Communityhealthservices forchildren,youngpeople andfamilies · WalsallHealthcareNHSTrust...

Walsall Healthcare NHS TrustProvider RBK

CommunityCommunity hehealthalth serservicvicesesfforor childrchildren,en, youngyoung peoplepeopleandand ffamiliesamiliesQuality Report

Tel:019201922Website:www.walsallhealthcare.nhs.uk

Date of inspection visit: 8-10 September 2015Date of publication: 26/01/2016

1 Community health services for children, young people and families Quality Report 26/01/2016

Locations inspected

Location ID Name of CQC registeredlocation

Name of service (e.g. ward/unit/team)

Postcodeofservice(ward/unit/team)

RBK Harden Health Centre WS31ET

RBK Old Hall Special School WS27LU

RBK Blakenhall Village, WS31LZ

RBK Sai Medical Centre WS28RE

RBK St Johns Medical Centre WS99LP

RBK Walsall Child DevelopmentCentre

WS41PL

This report describes our judgement of the quality of care provided within this core service by Walsall Healthcare NHSTrust. Where relevant we provide detail of each location or area of service visited.

Our judgement is based on a combination of what we found when we inspected, information from our ‘IntelligentMonitoring’ system, and information given to us from people who use services, the public and other organisations.

Where applicable, we have reported on each core service provided by Walsall Healthcare NHS Trust. and these arebrought together to inform our overall judgement of Walsall Healthcare NHS Trust.

Summary of findings


Ratings

Overall rating for the service Good –––

Are services safe? Requires improvement –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive? Good –––

Are services well-led? Good –––

Summary of findings


Contents

PageSummary of this inspectionOverall summary 5

Background to the service 6

Our inspection team 6

Why we carried out this inspection 6

How we carried out this inspection 7

What people who use the provider say 7

Good practice 7

Areas for improvement 7

Detailed findings from this inspectionThe five questions we ask about core services and what we found 8

Summary of findings


Overall summaryChildren and young people (CYP) services were rated asgood overall. We rated the service as good for effective,caring, responsive and well led domains and requiresimprovement for the safe domain.

During the inspection we met with managers, staff,children and parents in a range of community settings.We observed care being delivered in a special school, inclinics and in children’s own homes. We talked with staffworking across a range of services. CYP staff also workedwith other professionals and external organisations suchas CAMHS (child and adolescent mental health services)and social services.

There was evidence that the services for children andyoung people were delivered in line with best practiceguidance and local agreement. Staff were dedicated,professional and well supported by recent changes to themanagement structure. Staff told us that they were avalued member of their respective teams. We saw thatcare was centred on the child and individualised acrossall CYP services.

There was an effective system in place to report and learnfrom adverse incidents, errors and near misses. Themajority of staff told us they received feedback about theaction taken when they reported issues. We saw care wasdelivered to promote dignity and respect, and found staffwere very responsive to children and their families’needs.

There was a robust safeguarding process in place withgood safeguarding supervision for all staff. We saw

infection control practices across CYP services was good.Several electronic systems and handwritten notes wereused across the service. This presented a risk foraccessing complete and robust information whenrequired.

Staffing levels across CYP services were good. We saw thetrust had ongoing challenges with recruitment ofcommunity paediatricians. Staff had the rightqualifications, skills and knowledge to do their job. Therewere high numbers of newly qualified health visitors inpost but they were supported with a good preceptorshipprogramme. Staff were hindered in their roles whenworking away from their office bases by a lack of mobileIT equipment.

Care was effective and evidence based. There wasevidence of strong multidisciplinary working within thetrust and across other agencies.

Staff expressed satisfaction with the levels of supportfrom their local managers. There were clear lines ofmanagement in place and structures for assuring quality.Staff told us that on the whole they thought the executiveteam were doing well in leading the trust but there was alack of visible executive clinical leadership.

CYP services received very few complaints and people wespoke to during the inspection were very complimentaryabout the staff and the quality of the service theyreceived.

Summary of findings


Background to the serviceCommunity services for children, young people andfamilies under the age of 20 years make up 26% of thepopulation of Walsall. 33% of school children are from aminority ethnic group compared to the England averageof 27%. The level of child poverty is worse than theEngland average of 28%, with 29% of children aged 16years living in poverty. Children in Walsall also have worsethan average levels of obesity with 24% of children in yearsix classified as obese. The health and wellbeing ofchildren in Walsall is generally worse than the Englandaverage including the infant mortality rate, teenagepregnancy, breastfeeding and smoking at time ofdelivery.

Walsall’s Children’s Community Services provided a rangeof services for children and young people across theborough which included:

• Community children’s nursing service• Child development centre• Health visiting service• School nursing service• Family Nurse Partnership to support young parents• Children’s occupational therapy• Children’s physiotherapy• Children’s speech and language therapy

Care was delivered from a variety of settings: mainstreamschools, special schools, education at home, childrencentres, community health centres and the children’sown home for those children needing acute and chroniccare.

During the inspection we visited a variety of services forchildren, young people and families. This included achildren’s centre offering specialist services for childrenwith autism. We did two home visits, visited one specialschool and three health centres. We conductedinterviews with nurses, physiotherapists, speech andlanguage therapists, health visitors, managers and serviceleads. We spoke with31 members of staff in total. We heldthree community staff focus groups which were wellattended. Staff focus groups are a planned meeting withspecific staff members such as nurses, health visitors andtherapists to listen to their views about their work andhow their services are run.

During the inspection, we also spoke with five parentsand we reviewed 10 children’s records which includedindividual care plans and risk assessments and a varietyof team specific and service based documents and plans.

We also sought feedback from external partnerorganisationsand reviewed online feedback.

Our inspection teamChair: Professor, Juliet Beale, CQC National NursingAdvisor

Team Leader: Tim Cooper, Head of Hospital Inspections,Care Quality Commission.

The CYP inspection team included a CQC Inspector, aSpecialist Community Public Health Nurse and aContinuing Healthcare Coordinator.

Why we carried out this inspectionWe undertook this inspection as part of thecomprehensive combined acute and community healthservices inspection programme.

