Inspection Framework: Maternity Framework (Acute .
1NEXT PHASE METHODOLOGY (2018)Operating Model area: Core servicesSector: Acute, Community and Independent HealthcareProduct title: 900468 Single Assessment Framework MATERNITYInspection framework: Maternity Framework (Acute, community, independent)Log of changes since last versionSection / Report sub headingThroughoutPagenumber-Throughout-S1 Mandatory training5S1 Safeguarding620200324 900468 NHS IH Maternity core service framework v7Detail of updateThe whole framework has been reviewed and streamlined as part of lighteningthe loadProfessional standards updated - NICE QS15 previously comprised of 14statements but now only has six statements, references to the statements havebeen deleted/updated as appropriate.Professional standard added - Skills for Health Statutory/Mandatory Core SkillsTraining Framework (All healthcare staff)Professional standards added:- Adult Safeguarding: Roles and Competencies for Healthcare Staff (August2018)- Safeguarding Children and Young People: Roles and Competencies forHealthcare Staff (January 2019)
2S1 Environment and Equipment9S4 Medicines14E1 Evidence-based care and treatment18E2 Patient outcomes21E4 Seven-day services25E6 Consent, Mental Capacity Act andDoLS27R4 Learning from complaints andconcerns40W3 Culture47- HM Government: Working together to safeguard children: A guide to interagency working to safeguard and promote the welfare of children (March 2015)replaced by July 2018 versionProfessional standard added:- HSE Guidance on maintaining portable electrical equipment (2013)- MHRA guidance on managing medical devices (2015)Professional standard deleted – NMC standards for medicines managementSector specific guidance updated - Are best practice decision making toolsencouraged and does the service monitor their use? - for example the BMJBest Practice decision making app.Professional standard added - HQIP Detection and management for NationalClinical Audits: Implementation guideSector specific guidance updated - For statistics audit outliers, and in line withthe National Guidance on the management of audit outliers, does the serviceinvestigate why performance was much worse than expected, and makechanges to improve care?Professional standard updated – NHS Seven day services clinical standardsProfessional standards added- BMA/RCP Guidance on clinically-assisted nutrition and hydration and adultswho lack capacity to consent (2018)- BILD Restraint Reduction Network (RRN) Training Standards 2019Professional standard added – Link included to ISCAS – Patient complaintsadjudication service for independent healthcareSector specific guidance added - What arrangements are in place for theindependent review of complaints? (e.g. ISCAS, of which membership isvoluntary)Professional standard added - WRES & IH Providers Statementore service: Maternity Services20200324 900468 NHS IH Maternity core service framework v7
3This includes all services for women that relate to pregnancy. It includes antenatal and postnatal services, labour wards, midwifery ledunits and obstetric theatres.A hospital can provide some of these services in the community setting, or they may be the responsibility of a different provider. We willlook at the pathways between the two settings when we inspect. it is important that all providers are clear on what they do, what others doand the agreements that are made between them with clear pathways. If a new born baby requires treatment in a special care baby unit(SCBU) or neonatal unit where a paediatrician delivers the care, this comes under the core service for children and young people.Some aspects of maternity will link to gynaecology and termination of pregnancy services. Gynaecology and Termination of PregnancyServices are a separate additional service and have their own framework for inspection.Areas to inspect*Areas for inspection: Antenatal clinics including booking appointment activities both hospital and community basedMaternity day assessment unitEarly Pregnancy Unit, antenatal ward, induction of labour facilitiesScreening e.g. phlebotomy, ultrasonography.Consultant led obstetric unit – (including triage labour, delivery, recovery and postpartum rooms)Midwife led birth unit (alongside and/or freestanding) - (including triage, labour, delivery, recovery, postpartum) rooms and theescalation pathways.Obstetric theatres (both primary and back-up) including recoveryNewborn screening carried out by the maternity service.Postnatal ward and high dependency beds (including after caesarean section)Bereavement facilitiesFetal medicine unit (amniocentesis where provided and the referral to fetal medicine services if not provided on-site).In the community the inspection team may wish to visit ( as appropriate): Women’s homesFree standing, co-located or ‘pop up’ midwifery led units20200324 900468 NHS IH Maternity core service framework v7
4Interviews / observationsYou should conduct interviews of the following people where possible: Women who are using/have recently used this maternity service and those close to themClinical director for directorate/divisionHead of MidwiferySafeguarding leadRisk/Governance midwifeLead midwife for midwife led servicesLead midwife antenatal servicesLead midwife for post-natal servicesLead midwife labour wardLead midwife for communityLead obstetrician labour wardAntenatal & Newborn Screening midwifeMidwives at all levelsMaternity care assistantsLabour ward coordinator on dutyObstetrician and junior medical staff on labour wardBereavement leadLead anaesthetist for labour wardProfessional development leadConsultant midwifeStudent midwivesFor community based services you may wish to interview: A sample of community midwifery teams across the geographical area covered by the provider and from different bandings (*)Women and those close to them, who are using or recently used community based services (**)Lead midwife for communityHome birth teamsMaternity care assistantsStudent midwives20200324 900468 NHS IH Maternity core service framework v7
