CLCH Quality Report 2013 School Nursing 1. Summary of the service and the main features Locations The School Nursing service work across schools, health and community centres across Barnet, Hammersmith and Fulham, Kensington and Chelsea, and Westminster. Aims and Objectives The school health service is a screening, surveillance, education and support service with a strong holistic public health focus (prevention, early detection and management of poor health, as well as the development of child wellbeing). The service is available to all pupils from reception year until 19 yrs of age and their parents or carers, attending and staff employed by state schools within Central London Community Healthcare NHS Trust. The intention of the service is to monitor, improve and protect children and young people s health and to prevent illness either through the provision of direct nursing services or via health promotion. The primary objectives of the School Health Service are: To ensure optimal health and wellbeing for all children so that they may make healthier choices and achieve their maximum potential Early identification of problems to allow planned interventions and timely referral to appropriate specialist services To provide general and, when required, tailored health information to support a healthy lifestyle To provide specified and agreed health interventions in response to identified health needs To ensure that children and young people do not have unmet health needs that restrict their access to the national curriculum To support pupils, parents and staff in the management of pupils in school with specific health conditions and those requiring medication, ensuring the existence of a joint care plan and providing information and support to individual students To advise, train, and support school staff to be able to respond appropriately to student health conditions in terms of condition and medication management To meet all of the general as well as the more intensive clinical nursing needs of students attending special schools as specified in the individual health plans and personal education plans To advise and lead on matters of health protection and prevention in relation to communicable and
infectious diseases providing the school aged immunisation programme To ensure children and young people are protected from harm through robust safeguarding procedures 2. Patients at the heart of everything we do School Nurses work closely with Children and Young people providing a whole range of packages of care from Public Health promotion to large audiences to one to one intervention such as administering immunisations. In order for us to do this effectively we need to ensure that children and young people are central to our planning and service development. We need to consider the very different needs of the age range and therefore tailor care packages appropriately. These are some examples of how we have achieved this: Example of client Feedback: School Nurse led Enuresis Clinic - Child s perspective: The nurse at the clinic was really nice she spoke to me and listened to what I said, rather than speaking just to my mum. It was good to go when I was 6 as the nurse said that was the right time. It really helped being told that 3 or 4 others in the class probably wet the bed too. The nurse was nicer than the doctor. Parents perspective: The knowledge that came from the nurse was fantastic the nurse spoke to my daughter which impressed me, and she was lovely and so knowledgeable and I couldn t praise her enough. Patient stories- School Nursing has actively taken part in the CLCH patient story programme. 10 Young People and parents were consulted in relation to their experience and understanding of the School Nurse s role through undertaking Patient Stories. Areas/experiences explored included the National Child Measurement Programme (NCMP), Drop-In sessions and enuresis. Overall a very positive image of the school nurse was portrayed although some students were not fully aware of the role. Following thematic analysis of the Patient Stories recommendations have been formulated into several action plans which we have started to address. More accessible HPV Follow up clinics: Following requests by local parents to access HPV clinics in Hammersmith and Fulham, the School Health team have set up monthly catch up clinics. These run after school at two locations in the borough to allow pupils to complete their vaccinations and improve the HPV completion rates.