Summary of findings


How we carried out this inspectionTo get to the heart of people who use services’ experienceof care, we always ask the following five questions ofevery service and provider:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

For example:

Before visiting, we reviewed a range of information wehold about the core service and asked otherorganisations to share what they knew. We carried out anannounced visit on 9 and 10 September 2015. During thevisit we held focus groups with a range of staff whoworked within the service, such as managers, nurses,health visitors and therapists. We talked with people whoused services. We observed how people were being caredfor and talked with carers and/or family members andreviewed care or treatment records of people who useservices. We met with people who use services andcarers, who shared their views and experiences of thecore service.

What people who use the provider sayParents and carers of children and young people acrossall community CYP services we talked to told us theyreceived a good to excellent service. We were told staffwere very kind and caring and staff were always eager tohelp.

One young parent from the FNP service told us how theservice had taught them so much about caring for theirchild and that the FNP had brought them together as afamily.

Parents who used the children’s nursing service were verycomplimentary and praised the staff for organising coverand support for their child when they all went on holidaytogether.

Good practiceSchool Nursing Service Innovative practice with the introduction of school nurse

champions designed to improve the service offered bylistening to the young people in the area and offeringspecific training to schools and young people volunteers.

Areas for improvementAction the provider MUST or SHOULD take toimproveShould:

• Review children’s nursing services to bridge the out-of- hours gap in service provision.

• Ensure the Lone Working Policy applies to all staff.

Summary of findings


By safe, we mean that people are protected from abuse

SummaryWe rated this service as requires improvement becausechildren, young people and families were at an increasedrisk of avoidable harm due to the numerous electronicsystems in place to record information. Complete androbust information was not always available for multi-agency decisions about children at risk of abuse.

Incident reporting and recording was encouraged andembedded across all services. There was a robust processin place for staff to learn from lessons to minimise futurerisks to children, young people and families.

Infection control guidance was in place and practiced bystaff. Equipment was checked, serviced and cleaned in linewith trust policy and was in good supply. Mandatorytraining attendance was good.

There were effective safeguarding processes in place toprotect children from the risk of abuse. Risk was managedand incidents were reported and acted upon.

We saw quality of care and service performance wasmonitored and measured across CYP services. Risks topatients were effectively assessed and managed in mostareas and clinical practice was reviewed regularly toimprove care.

There was a full establishment of health visitors following arecent recruitment drive.However,this was having a ‘knockon’ effect to other services such as Speech and LanguageTherapy as more children and young people were referredto the service.

Incident reporting, learning and improvement

• Never Events are serious, wholly preventable patientsafety incidents that should not occur if the availablepreventative measures have been implemented. Therewere zero Never Events registered across Children andyoung people (CYP) services. There was one SeriousIncident requiring investigation for CYP communityservices between August 2014 and July 2015. This was

Walsall Healthcare NHS Trust

CommunityCommunity hehealthalth serservicvicesesfforor childrchildren,en, youngyoung peoplepeopleandand ffamiliesamiliesDetailed findings from this inspection

ArAree serservicviceses safsafe?e?

Requires improvement –––


reported in line with national guidance. We looked atthe learning that had occurred as a result of the incidentand found staff were aware of the incident and theimprovements. A full risk assessment had been put inplace to further develop learning and improve practice.Staff within the focus groups were able to tell us theimprovements they had made to their practice, such asthe use of locked bags for transporting notes.

• Staff across CYP services were encouraged to reportincidents and were able to access the trust’s electronicincident-reporting system. Staff told us it was easy touse and they were encouraged to do so.

• Within a 12 month period 2014 to 2015 there were 234incidents reported by staff across CYP services, 220 werereported as no harm, 11 as low harm and 3 as moderateharm. These three related to clinical assessment andaccess, admission, transfer and discharge.

• Staff were made aware of trust wide incidents in variousforms, for example: through weekly team meetings,monthly governance meetings and emails from linemanagers to share lessons learned. We saw evidence ofstaff communications related to a recent reportedincident. This contained feedback, lessons learned andan action plan. Most staff we spoke with felt theyreceived good feedback. Some of the administrativestaff felt they did not receive feedback and so did notknow what lessons had to be learned.

Duty of Candour

• Managers we spoke with were aware of the duty ofcandour regulation introduced in November 2014 (TheHealth and Social Care Act 2008 (Regulated Activities)Regulations 2014). The intention of the regulation is toensure providers are open and transparent with peoplewho use services. We heard an example of where themanagement had spoken with a family when a previousbreach of confidentiality had occurred and we sawevidence of a written apology.

• Staff told us they were confident about reportingincidents and were aware they needed to be open andtransparent with patients and their relatives if anythingwent wrong with their care.

Safeguarding

• Staff demonstrated a good knowledge of the trust’ssafeguarding policy and the processes involved forraising an alert. They told us about the changes to the

children’s safeguarding service and how things hadimproved. They found the service to be helpful andaccessible whenever needed. Staff knew the names ofthe trust safeguarding leads and were familiar with thethreshold descriptors for safeguarding and childprotection concerns. A named nurse for children’ssafeguarding has been in post since March 2015following the recommendations from the trust widereview of the service in 2014.

• We looked at the safeguarding policies and proceduresand saw posters displaying information in the staffbases which meant that staff had access to the relevantinformation and phone numbers to raise safeguardingconcerns. Again, following the recommendations fromthe review, there is now a central point of contact and afully staffed duty service.

• We spoke with health visitors, school nurses, nurserynurses and therapists about safeguarding referrals andthey all knew the procedure to follow. The safeguardingreferrals we looked at were appropriate, they were fullycompleted and alerts were made within the 24 hourtimeframe.

• Staff received safeguarding training upon induction andat three yearly intervals. All clinical staff were trained tosafeguarding level three. The CYP service achievedabove the trust target of 95% for mandatory traininglevels. We looked at the training tracking system andsaw that only staff on maternity leave had not receivedthe training. The children’s nursing team had 100%compliance with safeguarding level three.

• Staff told us there was a strong multidisciplinary, multi-agency approach and gave examples of working withthe Domestic Abuse Response Team (DART) and thecurrent Multi-Agency Screening Team (MAST). We weretold this service would be changing to ‘MASH’ (Multi-Agency Safeguarding Hub) where referrals will bereviewed by health, domestic abuse advisors, police,mental health services and the local authority.

• CYP services were aware of child sexual exploitation andhad robust systems to raise concerns. We saw evidenceof sexual health services contributing reports tosafeguarding conferences.

