Trust Board papers November 2012 - Barking Havering and ...
Trust Board papers November 2012 - Barking Havering and ...
Trust Board papers November 2012 - Barking Havering and ...
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CQC Update Report<br />
<strong>2012</strong><br />
MATERNITY<br />
MATERNITY<br />
this. maternity dashboard showed 84%<br />
complete. Regular audits of<br />
attendance are in place.<br />
17. Improve the quality of<br />
record keeping <strong>and</strong> records<br />
management in maternity<br />
services.<br />
19. Ensure that maternity audit<br />
processes are integrated with<br />
the rest of the <strong>Trust</strong>.<br />
Training for staff <strong>and</strong> a maternity<br />
records tracker <strong>and</strong> audit process<br />
are in place, but some problems<br />
with implementation <strong>and</strong> targets<br />
not being met to date. More that<br />
50% of staff have now been<br />
trained in appropriate governance.<br />
While a clinical audit plan is in<br />
place <strong>and</strong> infection control is being<br />
audited, an audit midwife has only<br />
recently been recruited. The full<br />
set of policy <strong>and</strong> process measures<br />
are in place but performance is not<br />
meeting expected levels as of the<br />
time of writing.<br />
st<strong>and</strong>ard approach to be taken 1. SOM review <strong>and</strong> education is<br />
required / template to be developed <strong>and</strong> used to show audit trail<br />
2. second offence ‐ disciplinary process + SOM input.<br />
For obstetric team need to liaise with tutors to determine correct<br />
process in line with deanery programme<br />
90% for June <strong>2012</strong>, however due to a number of SI's with CTG<br />
misinterpretation please see new process <strong>and</strong> comments above.<br />
Training in place highlights ‘barn door’ competence. The revised<br />
training package which has just been implemented will ensure<br />
that there is a test <strong>and</strong> assess element to the training. Specific<br />
support is available to those midwives who require additional<br />
support.<br />
There have been no SUI reports which have involved CTG<br />
interpretation in September.<br />
Tracker implemented. Audit of compliance commencing Sept<br />
<strong>2012</strong>.<br />
Retrospective tracking has been completed <strong>and</strong> all women are<br />
now covered.<br />
Old Maternity notes are subject to tracking as women attend the<br />
unit.<br />
Training in this is now included in M<strong>and</strong>atory Training for all staff<br />
<strong>and</strong> as part of Induction for all new staff.<br />
Maternity Department has in place an annual audit plan for<br />
<strong>2012</strong>/13 compiled by the Audit Lead Consultant <strong>and</strong> the Audit<br />
Midwife. Audit findings are presented at monthly Audit meetings<br />
attended by multidisciplinary representation. The action plans are<br />
discussed at the meeting <strong>and</strong> uploaded onto the intranet by the<br />
Clinical Audit Team .<br />
FU comment: The crib sheet has not been shared with the Audit<br />
midwife therefore cannot provide an update.<br />
Wendy<br />
Matthews<br />
MET<br />
BUSINESS<br />
AS USUAL<br />
MET<br />
BUSINESS<br />
AS USUAL<br />
MEDICINES<br />
MANAGEMENT<br />
48. Reinforce its policy on<br />
medication prescribing,<br />
dispensing <strong>and</strong> administration,<br />
ensuring that all staff are<br />
A briefing for clinical staff<br />
explaining the importance of this<br />
policy <strong>and</strong> setting out<br />
accountabilities for prescribing <strong>and</strong><br />
FU comment: The audit team adheres to the <strong>Trust</strong> procedures,<br />
uses approved tools <strong>and</strong> ensures that the audits are centrally<br />
recorded by the <strong>Trust</strong> Clinical Audit Team.<br />
The BHRuT Medicines Care, Custody, prescribing <strong>and</strong><br />
Administration Policy has been finalised <strong>and</strong> ratified by the Drugs<br />
<strong>and</strong> Therapeutics Committee, Nursing <strong>and</strong> Midwifery <strong>Board</strong> <strong>and</strong><br />
the Policy ratification Committee. It is available on the intranet<br />
Ian Grant<br />
Jane Stevens<br />
Pam Strange<br />
Portia Omo‐Bare<br />
MET<br />
BUSINESS<br />
AS USUAL<br />
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