have identified that midwives are often pulled out of training for service needs. Backfill costs are estimated at this stage. The plan will address the low percentage of obstetric medical staff participation (63%) to ensure a minimum 90% compliance is achieved for all obstetricians, including those in training Finally, it has been identified that theatre and anaesthetic staff have not routinely participated in multiprofessional training and this will also need to be addressed. The Trust s expectation for obstetric and anaesthetic medical staff is 100% compliance. Current funding for the external training provided will end this year and funding is required for 19/20 11k 1.5k a) 45k 5k Page 16 of 19

9. Safety Champions meetings. The Trust complies with Action nine in so far as regular meetings between Trust Safety Champions (midwifery and obstetrics) with Board Level Champions take place monthly. However, the evidence tor this action is weak in that the meetings do not follow a set agenda and are not minuted. From June 2018 all meeting between the Lead Clinician, Head of Midwifery, Medical Director and Chief Nurse will be documented on a standard template form. Safety Champion Meeting Record Template is appended as evidence Total financial investment 334k 202k Page 17 of 19

SECTION C: Sign-off.. For and on behalf of the Board of Surrey & Sussex Healthcare NHS Trust confirming that: The Board are satisfied that the evidence provided to demonstrate compliance with/achievement of the maternity safety actions meets the required standards and that the self-certification is accurate. The content of this report has been shared with the commissioner(s) of the Trust s maternity services If applicable, the Board agrees that any reimbursement of CNST funds will be used to deliver the action(s) referred to in Section B Position: Date:.. We expect trust Boards to self-certify the Trust s declarations following consideration of the evidence provided. Where subsequent verification checks demonstrate an incorrect declaration has been made, this may indicate a failure of board governance which the Steering group escalate to the appropriate arm s length body/nhs System leader... Page 18 of 19

SECTION D: Appendices Please list and attach copies of all relevant evidential appendices: 1. Maternity actions detailed slides for members FAQs and guidance for completing this report 2. Perinatal Mortality Review Tool 3. Confirmation from NHS Digital of Compliance with the MSDS data standard 4. Occupancy data 17/18 from BadgerNet 5. Policy for early discharge to neonatal outreach care 6. Completed medical workforce planning template 7. Confirmation from the RCOG of template submission 8. Maternity Workforce Review to the Trust Board 2016/17 9. Annually validated midwifery workforce calculations 10. Executive team report May 2017 midwifery ratios 11. DH Toolkit for High Quality Neonatal Services workforce calculator 2017 BAPM 2011 data 12. NNU Nursing Plan for Annual Report- BAPM 2011 Numbers 13. Saving babies lives care bundle self reporting tool 14. Surveillance audit of FGR 15. Example minutes of the MVP Meetings 16. Neonatal Unit Expansion Project Working Group Structure Page 19 of 19

17. Multiprofessional training action plan 18. Maternity Safety Champions Meeting Record Template Meeting 15 th June 2018 19. A- E NHS Resolution referral confirmations x 5 Page 20 of 19