• Staff involved in safeguarding received safeguardingsupervision. All staff reported this was working well.Speech and Language Therapy staff told us they havegood supervision support on a needs based model andthat access to the team was ‘excellent.’ Fourteen healthvisitors had been trained in the national accredited

Are services safe?



NSPCC (National Society for the Prevention of Cruelty toChildren) child protection supervision skills course. Wesaw staff from the Family Nurse Partnership (FNP). Theyoperated a tripartite safeguarding meeting with threehealth professionals involved in cases.

• Staff told us during focus groups that if they witnessedpoor practice they would have no reservation toescalate concerns to their line managers and ifnecessary whistle blow their concerns to either thesenior manager, the safeguarding lead, the socialworker or the Care Quality Commission.

Medicines

• Standard Operating Procedures for the children’scommunity nursing team were in place. These includedthe standard for managing medicines includingcontrolled drugs in special schools and the standard foradministering medicines in special schools. We saw theprocedure for administration of medicines was followedcorrectly. The assistant practitioner (band four supportworker) within the children’s community nursing teamchecked all the medication details beforeadministration such as drug type, quantity and expirydate. We saw this was part of their role and theyreceived appropriate training to support this.

• All records relating to the management andadministration of medicines were countersigned by theregistered children’s community nurse responsible forthe special schools.

• An audit for Medication Safety in Special Schools was inplace since August 2015. No results were available forthe special schools due to the summer break. We sawthe medicines were stored safely with room and fridgetemperatures checked regularly and recorded. All thedrug cupboards were locked and controlled medicineswere stored in a separate locked cupboard.

• All medication errors were reported as incidents,recorded on the electronic system, investigated andreviewed at the monthly divisional governance meeting.We saw evidence that these were investigated and thatlessons had been learned and communicated to staff.

Records and Management

• We looked at the management of children’s recordsacross CYP services and saw records were on the wholewell maintained although the outside folders of many of

the paper records were in need of some repair. Paperrecords were securely stored in locked rooms and wereonly accessible to staff who had the authority to viewthem. There was a robust tracking system for notes thatwere removed from their locations.

• All staff who worked in the community told us theelectronic records were not fit for purpose. There wereseveral systems in place including Care Plus, Fusion,Badgernet and Lorenzo. Lorenzo was an electronicpatient administration system implemented 18 monthsprevious which had caused the service and the trust as awhole significant problems with booking appointments,access to discharge information and general gatheringof performance information for the service. A paperdiary system was in use by health visitors.

• Managers told us the issue was listed on the care grouprisk register. An action plan was in place to improve thefunctions of the electronic patient administrationsystem in line with the community service requirements.We were told the professional leads had met with thesenior IT team to progress this.

• School nurses told us they often did not have acomplete set of records to take to safeguardingmeetings and would rely on a summary sheet. Recordswere requested from the storage location but could takeseveral days to arriveand therefore staff were not alwaysequipped with the necessary information to refer to atthe safeguarding meetings.

• The children’s nurses in special schools had to transportnotes in their own cars. They had raised this with theirmanagers as a safeguarding risk. The team were holdingdiscussions as to how to reduce this risk. However, therewere no plans in place to address this issue in the nearfuture.

• We saw that records were completed in accordance withtrust records policy and were in line with good practiceguidelines from professional bodies such as the Nursingand Midwifery Council. The records were audited on anannual basis.

• There was evidence of written consent and familyinvolvement in records as well as demonstrating carecontinuity and a multidisciplinary approach to the caredelivered.

Environment and equipment

• We looked at the storage, maintenance and availabilityof equipment used in clinics, schools and equipment

Are services safe?



used by staff in children’s own homes. We saw electrical‘safety test’ stickers were in place on equipment andwere within the recommended test date. Staff told usequipment was in good supply and easy to access.

• The staff from the National Child MeasurementProgramme (NCMP) organised an annual service wideday for cleaning and calibrating all the weighing scalesused in the school nursing teams in line with localpolicy.

• A health visitor attended the trust health and safetymeetings and feedback was given to the wider CYPteam.

Cleanliness, infection control and hygiene

• We saw clinical areas at baby clinics, children centresand special schools were clean and well maintained.

• We saw staff washing their hands and using hand gelinbetween each intervention at the special school andon home visits.

• All staff were required to complete infection controltraining. Records showed a completion rate above 95%for CYP services.

• Signs were displayed around clinical areas remindingstaff and visitors to wash their hands and alcohol handgel was available at all the centres we inspected.

• We saw completed cleaning schedules for larger piecesof equipment such as hoists and profiling beds used inspecial schools.

Mandatory training

• Mandatory training records showed that childrencommunity nursing, school nursing and physiotherapystaff scored 100% for patient handling training. Theareas which scored the lowest training figures was theFamily Nurse Partnership (FNP) with 75% andOccupational therapy with 88%. We saw theoccupational therapy team scored 90% for fire safetytraining, Physiotherapy team scored 81%, FNP scored75% and Health visitor teams scored between 88 to100%.

• One member of staff on maternity leave had beenencouraged to use a ‘Keep in Touch’ day to completethe mandatory training. This showed a commitmentfrom the team to the importance of mandatory training.

• Staff told us they were actively encouraged by their linemanagers to attend mandatory training and receivedemails as reminders when training was due. They told usthe training had become more flexible to use.

• The health visitor professional lead told us they haddeveloped a role specific mandatory training day inconjunction with the trust training team. A half day wasdedicated to role specific issues such as Female GenitalMutilation, Nurse Prescribing and Serious Case Reviews.They told us this would be further adapted to meet localand national needs. There were no training figuresavailable for these newly developed training topics.

Assessing and responding to patient risk

• A wide range of risk assessments were used across CYPservices to assess and manage individual risks tochildren. For example, the Family Nurse Partnershipservice used a child sexual exploitation risk assessmentand children’s nurses in the special school assessed therisks for children on oxygen.

• We spoke with the paediatric physiotherapy leadfollowing a home visit. They told us risk assessmentshad been undertaken to help manage a young childreturning from overseas following a surgical procedure.

• Formal arrangements were in place to deal with themanagement of a child identified to be at risk. Multi-agency professionals such as teachers, police, socialworkers and healthcare professionals attended thesemeetings. Individual cases were reviewed, risksidentified, care plans agreed and actions plans put inplace to protect the child and support the family.