5 Health visitor lead (linked to community inspections)For independent midwifery services you may wish to interview: Women who are using/have recently used this maternity service and those close to themChief ExecutiveClinical Director for the serviceLead MidwifeClinical LeadSafeguarding LeadRisk / Governance MidwifeObstetricianBereavement leadProfessional development midwifeMidwifery support workersStudent MidwivesCCG lead for maternity contracts (interview prior to inspection)SafeBy safe, we mean people are protected from abuse* and avoidable harm.*Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse.Key lines of enquiry: S1S1. How do systems, processes and practices keep people safe and safeguarded from abuse?Report sub-heading: Mandatory training20200324 900468 NHS IH Maternity core service framework v7
6Prompts S1.1 How are safety and safeguardingsystems, processes and practicesdeveloped, implemented and communicatedto staff? S1.5 Do staff receive effective training insafety systems, processes and practices?Professional standardSector specific guidance Safer Childbirth: Minimum Standardsfor the Organisation and Delivery ofCare in Labour. Statutory and Mandatory training forstaff working in maternity would beexpected to include neonatal andobstetric emergencies as a minimum.Trust and maternity specific mandatorytraining records:o How is the content decidedupon?o Is it multidisciplinary?o Does the content respond toincidents?o Live emergency drills NICE Guidelines NG51: SepsisRecognition, diagnosis and earlymanagement Skills for Health Statutory/MandatoryCore Skills Training Framework (Allhealthcare staff)Can the service evidence that 90% ofeach maternity unit staff group haveattended an ‘in-house’ multiprofessional maternity emergenciestraining session within the last trainingyear? Do community midwives haveemergency skills training specific to thecommunity? Cardiotocography (CTG) training andsigned off competencies? If staff havenot completed training do they interpretCTG’s? Is there a policy for sepsis and havestaff had training in sepsis?Report sub-heading: Safeguarding S1.1 How are safety and safeguardingsystems, processes and practicesdeveloped, implemented and communicatedto staff? 20200324 900468 NHS IH Maternity core service framework v7Safeguarding IntercollegiateDocument: Safeguarding children andyoung people: roles and competencesfor health care staff (2014) What are the safeguarding trainingattendance statistics? What level of training do staff have? What risk assessments are undertaken?
7 S1.2 How do systems, processes and practices protect people from abuse, neglect,harassment and breaches of their dignity andrespect? How are these monitored andimproved?S1.3 How are people protected fromdiscrimination, which might amount to abuseor cause psychological harm? This includesharassment and discrimination in relation toprotected characteristics under the EqualityAct.S1.4 How is safety promoted in recruitmentpractice staff support arrangements,disciplinary procedures, and ongoingchecks? (For example Disclosure andBarring Service checks). S1.5 Do staff receive effective training insafety systems, processes and practices? S1.6 Are there arrangements to safeguardadults and children from abuse and neglectthat reflect relevant legislation and localrequirements? Do staff understand theirresponsibilities and adhere to safeguardingpolicies and procedures, including working inpartnership with other agencies? Clinical staff working with children,young people and/or their parents /carers and who could contribute toassessing, planning, intervening andevaluating the needs of a child oryoung person should be trained tosafeguarding at level 3.Adult Safeguarding: Roles andCompetencies for Healthcare Staff(August 2018)Safeguarding Children and YoungPeople: Roles and Competencies forHealthcare Staff (January 2019)HM Government: Working together tosafeguard children: A guide to interagency working to safeguard andpromote the welfare of children. July2018 Female genital mutilation multi-agencypractice guidelines published in 2016 DH Female Genital Mutilation andSafeguarding: Guidance forprofessionals March 2015S1.7 Do staff identify adults and children atrisk of, or suffering, significant harm? How do they work in partnership with other agenciesto ensure they are helped, supported and protected?20200324 900468 NHS IH Maternity core service framework v7Working together to safeguardchildren: HM Gov. 2015FGM Mandatory reporting of FGM inhealthcare Is the national enquiry question aboutdomestic abuse asked antenatally? Are there arrangements in place tosafeguard women with, or at risk of,Female Genital Mutilation (FGM). What systems are in place to notify staffof women/families are subject to a childprotection/child in need plan? Is information on safeguarding andlearning from safeguarding incidentsshared? Do staff have an awareness of ChildSexual Exploitation (CSE)? Does the trust have an abduction policy? What ‘prevent’ training is provided tocommunity midwives?