3. Looking back what have we done to improve the quality of the service? School Nursing applies a continuous improvement cycle approach, to how we work with our clients, families and develop service. Paramount to this is a focus on safety and clinical effective. Below are some examples of how we have achieved this. - Patient safety - a culture of being open and safe School Nursing has taken the following steps to improve patient safety in the last year: HPV- yearly update for School Nurses to maximise patient safety, Patient Group Directives -The Immunisation Specialist Nurse regularly attends the school nurse team meetings in Kensington & Chelsea to discuss Incident reports around immunisations. Incidents and near misses are discussed and safe procedures are emphasised to ensure we learn from these. All school nurses work within the guidelines described in the CLCH Patient Group Directions and attend yearly training courses to ensure their knowledge and skills are up to date and the service they provide is safe and effective. Transforming Children s Services NICE and standardisation Project We have transformed how we manage and incorporate NICE guidance into clinical practice. We have developed an extensive NICE Database which highlights relevant guidance summaries to specific services including a level of relevance and guidance graded according to level of risk, KPIs and safety ranging from 1-3 (3 = highest risk In School Nursing compliance was 33% and 63%respectively for level 3). Level 3 guidance has been prioritised and built into core contacts across School Nursing to ensure compliance. In response to this we have developed Clinical Practice standard, around 15 clinical interventions in school nursing and to support this - a robust training programme, pilot of associated tools and audit process. For example, we have developed guidance around the seamless and safe transfer of children from the Health Visiting service to the School Nursing service. This guidance is currently being piloted and is modelled on the Department of Health recommendations. Once the pilots have been completed and data reviewed, finding will help shape the final version of the guidance in the form of a Clinical Practice Standard. Clinical effectiveness - no decision about me without me School Nursing has taken the following steps to improve clinical effectiveness in the last year: The QK Pilot: Health at the Heart of School Life. This year saw completion of the three year pilot post led by school nurse. The pilot has been successful, receiving national attention and has been highlighted by the Department of Health as an example of best practice: The Central London Community Healthcare trust have piloted a full time school nurse post, in one high
need, diverse Central London secondary school in order to reach young people early, at the preventative stage. The aim is for the school nurse to be alongside the young people on their journey through puberty, towards adulthood, helping to lower barriers to education and support in all sorts of ways, their health and wellbeing. Being full time in the school enables the school nurse to be highly visible to students and more available, for drop in, organised groups and individual work. ( DH BYP Report. 23.11.2011) Outcomes for young people include increased immunisation response rate and uptake, significant reduction in the number of young people with a Child Protection Plan and the visible, confidential and accessible service that young people request. The pilot has also proved an excellent placement for SCPHN SN students, who have achieved good academic results and all moved on to Band 7 leadership roles subsequently. The CLCH School Nurse was invited to speak at the CPHVA 150 th anniversary conference, and presented at the National Child Health Conference 2012. Strengthening links with GP's Our Senior School Nurse in Hammersmith and Fulham have built strong positive links with the local GP practice. She meets with the G.P s every three months or sometimes more frequently. These meetings have promoted and strengthened the role of the school nurse in general practice and primary health care, improved communication between professionals by having a named school nurse to contact and has enabled regular liaison face to face in relation to safeguarding children. The school nurse has seen the increase in referrals from GP s to their specialist services e.g. enuresis clinic. Children and families are being appropriately supported with their identified health needs at school. The school nurse began her links into the GP surgery with the Health Visitor who already visits and attends meetings; this gives support to the whole family including siblings. HEADDSS Pilot - Westminster - Transforming Children's Services Programme A year-long pilot within selected secondary schools in Westminster with a focus on improving the delivery health care to secondary students. The HEADSS assessment covers topics relevant to the health, wellbeing and safety of adolescents; Home, Education, Eating, Activities, Drugs and Alcohol, Sexuality, Self-Harm, Suicidal Ideation, and Safety. During a HEADSS assessment, a young person has a confidential and therapeutic conversation with their School Nurse around these topics. HEADSS is a unique universal assessment with a focus on early intervention best practice assessment tool for adolescents. A cohort of students across participating schools will be invited to participate in a HEADSS assessment with their School Nurse. Staff involved in the pilot have received speciality training to effectively conduct the HEADSS assessment. Anonymous information is collected from each assessment across all areas, and this richness of data will allow us to depict trends and identify areas where more health promotion or targeted work could benefit schools and students.