• We saw from records of children on child protectionplans and child in need plans that the required numberof health visiting appointments were always met.

• Infant mortality rate in Walsall was one of the highest inthe country at 7 per 1,000 live births. It is one of the coreobjectives for the trust in 2015/16 to address the issue.

Staffing levels and caseload

• The trust was making good progress towards meetingthe number of health visitors required in line with theNational Health Visitor Plan 2011-15. The trust had atarget of 67.2 whole time equivalent staff. 63.43 werenow in post and the remainder were currently out toadvert. The trust had previously met the target but staffhad subsequently retired. The professional lead forhealth visitors told us the staffing levels were adequate

Are services safe?



although many of the new staff were newly qualifiedand undergoing the preceptorship programme. Theytold us this added extra strain to the teams in managingthe caseloads. We looked at the monthly reportgenerated to allocate resources across the teamsappropriately.

• The Family Nurse Partnership service provided carefrom Harden Health Centre. The staffing levels consistedof one supervisor at band 8a, seven registered nurses atband 7 and one administration support officer at band4. Staff told us of their concerns around the capacity ofthe team. They currently receive approximately 25-30referrals per month. The caseload is set at 25 for eachfull time member of staff. However, to meet the needs ofthe wider population and offer support to more youngparents, further staff are required. There were no plansto recruit more nurses into this service.

• We saw generally there was adequate staffing levelsacross therapy services to meet the majority of needs ofchildren and families. We looked at the TAC (TeamAround the Child) three year plan which identifiedconcerns around capacity. A service review in 2014looked at streamlining processes to increase capacity atthe diagnostic and support groups from four to six.Referral rates into the service were increasing since theincrease in health visitor staff. The TAC team had nothad access to clinical psychologists for some months.Two clinical psychologists from the Children’s andAdolescents Mental Health Service (CAMHS) startedwork the week of the inspection to offer the requiredsupport. This issue had been on the risk register but willnow be removed as the team follows NICE guidelinesand best practice with the staff team now in place.

• Staffing levels for children’s nursing services includednurses and assistant practitioners who provided care inchildren’s own homes and across three special schools.The team were fully staffed.

• The staff based in the team which the inspectors visitedcomprised of one whole time equivalent (WTE) clinicalteam leader, four WTE Band 6 School Nurse, 1.47 WTEBand 5 School Nurse Staff Nurses and 1.38 WTE Band 4

School Nurse Nursery Nurses.The nationalrecommended staff levels of one WTE SpecialistCommunity Public Health Nurse (SCPHN) per secondaryschool which in Walsall equates to 17 WTE.

• The team spoke highly of the professional lead for theservice. The service had been fully reviewed since theprofessional lead had been in post. Staff told us theworkload had been made more fairer and evenly sharedacross the staff with particular regard to child protectioncases.

Managing anticipated risks

• There was a women’s and children’s care group riskregister in place. Four out of 21 risks directly related toCYP services however, none of them were noted on thecorporate risk register. All four were rated amber andhad a risk rating between 9 and 10 which was deemedby the trust as low to moderate. For example, one riskrelated to ‘poor access to child health records’ withinthe school nursing service which may impact on accessto safeguarding information’. Another risk related to‘physiotherapy equipment transferring to adults, noprocess currently in place to get funds back’. We saw allrisks were supported with an action plan and had beenreviewed in May 2015 or June 2015.

• We looked at the divisional quality meeting minutesheld in August 2015. The meeting reviewed incidentsand trends, audits, complaints and risks.

• The trust had a lone worker policy in place. Staff wespoke with described lone working arrangements in linewith the policy.

• Health visitors felt concerned that they did not have awork mobile phone to use when away from the office.They told us this had been raised with their managers.However, the response was to use their own phoneswherever possible. The staff did not feel this was anadequate response. Other teams within the CYPcommunity service had access to work mobile phones.

Major incident awareness and training

• We saw there was a major incident and adverse weatherpolicy in place and staff were aware how to access itwhen required.

Are services safe?



By effective, we mean that people’s care, treatment and support achieves goodoutcomes, promotes a good quality of life and is based on the best availableevidence.

SummaryThe effectiveness of children and young people serviceswas rated as good.

Services were underpinned by evidence-based practiceand followed recognised and approved national guidance.We saw CYP services participated in and completed clinicalaudits and performance of services was monitored andmeasured at regular intervals to achieve the best possibleoutcomes.

There was a multi-disciplinary approach to care andtreatment and a proactive engagement with other healthand social care providers to achieve best outcomes. Staffwere involved in local, regional and national forums. Staffwere appropriately trained and competent to do their role.

Transfers and transitions between CYP services wereplanned in advance. There was an assessment of the child’sindividual needs; this included working with other agenciesto assess, plan and coordinate care.

We saw staff gained verbal or written consent for eachnursing and therapy intervention.

We saw documentation to show that staff competencieswere checked, annual appraisals done and regularsupervision undertaken.

Evidence based care and treatment

• The trust policies and procedures were based onnational guidelines and best practice. Policies wereavailable on the trust intranet system and staff knewhow to access them.

• Standard Operating Procedures (SOP) had beendeveloped for the School Nursing team and thesefollowed national guidance in accordance with relevantgoverning bodies. This included the NMC (Nursing andMidwifery Council) and the RCPCH (Royal College ofPaediatrics and Child Health).

• The CYP service had developed an award winningintegrated asthma pathway. The pathway had reachedits targets to ensure 80% of asthmatic children on thepathway received an evidence based bundle of care ondischarge, 80% of carers were fully confident to manage

the child’s condition on discharge and 100% of familieswould recommend the service to another family whoneeded treatment for asthma. The community staff wespoke with were fully aware of the pathway and theirrole within it.

• The family nurse partnership service provided evidence-based, preventative support for vulnerable first timeyoung mothers, from pregnancy to until the child is twoyears of age. Family nurses delivered the programmewithin a defined and structured service model.