8 FGM-video-resources for healthcareprofessionals Guidelines for physicians on thedetection of child sexual exploitation(RCP, November 2015) Sexual Offences Act 2003Under Section 5 of the SexualOffences Act 2003, a girl under 13years of age is not considered capableof giving her consent to sexualintercourse. Disclosure is not invariablyrequired but it is usual in order that theinterests of the child, which areparamount, may be protected. Not always restricted to, but includesinterventions under the MHA, seeMHA Code of Practice. Guidance for specified authoritiesin England and Wales on the dutyin the Counter-Terrorism andSecurity Act 2015 to have dueregard to the need to prevent peoplefrom being drawn into terrorism.Report sub-heading: Cleanliness, infection control and hygiene S1.1 How are safety and safeguardingsystems, processes and practicesdeveloped, implemented and communicatedto staff? 20200324 900468 NHS IH Maternity core service framework v7NICE QS61 Statement 3: Peoplereceive healthcare from healthcareworkers who decontaminate theirhands immediately before and afterevery episode of direct contact or care. What is the incidence of Puerperalsepsis and other puerperal infectionswithin 42 days of delivery andreadmission rates for infections inmothers and baby? This should be inthe PIR for analyst review
9 S1.8 How are standards of cleanliness andhygiene maintained? Are there reliablesystems in place to prevent and protectpeople from a healthcare-associatedinfection? NICE QS61 Statement 4: People whoneed a urinary catheter have their riskof infection minimised.NICE QS61 Statement 5: People whoneed a vascular access device havetheir risk of infection minimised. How are standards of cleanliness andhygiene maintained e.g. hand washing,bare below the elbow. Are there hand hygiene audits? Thisshould be in the PIR for analystreview Are the hand gel sanitisers available?Code of practice on the prevention and control of infectionsAre staff adhering to the uniform policy?Are there cleaning schedulescompleted?Safer Childbirth: At a minimum amaternity unit offering obstetric careshould have: Cardiotocography (CTG)machines Resuscitation equipment – foradults and the new-born Fetal blood analyser Access to ultrasoundassessment of fetal wellbeing(Doppler, liquor volume) Laboratory facilities withavailability of blood and bloodproducts. How far are the obstetric theatres/neonatal unit from the delivery suite? Is there a second theatre and what levelof facilities does it have. Are relevant safety standards andannual services in place? Do community midwives have their ownbaby scales, sonicaids, bilirubinometers,blood pressure machines with differentsize cuffs, baby scales andthermometers. Do they have carbon monoxidemonitors?Safer Childbirth: Facilities should bereviewed at least biannually and plansmade to rectify deficiencies withinagreed timescales What emergency equipment docommunity midwives carry and how isthis maintained and checked? How do midwives transport gasesequipment, is this safe and secure andReport sub-heading: Environment and equipment S1.1 How are safety and safeguardingsystems, processes and practicesdeveloped, implemented and communicatedto staff? S1.9 Do the design, maintenance and use offacilities and premises keep people safe? S1.10 Do the maintenance and use ofequipment keep people safe? S1.11 Do the arrangements for managingwaste and clinical specimens keep peoplesafe? (This includes classification,segregation, storage, labelling, handling and,where appropriate, treatment and disposal ofwaste.) 20200324 900468 NHS IH Maternity core service framework v7
10 Maternity care facilities should bedesigned in keeping with the DHguidance Health Building Note 09-02 t-used-inhomebirth/ MHRA guidance on managingmedical devices (2015) HSE Guidance on maintainingportable electrical equipment (2013)compliant with local protocols andlegislation? Does the service have “waterproof”sonicaids? Do community midwives follow the loneworking policy?Key line of enquiry: S2S2. How are risks to people assessed, and their safety monitored and managed so they are supported to stay safe?Report sub-heading: Assessing and responding to patient riskPromptsProfessional standard S2.5 Are comprehensive risk assessmentscarried out for people who use services andrisk management plans developed in linewith national guidance? Are risks managedpositively?S2.6 How do staff identify and respondappropriately to changing risks to peoplewho use services, including deterioratinghealth and wellbeing, medical emergenciesor behaviour that challenges? Are staff ableSepsis: recognition, diagnosis andearly management (NICE Guideline51)Sector specific guidance NICE CG 190: Section 1.10:Monitoring in labour. Safer Childbirth: The consultantobstetrician must be contacted prior toemergency caesarean section andmust be involved when a woman’s 20200324 900468 NHS IH Maternity core service framework v7Is a lead professional identified (midwifeled care or consultant led care)?Do women have a risk assessment atevery antenatal appointment?Are high risk women in the hospital seenwith 30 minutes by a midwife and withinan hour by medical staff?Are VTE assessments recorded atbooking, following birth and at everyadmission?