The results will be shared with individual schools, and collated into a formal evaluation report to be shared with stakeholders and interested parties. The pilot has continued to gain growing interest from various groups and organisations that work with young people, and is the first of its kind within the UK. - Patient experience - you said-we did The School Nursing Service offers all patients that access the service the opportunity to return a Patient Reported Experience Measures (PREMs) so that patients can provide feedback the service they receive. There have been a total of 520 PREM responses received this year, of which 80% of patients reported their overall experience of care as good or excellent. You said We did 1. Increased accessibility in HPV clinic times 1. Evening opening Hammersmith and Fulham extended their HPV clinic's to the evening to 7pm 2. More support with diabetes within the school- A child reported patient story 3.Request for closer partnership working with School nurses and Head teachers in Westminster 2. User-led Diabetic Club at QK School: An ex-qk student agreed to be interviewed for patient stories and gave a powerful account of her experience as a young person with diabetes, first without and then with school nurse involvement. As a result of her testimony, the school nursing service arranged for all the diabetic students to get together at QK School and they have elected to form a group, meeting regularly for mutual support in school. This project is facilitated by the school nurse, liaising closely with the diabetic specialist liaison nurses at St Mary s Hospital. The young person who left school and is now an undergraduate at a London University, is coming back to school to mentor fellow diabetics within this group context. The project has full support of the QK School Senior Management and is at pilot stage 3. Individualised School health Report: The school presented with their own individualised school health report explaining the work that had been done in the school over the last year by the school health team, with statistics and results of students screening outcomes etc,
evaluation of the outcomes, and offering recommendations for the year forward. This has resulted in a fantastic working relationship with Head teachers, who are now proactively engaged in contributing the health and wellbeing of their students. The benefit of this for students is immense 4.5. School Nurse Accessibility key feature of the School Nurse call for action (DOH 2012) reflects the feedback from pupils via the British Youth council. Clear, regular communication with schools has highly improved the satisfaction of the service received along with the relationship between the school and school nurse. Regular days in school, with regular drop in times provide a reliable and accessible service for young people, their families, and school staff consultations around specific cases. This is mitigated with Child Protection meetings and immunisation programmes, however clearly communicating this long ahead of time helps to continue a smooth and effective partnership 4. School Nurse Poster: Children/students: 103 Secondary school children in several schools consulted re all the initial posters All Team Leads in School Nursing and who manage school nurses (n = 15) consulted (many with their teams) and The DH template was utilised, we adapted the Primary school poster as some topics were inappropriate to advertise i.e. smoking cessation and sexual health) and new pictures added of real-life students rather than cartoon characters the real-life children now reflect London s diversity as pointed out initially by staff and students alike 6. Healthcare plans updated in schools Updating the school health information kept on record at school about pupils with medical conditions. Attendance at school staff briefings to discuss how this would operate, and then accessed the health information parents share directly with the school (thereby avoiding any breach of confidentiality), created a database, added photos of all students so they could be easily recognised by teaching staff, and made this available to staff online, in the staff room in school, and also in the first aid area. This allows children who have health risks to be safely cared for a managed in a crisis 7. School staff requested for young people to be given 4. Young people who are distressed to be seen first
immunisations in a timely manner. 4. What resources were utilised in the process of improving quality? We have utilised various resources to improve the quality of care provided by the School Nursing service, some of the main areas include: Internet Premises Transformational Programme management team School nurse NHS careers A film crew came to QK School and filmed young people talking very positively about the service. The school nurses were then interviewed, covering why we came into school nursing and why we find it a rewarding career. NICE guidance- NICE and standardisation project: Relevant NICE Guidance and the HCP were utilised to improve quality including client and staff feedback. We also utilised audio and video recording devices and pilot project feedback. The role required protected time and so a band 7 staff member was seconded for this purpose. Audit tools: Recent order of electronic weighing scales based on research and training at the height and weight programme. Lap tops for audio and vision DOH Staff Lap tops for mobile working in schools for ease of access to records INWL additional funding for immunisation programme HF all SN have access to the school computer Social networking: Using social networking to redesign the enuresis pathway. A questionnaire with the aim of using an online questionnaire was to ensure public participation in redesigning the enuresis pathway. The service users I had approached using more traditional methods had been reluctant to speak to me, possibly due to the element of shame and embarrassment that can surround enuresis. The results showed that 80% of parents searched the internet for advice, or asked a friend and saw the GP. Only 8% would ask the school nurse. When asked where and
when they would like to be seen 29% said weekday mornings and 31% weekday evenings. With 40% wanting to be seen in a health centre and 35% in a GP surgery. 5. Top Tips Things that worked well Children s divisional Quality group This group has been established with a clear focus of bringing children s community nurses together with the explicit focus of putting quality at the heart of everything we do. Nice standardisation project: We have developed a methodology for reviewing both the current NICE guidance compliance and understanding as well as newly published guidance. We have a robust project plan which has involved developing new clinical practice standards with staff and clients and piloting new tools. Securing additional resourcing both internally and externally-projects where dedicated resources were made available were successful. For example externally funded, QK project by the DOH, School Nurse led weight management programme which obtained a grant for the Florence Nightingale institute Lessons learned: Involve frontline staff and be more visible with them to address their clinical issues/concerns. Attend team meetings, forums etc. Need stronger leadership and planned change management approaches specific to the NHS Developing Clinical Practice Standards: Engagement with the teams helped ensure change came from within so is likely to be more sustainable. Working parties involving frontline staff and relevant therapy services are help shaping the development of Clinical Practice Standards. Partnerships working with the Schools quality initiatives where the schools and Head teachers are fully engaged have been more effectively implemented and evaluated. This has led to innovative ways of meeting the children and young people s needs. Rotate venues and explore ways to involve all teams. Sharing best practice with other boroughs via away days, quality group etc. Overtly working with NICE guidelines positive as provides a robust evidence base when implementing change. Successful communication with school staff.