• Health visitors and their teams delivered the HealthyChild Programme (HCP) to all children and familiesduring pregnancy until five years of age. The HealthyChild Programme is the key universal public healthservice for improving the health and wellbeing ofchildren through health and development reviews,health promotion, parenting support, screening andimmunisation programmes. Health visiting staff hadbeen trained to use the Ages and Stages Questionnaire(ASQ) which considers the development skills of thechild. The CYP teams also told us they were trained inthe ‘Solihull Approach’ which is a behavioural approachto child health and wellbeing which increases theparents understanding of the child’s development.

• We looked at the audit undertaken in 2014 to assess theservice against the NICE guidelines for the managementand support of children and young people on theautism spectrum. A detailed action plan was in place toensure the service was aligned to the NICE guidelines.

Pain relief

• There were clear guidelines for staff to follow whichreflected national guidance where pain managementwas appropriate.

• The children’s nursing staff at a special school knew thechildren well and could identify if a child wasuncomfortable or in pain, based on their body language,noises and facial expressions. There was a StandardOperating Procedure in place for administering painrelief medication.

• We saw pain care plans were in place to supportchildren and young people who required pain relief athome and in special schools.

Are services effective?

Good –––


Nutrition and hydration

• Where appropriate, children had a nutritional andhydration plan in place which reflected nationalguidance and demonstrated a multidisciplinaryapproach to meeting children’s dietary needs.

• Children who were at risk of obesity had access to aweight clinic to monitor their progress. The child andtheir parents had access to a dietician who provided aregular review of their dietary requirements andprovided dietary support for parents.

• There was a multidisciplinary paediatric dysphagiateam in place providing support and advice for childrenwith feeding and swallowing difficulties. As part of thedysphagia pathway, eating and drinking plans and dietadvice leaflets were developed.

• The National Child Measurement Programme team toldus they had a good professional relationship with thelifestyle services within the trust and meet with them bi-monthly to discuss their findings from the schoolmeasurements.

• A specialist health visitor ran the tongue tied clinic forbabies. Tongue tie is a thin piece of skin called thefrenulum which attaches the baby's tongue to thebottom ofits mouth. Tongue tie restricts movement ofthe tongue and can often make breastfeeding difficult.Staff reported good referral pathways into the service.There was no information available as to how manybabies were placed on the pathway.

Patient outcomes

• The professional lead for health visitors told us the newnational indicator for antenatal contact from 28 weekspregnant onwards had been in place at the Trust sinceNovember 2014. Further work was being carried outwithin the trust to address antenatal contacts with ahigh social need.

• The health visiting service monitored the post-natal 10to 14 day visit on a weekly basis. The figures for August2015 showed the target of 95% was met apart from thefinal week which showed a figure of 93.4%.

• The percentage of children who received a 12 monthreview from April to June 2015 was 83%. Theprofessional lead for health visiting told us the figureshad increased each quarter due to the increase in staff.

• The percentage of children who received a two to twoand half year review was 87% from April to June 2015.

The breastfeeding initiation rate for April to June 2015was 65% against a national target of 73%. Hospitalbased peer support workers supported the service andinitiation rates have increased. The local ClinicalCommissioning Group (CCG) target is set at 65%.

• The Woman and Children’s division looked at improvedintegrated care between the hospital and thecommunity services. A new paediatric referral pathwaywas in place. Referrals were reviewed every Fridaymorning by a multidisciplinary team to ensure thechildren, young people and their families were directedto the most suitable team to support the bestoutcomes.

• The National Child Measurement Programme teamreported their latest target figures as 99% for theweighing and measuring of year six children and 99 % ofreception age children against a national target of 85%.

• The Teenage Pregnancy team reported significantimprovements for the teenage pregnancy rate and theabortion rate. Since 1998 the conception rate has fallenfrom 47% to 36%. The date from 2013 showed theabortion rate had fallen from 18.9 per 1000 teenagepregnancies to 14.4 per 1000. The repeat abortion ratefor Walsall in 2012 was double the England rate but in2014 had reached the same as the England rate at 10%.

• The school nursing team recently won the contract todeliver their services across the borough. The newcontract started 1 August 2015. Discussions werecurrently in place with the commissioners to setbaseline targets for monitoring the quality andoutcomes of the service. The professional lead forschool nursing told us the qualitative data collected viathe service was an integral part of measuring the qualityof the service. We saw feedback from parents followinga parenting group such as,

“I’m glad we came on the course” and “It has beenexcellent.”

• The community CYP service monitored feedback fromservice users through the ‘I Want Great Care’ initiative.Online feedback from August 2015 regarding postnatalcare said “I was always kept fully informed of all aspectsand received full support and information from thecommunity team.”


Good –––


• A new monthly audit had been introduced in thechildren’s nursing team to assess the quality of serviceagainst the Paediatric Care Quality Standards. Staff toldus they did not take part in any national audits.

• All teams we spoke with undertook an annual recordsaudit. We were told that good compliance was achievedwith the audit however, there were no audit results tosupport this statement.

Competent staff

• Newly employed health visitors said they felt wellsupported in their teams, had received an appropriateinduction and found the preceptorship programmehelpful. This consisted of a two week orientation,followed by twelve weeks with a small caseload. Acompetency booklet was completed which ensured thehealth visitors had the relevant skills and knowledgesuch as communication skills, health promotion andbeing able to use the Ages and Stages Questionnaire.

• Assistant practitioners in the children’s nursing servicewere assessed for their competency by the registerednurses. Nursing staff within the CYP community teamwere assessed against a competency framework whichcovered areas such as the care of the child requiringsuction and care of the child requiring wound care.

• Staff across CYP services demonstrated they possessedsufficient knowledge and were competent to delivercare and treatment to children and their families. Theyfelt well supported in their personal development plans.

• Some of the staff had been able to access the trustleadership development programme and found thisvery helpful to their work.

• All staff spoke positively about the quality andfrequency of their supervision sessions. All the staff wespoke with said they had received an appraisal duringthe last year.

• The trust had a corporate membership to the Institute ofHealth Visiting which offers further online evidencebased courses for the health visitors to access.

• The Family Nurse Partnership team used an onlinecompetency framework. This assessed skills andknowledge in areas such as accountability and buildingconfidence. They felt competent to do their work andwere able to do weekly supervision sessions and haveaccess to a psychologist on a monthly basis to discusscases.

• A lactation consultant is currently being trained tofurther support the breastfeeding team.

• The nursery nurses all have a competency based area ofexpertise such as toilet training, baby massage andgetting ready for school.

