Clinical Negligence Scheme for Trusts. Maternity Risk Management Standards Report of Assessment

Transcription

1 Clinical Negligence Scheme for Trusts Maternity Risk Management Standards Report of Assessment

2 Clinical Negligence Scheme for Trusts Maternity Risk Management Standards Report of Assessment at Level 2 Trust Name: The Peterborough and Stamford Hospitals NHS Foundation Trust Trust Contact: Doreen Simpson Risk & Clinical Governance Manager, Woman & Child Services Trust No: T002 Assessor: Edward FitzGerald of Visit: 9 th &10 th January 2007 Outcome: Compliance of Report: 19 th January 2007 Reassessment : No Later than January 2010 Standard Level 1 Level 2 Compliance 1. Organisation 100% 75% 2. Learning from Experience 100% 100% 3. Communication 90% 100% 4. Clinical Care 100% 100% 5. Induction, Training and Competence 100% 80% 6. Health Records 100% 100% 7. Implementation of Clinical Risk Management N/A 97% 8. Staffing Levels 100% 100% You will receive a discount from your CNST contribution for next year and will be eligible to apply for a level 3 assessment after the 1 st April Disclaimer - The comments made in this report reflect the opinions of the NHSLA risk management assessment team in relation to the standards contained in the Maternity Services manual April They should not be read as approval or comment in any other context.

3 Action Points Long-term Before a level 3 assessment, to be confident of achieving the required 90% compliance with level 2, the following points will need to be addressed: Standard 1: Organisation The maternity service can produce documentary evidence demonstrating that its strategy is being implemented and is subject to annual review. A partial score was awarded for this criterion. The Maternity Risk Management Strategy and Policy was reviewed January 2006 and is being reexamined at present, however the previous Maternity Risk Management Strategy and Policy was due for review in September 2005 and therefore was not subject to annual scrutiny. To achieve a full score within this criterion the maternity service should have an annual examination of the risk management strategy that documents the future review date and who is responsible for the process. Standard 2: Learning from Experience Standard 3: Communication There is a labour ward forum or equivalent, to ensure that there is a clear documented system for management and communication throughout the key stages of maternity care. A partial score was awarded for this criterion. The maternity service demonstrated that there is a multi-disciplinary labour ward forum. This group appears to meet the requirements of the CNST Maternity Standards and meets monthly to review all aspects of labour ward activity. This includes looking at professional (clinical) issues and organisational issues. The minutes seen demonstrate that subjects range from specific aspects of care, staff issues and organisational aspects of services. Whilst the group does comprise all of the required personnel, a partial score was awarded because the minutes of the previous twelve months failed to demonstrate regular attendance of a number of the members at the meetings including a consumer representative who has resigned. To achieve a full score in this criterion the terms of reference should be amended so that if a member cannot attend a nominated deputy is authorised to attend. The minutes should clearly demonstrate attendance of nominated deputies when this is the case. The meeting minutes of the previous twelve months should demonstrate attendance of the member, or their deputy, in a minimum of 50% of the meetings. 2

4 Standard 4: Clinical Care Standard 5: Induction, Training and Competence There is a system in place to ensure that all relevant staff participate in an annual skills drill. A partial score was awarded for this criterion Whilst the maternity service assured the assessor that they provided regular training in annual skills drills at training events, the skills drills study day, and other training sessions the evidence seen at assessment did not demonstrate that 90% of relevant staff have attended in the last twelve months. To achieve a full score at a future assessment the maternity service will need to demonstrate 90% attendance by the staff the maternity service has identified as relevant staff at the required skills drills training. This training should include: cord prolapse vaginal breech delivery shoulder dystocia antepartum haemorrhage /severe postpartum haemorrhage Ideally skills drills training should be multidisciplinary to ensure that each member of staff likely to be involved in an obstetric emergency is aware of what their responsibilities are and what is expected from his/her role in order to minimise harm to the patient. Standard 6: Health Records Standard 7: Implementation of Clinical Risk Management All clinical risk management systems are in place and operational. The evidence for the criterion is drawn from interviews with staff, and from the documentation seen in relation with other standards. Level 2 fundamentally examines the implementation and understanding of clinical risk management by staff at all levels. This criterion is one of the features that support this. The maternity service was unable to demonstrate full compliance with this criterion. Prior to a subsequent assessment the maternity service should ensure that all staff are made aware of strategies, policies and guidelines and make certain that they are available e.g. at induction, in staff newsletters, on the intranet. Standard 8: Staffing Levels 3

5 Final Comment The maternity service should be very pleased at maintaining Level 2 of the CNST Maternity Standards. It was evident at the visit that a considerable amount of work had been done in preparation for the assessment. Good practice was demonstrated throughout all of the standards and by all the staff involved in the assessment process, it was also apparent to the assessor, that everybody within the maternity service is committed to minimising risk and providing a safe service for patients. Having achieved Level 2 the maternity service may apply for assessment at Level 3 after 1 st April 2007, however in line with the current rules of the scheme the maternity service must be reassessed before the end of January An action plan is attached to this report which highlights the areas which need to be addressed prior to a level three assessment. A completed copy should be forwarded to your assessor as soon as possible, progress can then be discussed with your Assessor as necessary. 4

6 Action Plan for Achievement of CNST Maternity Risk Management Standards The maternity service can produce documentary evidence demonstrating that its strategy is being implemented and is subject to annual review. Action Plan Person Responsible There is a labour ward forum or equivalent, to ensure that there is a clear documented system for management and communication throughout the key stages of maternity care. Action Plan Person Responsible There is a system in place to ensure that all relevant staff participate in an annual skills drill. Action Plan Person Responsible All clinical risk management systems are in place and operational. 5

7 Action Plan Person responsible 6