11to seek support from senior staff in thesesituations?condition gives rise for concern andattend as required. MBRRACE-UK report: Saving Lives,Improving Mothers’ Care –Surveillance of maternal deaths in theUK 2011-13 and lessons learned toinform maternity care from the UK andIreland Confidential Enquiries intoMaternal Deaths and Morbidity 200913 (published Dec 2015). NICE QS3 statement 1: All patients,on admission, receive an assessmentof VTE and bleeding risk using theclinical risk assessment criteriadescribed in the national tool. The service should ensure compliancewith the 5 steps to safer surgery WorldHealth Organization for patientsundergoing surgery and the modifiedMaternity WHO surgical safetychecklist in maternity. NICE QS 22: Antenatal care Riskassessments. Brief guide: NatSSIPs and LocSSIPs(CQC internal guidance) Does the service audit the modifiedWHO maternity theatre checklist?Are fresh eyes performed hourly forcontinuous fetal monitoring?Are women with pre-labour spontaneousrupture of membranes of 24hrs offeredan induction of labour.Are Consultant Obstetricians present fordifficult births?Are swab counts performed and signedby two professionals?Do staff handovers routinely refer to thephysical, psychological and emotionalneeds of women, as well as theirrelatives / carers?Report sub-heading: Midwifery and Nurse staffing S2.1 How are staffing levels and skill mixplanned and reviewed so that people receive 20200324 900468 NHS IH Maternity core service framework v7NICE NG4: Safe Midwifery Staffing What is the midwife to birth ratio?
12safe care and treatment at all times and staffdo not work excessive hours? S2.2 How do actual staffing levels and skillmix compare with the planned levels? Iscover provided for staff absence?S2.3 Do arrangements for using bank,agency and locum staff keep people safe atall times? S2.4 How do arrangements for handoversand shift changes ensure that people aresafe? S2.7 How is the impact on safety assessedand monitored when carrying out changes tothe service or the staff? Safer Childbirth: An experiencedmidwife (shift coordinator) is availablefor each shift on the labour ward. Is there an effective system of midwiferyworkforce planning to the requiredstandard? Safer Childbirth: All midwifery unitsmust have one WTE consultantmidwife. Does the service use an acuity tool? Is there an assessment of safe staffingon a shift by shift basis? How are staffing gaps covered? What percentage of staffing areMaternity Support Workers, what trainingdo they receive and how is this updated? Safer Childbirth: Student midwivesshould be supernumerary to themidwife establishment. Staffing numbers need to be displayed outside all ward areas in line with NHSEngland / CQC: Hard Truths. Birthrate Plus Assessment and use ofthe acuity tool,If the service has midwife led units howis staffing calculated to incorporate thestaffing requirements of this service? How do actual staffing levels compare tothe planned levels? Are community midwives used in thestaffing escalation policy? If they do whatis the effect on the delivery of communityservices? Are staffing levels displayed? Is the recommended obstetric consultantstaffing levels being met? Is there an effective system of medicalworkforce planning to the requiredstandard?Report sub-heading: Medical staffing S2.1 How are staffing levels and skill mixplanned and reviewed so that people receivesafe care and
Inspection framework: Maternity Framework (Acute, community, independent) Log of changes since last version Section / Report sub heading Page number Detail of update Throughout - The whole framework has been reviewed and streamlined as part of lightening the load Throughout - Professional sta
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