• The therapies team used a training needs analysis toidentify the need for postgraduate training fordysphagia support.

• The assistant practitioner in the children’s’ communitynursing team was signed off as competent to manageand administer the medicines. We looked at thecompetency record and saw this had been completed.

• We saw competency documentation which confirmedchildren’s community nursing staff were trained and hadtheir competencies assessed and signed off inadministration of medication via a nasogastric tube andthe administration of medication via injection.

Multi-disciplinary working and coordinated carepathways

• There was evidence of multi-agency working at the‘team around the child’ meetings with effective sharingof information and detailed planning to meet the child’sneeds.

• To improve communication between the health visitingand school nursing team, a handover week wasarranged every September for health visitors tohandover their notes and ensure they are up to date.The services discuss how they overlap and how care canbe best coordinated.

• Staff told us of proactive engagement with other healthand social care providers to coordinate care and meetthe needs of the children and young people in Walsall.They were proud of their positive working relationships.

• Staff talked about the need to see further integratedcare pathways but were pleased with the progress todate.

• School nurses told us how they engaged with theasthma pathway by offering training and advice toschools as part of their MDT working.

• School nurses and health visitors sit on the Multi-agencySafeguarding Team.They supported any backgroundchecks required on the NHS systems for children withidentified health issues.


Good –––


• The multidisciplinary members of the dysphagia teamworked closely together in order to produce anintegrated care pathway.They use shared electronicresource folders and a database to ensure an effectiveapproach to managing the joint caseload.

• The children’s community nursing team worked closelywith the Birmingham Children’s Hospital and the localhospice to ensure coordination of care. We observedinteractions between the specialist health visitor andthe children’s community nurse in planning coordinatedcare for a patient.

Referral, transfer, discharge and transition

• Referral arrangements were in place for children andyoung people transferring between services.Arrangements to transfer children from health visiting tothe school nursing service were well established.

• We spoke with the Transition team case manager. Theylooked after children from year 9 to age 25 years. Stafftold us that young people usually experience a smoothtransition to adult services.

• The transition team offered one to oneand groupsessions for children with physical impairment. Fundinghad just been secured to offer a youth club for childrenwith physical disabilities twice a month.

• We looked at the minutes for the transition meeting forpalliative and end of life care. The CYP transition casemanager and community children’s nursing serviceattended these meetings.

Access to information

• Across children’s centres, baby clinics, mainstream andspecial schools we saw information leaflets andbooklets available for parents that included clinic times,support networks, self-help group and contact details.

• The school nursing team had posters in all the schoolswith a picture of the named nurse, a description of theservices offered and the relevant contact details.

• The health visiting team published a weekly staffnewsletter called ‘Treat of the Week.’ This promoted anopen and transparent service, looked at changes inpractice, NICE guidelines and learning from incidents.

• The transition team developed a Facebook page forinformation sharing and support.

• The School nursing service werein the process ofimplementing the ‘Chathealth’ system which was due alive launch in 2016, this is endorsed by the Departmentof Health. This gives children and young people anopportunity to text questions on health issues. Aresponse is sent via text conversation which can lead todirect appointments. The conversation can be uploadedto the electronic records system.

• The community teams did not have a fully integrated ITsystem and access to comprehensive information waslimited if needed quickly.

Consent

• To assess whether a child was mature enough to maketheir own decisions and give consent, staff used the‘Gillick competences’ and ‘Fraser guidelines.’ We lookedat the school nursing Standard Operating Procedure(SOP) in place for consent.

• One staff member on the day of inspection told us theyhad used the SOP for consent when a child refused tobe weighed, even though the parents had previouslygiven consent. This decision was recorded on the notesand feedback given to the team leader.

• Parents told us they were always asked for verbalconsent and sometimes written consent depending onwhat the treatment of care was.

• We saw consent was recorded in school records andincluded in care pathways and documentation.


Good –––


By caring, we mean that staff involve and treat people with compassion, kindness,dignity and respect.

SummaryThe caring of children, young people and families was ratedas good. Staff were very caring and compassionate andstaff engagement was respectful and provided care in adignified way.

Staff involved children and parents through every aspect ofcare delivered and we saw staff took time to explain whatwas going to happen and answered questions clearly andpatiently. Parents were encouraged to be involved in thecare of their children as much as they wanted to be.

All parents we spoke with felt they had enough informationabout their child’s condition and treatment plan and wereinvolved in planning care. Feedback from parents wasconsistently positive.

Compassionate care

• Interactions we observed across all CYP services wereundertaken in a dignified and compassionate way.

• We talked with five parents who told us they werealways treated with dignity and respect.

• We accompanied children’s community nursing staff onhome visits. We observed how one nurse took extra careto support the mother in seeking betteraccommodation.

• We observed interactions between staff at clinics andschools. We saw staff helped children and their familiesunderstand the care treatment and care supportavailable to them. One parent said “We have been givenloads of information which is really helpful.” Weobserved one parent asking about changing from onefortified milk supplement to another type. Staff allowedtime for a full discussion and answered the parent’squestions before the decision was made. The parentwas happy with the decision they had made; we sawstaff had helped them make an informed choice.

Understanding and involvement of patients andthose close to them

• Support for children across CYP services was childcentred and we saw children and parents were involvedin decision making andtreatments and optionsavailable to them. The ‘team around the child’ model

was in place. This meant the team placed the child atthe heart of care provision and worked together toensure the child and their parent/carer were fullyinvolved where possible. All five parents told us they feltinvolved and knew where to go to seek any help andsupport.

• People we talked to told us, they felt understood andlistened to by staff, because staff had taken the time toexplain. For example, one child required a new feedingregime to prevent sickness. The nurse discussed withthe parent what could be done to improve the feedingand reduce sickness. They told the parent that thisinformation would be passed on to the communitydietician for further support.

• Staff were proactive about seeking the views of peoplewho used services and to ensure children and theirparents were not only involved, but understood theircare.

• The NHS Friends and Family test was used incommunity services. The campaign ‘I want great care’was also introduced in 2015. We saw feedback from the‘Starting Out’ group to support children and families onthe autistic spectrum. The feedback was rated as eitherexcellent or good. One parent said “It has helped meunderstand my child’s needs.”

