Trust Board papers November 2012 - Barking Havering and ...

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