Things that didn t work as well Due to the difference in commissioning arrangements across the inner and outer boroughs and therefore delivery of service this has been difficult to manage whilst standardising services and developing standards. For example in Barnet the School Nurses are under resourced compared to the inner boroughs and national guidance therefore we have had to adapt considerably how we have implement the new standards whilst not compromising the quality of service. Geography of CLCH has proved difficult and gaining full representation across all boroughs has been difficult to achieve when piloting projects. There are still local variations in delivery. 6. Key Improvement Areas 1. Ability for School Nurses to evidence their activity to demonstrate quality 2. Standardisation of high quality safe care 3. The implementation of the Enuresis pathway across the 4 boroughs 4. Provide high quality clinical care, continued sharing of learning 5. Specialist PROM which is child friendly 6. Streamline further referral management into and out of School Nursing- PRM 7. Patient story action for NCMP programme 8. Patient story action for Enuresis service
7. Action Plan Improvement area Our target How will we measure? Who is responsible? By when? Feedback from schools/other professionals (MDT). Outcomes of PREMS AND Increase Service user feedback- PROMS 1.Ability for SN to evidence PREMs, patient stories and Increase in referrals and better Team leaders, professional their activity to demonstrate proms, service evaluation access to school nurse service leads quality targets increased up take re HPV and July 2013 leavers booster. Feedback from teachers and the head executive Audit of Clinical practice standards PADR 2.Standardisation of high quality safe care Nice compliance One to one meetings More discussion in the team More uniformity Project lead Sept 2013 Better team working and increased morals and more adaption to change Choice to be seen in school or 3. Enuresis Implementation of the pathway across 4 boroughs clinic both in term time and in the holidays. All school nurses/school health technicians Summer 2013 Attendance at clinics and how
many children become dry. Good feedback from parents and children Enuresis advertised in schools and clinics. More discussions and presentations in schools. More clinics across CLCH 4.Provide high quality clinical care, continued sharing of learning Clinical Supervision to be rolled out across School Nursing, full implementation of the policy Clinical supervision databasequarterly reports to IGM children s division Joint responsibility Quality - Professional lead Implementation Senior manager 31 st April 5.Specialist PROM which is child friendly User friendly PROM which clearly feeds back to CLCH how to improve their services PROM JC March 2013 6. Streamline further referral management into and out of School Nursing - PRM Release further clinical time Part of the TCS programme- productivity project plan Children s division SMT Phase 2 end April 2013 7. Patient story action for NCMP programme Clients felt the Results Letter could be clearer, Time of programme, delivery could change/follow up in the summer break and unclear what the follow up will be. The NCMP results letter sent to parents to be amended. The NCMP to be delivered earlier in the academic year and the follow up service to be clearly advertised Some DH Standard requirements to be included in the results letter, the initial NCMP letter to be amended to include "you" in reference to the parents, to advertise the follow up services in the school newsletters. To look into when the programme can be School nurses and Service managers March 2013
delivered in the school year School nurse poster with name 8. Patient story action for Enuresis service Parents not aware of the role of For school nurse role to be advertised in the schools and contact details of SN to be in schools, SN to do a year 7 assembly, where available SN to Service Managers and school nurses March 2013 the school nurse advertise through school internal internet