Emotional support

• Parents told us they felt supported emotionally by staff.We observed staff providing emotional support tochildren, young people and their parents during theinspection. A parent who had received support from thetherapy staff told us “They have helped me at a greattime of need.”

• We saw a specialist health visitor offered emotionalsupport to a parent who was finding it difficult to gainsupport from friends and family. The parent explainedthey felt isolated , we saw the health visitor hadarranged visits at another address to reduce the parentsanxiety.

Are services caring?

Good –––


• An emotional health pathway was in place for theschool nurses to follow. This enabled staff to refer intolocal support groups, the GP or to escalate to a seniormanager for a referral to CAMHS.

Are services caring?

Good –––


By responsive, we mean that services are organised so that they meet people’sneeds.

SummaryWe rated this domain as good overall. The serviceresponded well to the needs of children, young people andtheir families.

The service was responsive to the diverse community anddifficult to reach groups. Staff worked with other healthprofessionals to provide an integrated and seamlessservice in a timely manner.

Services were delivered in a flexible way across awidespread geography at locations to suit the children andthe parents. This included health visitor clinics at theroadside to address the traveller communities.

There was a low level of complaints across the service.Parents told us they were aware of how to make acomplaint if needed. Staff had a good understanding of theprocesses and how to deal with complaints appropriately.Staff were very open to feedback and learning.

We saw children’s nursing services was not commissionedto offer 24 hour care services to children at home. We sawthe trust had plans in place to work around this with directaccess to the Paediatric Assessment Unit out of hours.

Planning and delivering services which meetpeople’s needs

• The Family Nurse Partnership service tailored supportand care to young expectant mothers, taking intoconsideration their individual circumstances.

• We attended home visits with the children’s nurseservice and saw care delivery was individualised to meetthe complex needs of children and support for theparents.

• We saw translators were sometimes used but there wasoften a problem with the service. For example, thebreastfeeding advice team told us they had booked aninterpreter to attend with a patient but they did not turnup. We observed one family attending a clinic. Thefather was always in attendance as the mother did notspeak English. It was not clear to assess whether thefather had given accurate feedback and information tothe mother.

• The service had a specialist health visitor for the asylumseekers and traveller communities. They worked closelywith the border agencies, police and local authority toplan and deliver the required services. Clinics were heldtwice a week on the traveller site and at the roadsidenear other camps, as required. Staff told us these clinicswere well attended and the specialist health visitor wasrespected for the service they offered.

• We saw Health Visitor teams provided care from varioussettings for example, children’s centres, baby clinics andchildren’s own homes. A pilot ‘well child clinic’ wasdelivered weekly at the children’s centre near the mainhospital between November 2014 and March 2015. Theprofessional lead told us data was being collatedandearly results showed attendance at the emergencydepartment (ED) for children had reduced. Informationprovided by the service post inspection showedsignificant reductions across ages 0 years to 5 years in2013/2014 compared to 2014/2015. For example inNovember 2013, 289 children aged 0 years wereadmitted to ED, in October 2014 the figure had reducedto 116. In December 2013, 258 children aged one yearwere admitted ot ED, this had reduced to 119 in October2014. The same trend applied across ages, two, three,four and five year olds.

• The ‘team around the child’ approach meant care wasplanned and delivered around the needs of the child.

• The children’s community nurse service included‘Hospital at Home.’ This service offered a two weekpackage of continuing care following discharge fromhospital from conditions such as bronchiolitis andgastroenteritis. The child was then discharged from thepackage if suitable or referred back to the paediatricassessment unit for further advice. Staff told us thepackage of support could be extended if required tomeet the needs of the child and their family.

• School Nurses told us they offered their service tochildren who were electively home educated.

Are services responsive to people’s needs?

Good –––


Equality and diversity

• CYP staff had access to translators, success of theservice was variable and depended on whether thetranslator was booked well in advance and also if theyturned up to the appointment.

• < >YP services provided advice literature in a differentstyle to ensure parents understood the information.The Speech and Language therapy team had introducedan audit to look at families where English was not theirfirst language. The team lead told us the results wouldhelp inform and improve future service. We saw equalityand diversity training was well attended across CYPservices. For example, Children’s nurses and FNPachieved 100%, Health Visitor teams within the Southand North clusters achieved 100%, Health Visitor teamswithin the Central cluster achieved 97% and East clusterteam scored 89% against a target of 90%. There were nofigures available for therapy services.

Meeting the needs of people in vulnerablecircumstances

• We saw teams working together to meet the needs ofvulnerable children through specialist pathways, forexample, autism spectrum disorder, dysphagia andcomplex health needs.

• The children in care team provided specialist services tochildren looked after by the local authority. Initial healthassessments were offered to all young people in care.The service had reached 100% of assessmentscompleted.

• The team saw children in school if required and workedclosely with other agencies such as fostering. Some ofthe children in care were offered a place on the ‘Teensand Toddlers’ programme, looking at developinghealthy relationships.

• Support was offered to young people in care withcomplex needs up to the age of twenty four.

Access to the right care at the right time

• We visited a young mother at home who was receivingcare for her new baby. The children’s community nursehad trained the mother to change nasogastric tubes anddeliver feeds so that care could be given through thenight at home. She told us:“I’ve been supported all theway along.”

• We noted strategies to improve breastfeeding rates suchas drop in groups. A large event was held in the mainshopping centre in Walsall to promote breastfeeding.

• Access to the children’s nurse service covered sevendays a week but was limited out- of -hours. There wasno service provision from 8pm to 8am Monday to Fridayor from 4.30pm to 8am Saturday and Sunday. Trainingwas offered to parents for some of the interventionsrequired but not all parents wanted to have thisresponsibility. Should a parent require support out -of -hours for example, their child’s blocked catheter orfaulty syringe driver, the parent was required to taketheir child to hospital.

• We saw there was an enuresis (bed wetting),constipation and allergies provision within CYP serviceswith a range of clinics available.

• A duty service was available for the school nursing andhealth visiting teams. This was a separate duty systemvia a single point of access for school nursing servicesmanned by a SCPHN. This meant the right care wasgiven at the right time and place.

Learning from complaints and concerns

• Staff we talked with were aware of and knew how toaccess the trusts complaints policy.

• We saw PALS (patient advice and liaison service) posterswere displayed in clinics, children centres and schools.

• Staff were able to tell us how they would try to resolvecomplaints locally and when to escalate to seniormanagement.

• Staff told uslearning from complaints had beencommunicated back to them. For example, staff wereaware of a recent complaint from a patient aboutinappropriate car parking during a home visit and howthey were to be more careful in future.

• From April 2014 to March 2015 there had been 19complaints reported. Eight related to dissatisfaction ofmedical treatment. Seven related to either long waits inthe clinic or cancelled appointments. Other complaintsrelated to failure to obtain consent, attitude of non-clinical staff and dissatisfied nursing care.


Good –––


• We saw all complaints had been investigated; four hadbeen upheld, seven were partially upheld, four were notupheld, two had been resolved locally and two were stillin progress.


Good –––


By well-led, we mean that the leadership, management and governance of theorganisation assure the delivery of high-quality person-centred care, supportslearning and innovation, and promotes an open and fair culture.

SummaryWe rated the well-led domain as good.

The leadership, governance and culture promoted thedelivery of high quality child-centred care.

Staff knew and understood the trusts’ vision and felt CYPservices was connected to the trust as a whole. Staff werevery happy with their teams and made particular note ofthe leadership of the professional leads. Governancearrangements to monitor and measure care quality andperformance were robust and structured.

Local leaders took a proactive approach to improve careand the experience for children, young people and families.

Staff were well supported by local and senior leaders andfelt most of the executive board had the right skill set andexperience to take the trust forward. The staff felt there wasa lack of senior clinical engagement within CYP servicesand they were not visible.

Across all CYP services staff were committed andcompassionate in delivering quality care and took pride instriving to deliver the best care possible. Staff were proudof their innovative practice and had introduced several newinitiatives.

Service vision and strategy

• The senior management team for the Women’s andChildren’s directorate had a clear vision for the service.Staff felt the new care groups were working well andcould see changes for the better following theappointment of the directorate director.

• Staff across CYP services told us they thought the trustwas working together in the right direction.

• Staff from all disciplines described themselves as‘happy’ to work within their respective teams and wereproud of the care and treatment they provided tochildren young people and families. This was displayedby all staff we talked to individually and in staff focusgroups.

• We saw strong local leadership of all the teams and allstaff spoke well of their local managers.

Governance, risk management and qualitymeasurement

• The quality of care was monitored and measured andperformance was discussed at weekly team meetingsand monthly governance meetings. We looked at theminutes from the monthly team ‘connect’ meetings andquality meetings. Topics such as: risks, incidents andtrends, audits, complaints, safeguarding, workforce andtraining were all discussed.

• Key messages were further shared to staff to encourageimprovements in practice at the monthly staff meeting.

• Staff confirmed information had regularly been sharedwith them.

• The CYP community service had a risk register in placewhich identified sixteen risks in total. Action plans werein place against all the identified risks, we saw they hadbeen reviewed at regular intervals.

Leadership of this service

• Staff told us their immediate care group managers,directorate leads, professional leads and the chiefexecutive were visible, accessible and approachable,and described good support systems in place. We weretold by many staff across the CYP service they neededmore support and leadership from Director of Nursingwho was not as visible across community CYP servicescompared to acute services.

• Staff felt the professional lead for school nursing and theprofessional lead for health visitors were making a realdifference’ to the services they provided. Strong localleadership was also evident across therapy services.These services were well-organised and strong teamworking and collaboration was encouraged. Themessage of the child at the centre came across veryclearly when speaking with the team leads.

• Staff were supported to attend mandatory andspecialist training where required. Supervision was apriority across the service.

• Health visiting staff were not happy about the upcomingchange to wear a uniform. They felt they had not been

Are services well-led?

Good –––


listened to and had provided evidence this was not whatthe patients wanted. At the time of the inspection, thestaff felt the decision had been made to move towards auniform.

• We saw lone working arrangements did not work wellfor health visitors. They were not provided with trustmobile phones and had to use their own. There wasdisparity across the CYP service in this respect.

Culture within this service

• Staff told us and we saw there was a very positiveculture within the service and staff supported eachother well. We saw staff worked well together in multi-disciplinary teams and this ethos was evidentthroughout the visit.

• Staff were hard-working and committed to providing thebest care possible to children, young people and theirfamilies on a daily basis. Some of the administrationstaff said they had witnessed on many occasions, staffgoing over and above their duty to ensure patients werelooked after well, for example, working late, startingearly and coming in on their days off, if the team wasshort staffed. Staff appeared self-motivated andenergised to continually improve, giving many examplesof innovative practice.

• The National Child Measurement Team had recentlybeen aligned with the school nursing team. We weretold that staff were happy with this move as it providedmore integration to review data and improve outcomesfor children.

• The professional leads for health visiting and schoolnursing spoke positively of the improved culturebetween their services.

• Staff described an open working culture where theywere able to report incidents, concerns and complaintswithout fear of any recriminations.

Public engagement

• We saw a number of example show CYP staff were keptinformed by managers of service developments. Forexample, we looked at ‘Treat of the Week’ newsletterand staff told us how helpful they were for providinginformation.

• Services used a variety of methods to collect feedbackfrom patients and parents regarding the care andtreatment provided. We saw ‘iWantGreatCare’ was inplace in the community. We saw feedback collated fromthe health transition team following a recent course. Allfourteen respondents said the staff had helped co-ordinate their needs. The Looked After Children teamused an iPad device to capture feedback afterattendance at clinics. We looked at the feedback from a‘Friends for Life’ course, giving children and youngpeople time to help improve self-esteem andconfidence. The children’s version used a ‘smiley’ faceapproach. The adults completed a questionnaire.

• We saw services gathered verbal and written feedbackin the form of thank you letters and cards to evidencesatisfaction across CYP services. For example, one youngmother from the children’s nursing service sent a cardsaying, “Thank you so much for the great care we havereceived. You have been a lifeline.”

Innovation, improvement and sustainability

• We saw a range of innovations which helped provide aflexible and responsive service. These included ‘ChatHealth’ texting service for school children and theFacebook page for young people in transition service.

• Senior managers encouraged innovation andimprovements in practice across CYP services. Theywere proud to be the only trust in the Black Country tosecure their own school nursing tender.

• There was a lack of innovative use of IT technology forthe staff working away from their desks.

Are services well-led?

Good –––


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