Bradford Royal Infirmary

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We rated this question as good. Safety was considered a priority for the service. Staffing levels and skill mix were managed to ensure safety within the unit. Staff completed safeguarding training and understood how to protect people from abuse. There were safe systems and pathways in place. The service managed safety incidents well and learned lessons from them.

This service scored 84 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We saw that feedback from people using the neonatal service was highly valued across all areas of the service in order to ensure that there was a consistent culture of safety and learning that truly involved everyone. The team consistently reviewed processes for feedback from families and looked for innovative and creative ways to engage families in providing feedback to embed good practices.

Prior to our assessment concerns had been raised to us about how the unit learned from incidents. These concerns had referenced incidents that occurred during 2021. We reviewed these incidents and talked with staff about learning. We understood from leaders that the team had worked well together to develop a consistently positive learning culture. During our assessment staff at all levels and in all parts of the neonatal service consistently told us about an open learning culture. We heard about regular learning opportunities that were inclusive of all staff. Staff told us they were confident in reporting incidents and raising concerns. Actions were taken in a timely manner. Risks were not overlooked or ignored. We heard an example of a recent incident that had been reported and acted upon within 24 hours of the incident report. There was an understanding across the neonatal service that raising concerns helped to proactively identify and manage risks before safety events might happen. We heard examples of immediate learning following incident reporting.

We saw and heard about clear processes and opportunities for learning that were embedded into daily practice. We saw evidence that incidents and complaints were appropriately investigated and reported. The findings were linked to daily practice and made accessible for all staff through recognised learning processes. For example, there was a weekly Friday learning session. This information was also shared visually through a weekly bulletin and displayed on notice boards. During our assessment we found lessons were consistently learned from safety incidents or complaints, resulting in changes that improved care for others and embedded areas of good practice.

The views of people who use services, partners and staff were listened to and taken into account by the neonatal team. The team had listened to peoples experiences and made improvements to systems, pathways and transitions for families using the neonatal service. For example, we heard that ward rounds had been set up for parents or carers to attend virtually as feedback had suggested that attendance was not always possible. We also saw that following feedback from a family, a clear process for downs syndrome diagnosis had been developed. This detailed ongoing care with expected pathways and transitions until the age of 16 years.

Safety and continuity of care was consistently a priority throughout families and babies care journeys. This happened through a collaborative, joined-up approach to safety that involved babies and families along with staff and other partners in their care. This included engaging with mothers and birthing people pre-delivery, discussing admission and transfer to the neonatal service post-delivery, admissions and transfer between the neonatal areas within the neonatal service and transfer of care to other services. There was a strong awareness of the risks to people across their care journeys. The approach to identifying and managing these risks was proactive and effective. Staff and leaders were able to clearly identify that the effectiveness of processes were regularly monitored and altered accordingly to ensure the needs of all babies and families were met. Care and support was planned and organised with people, together with partners and communities in ways that ensured continuity.

We spoke to a range of professionals including nurses, doctors, physiotherapist, occupational therapist, psychologist and bereavement worker. We met with staff in all areas of the neonatal unit, the neonatal transitional care unit and the neonatal outreach team. We also sought feedback from a local hospice service that worked closely with the unit. We heard there were effective referral routes and pathways through the services ensuring timely transitions.

Care records we reviewed evidenced appropriate referrals were made where necessary. We reviewed a range of guidelines including transition to the neonatal outreach service, two year and neuro-developmental follow up programmes. These were appropriately aligned with other key partners involved in babies and families care journey to enable full involvement of families and holistic care provision.

We did not speak directly to families regarding their experiences of safeguarding. However, we reviewed a security and abduction risk assessment that set out the involvement of families in supporting the safety of themselves and others within the unit. This provided evidence that families were supported to understand safeguarding, what being safe meant to them and how to raise concerns if they or others did not feel safe.

All staff we spoke to where aware of safeguarding procedures and how to make a safeguarding referral. Staff were knowledgeable about signs of abuse or neglect and community based staff were aware of the process to follow should they witness any concerns regarding, for example, siblings or non-accidental injuries in families homes whilst visiting. There was a clear commitment to taking action to safeguard families, children and babies from abuse and neglect.

There was an up to date children's services policy on safeguarding children. Staff completed safeguarding training in line with trust requirements. There were effective safeguarding processes in place. We observed a weekly safeguarding meeting for neonatal services that demonstrated effective safeguarding systems, processes and practices including working collaboratively with partner agencies. The neonatal team also liaised closely with the midwifery team to ensure awareness of any safeguarding concerns in a timely way on transfer of babies between units.

Feedback from families who used the neonatal services was consistently positive and demonstrated that families were involved and empowered to manage risks to support keeping their babies and themselves safe. For example, families provided positive feedback about the opportunity to attend ward rounds, to learn and be involved in all aspects of decision making.

Staff told us about daily huddles, ward rounds and opportunities to discuss and manage risk. Risks were assessed for babies and families throughout their involvement with neonatal services including on the neonatal unit, transitional care and outreach support. Clinical risk was assessed alongside holistic risk assessments of the wider family needs. We heard about positive learning carried out collaboratively between allied health professional and nursing staff that supported longer term holistic risk management. For example, the importance of skin to skin contact and swaddling techniques in promoting longer term positive mental well-being for babies.

We found appropriate processes in place to ensure risk assessments were carried out in a timely way. The service used nationally recognised risk assessments and staff followed evidence based practices to manage risk. Routine daily checks were carried out through huddles and ward rounds alongside record keeping checks and audits as assurance that areas of risk were constantly monitored and managed. We saw evidence of family involvement through visiting logs and consistently heard that ward rounds provided excellent opportunities for family involvement throughout their journeys. The service had processes in place to regularly review the understanding of staff regarding the importance of involving families and supporting them to be primary care givers.

Feedback from families who used the neonatal services was consistently positive and demonstrated that families felt cared for in a safe environment that was designed to meet their needs. We spoke with 10 women who gave a positive response when asked about the cleanliness of the units and no concerns were raised. Visitors to the unit were able to access large theatre style handwash units on entering. There were videos in the immediate area explaining the correct handwashing technique and prompts by reception staff.

Staff disposed of clinical waste safely. Staff knew what arrangements were in place for the handling, storage, and disposal of clinical waste, including sharps. Staff were trained to use equipment and managed clinical waste well.

The design, use of facilities and equipment kept people safe. All sharp boxes that we looked at were signed, dated, and stored appropriately. Parents and carers had access to their own fridge to store breast milk. There was also another dedicated locked milk fridge. There was a kitchen area and room where parents and carers could access hot drinks and meet with other parents and staff. Facilities, equipment and technology were well-maintained and consistently supported staff to deliver safe and effective care. There were effective arrangements to monitor the safety and upkeep of the premises. Equipment used to deliver care and treatment was suitable for the intended purpose. All equipment was stored securely and appropriately.

We saw that staff carried out effective daily safety checks of specialist equipment such as on the resuscitation trolley equipment and checked safe storage of oxygen cylinders. All daily checks had been completed for the previous six months for the resuscitation trolley, as per process. A recent audit for the neonatal unit showed high compliance for managing waste and the safe handling and disposal of sharps. The emergency call bell was tested daily and could be heard in all areas.

Feedback from people demonstrated that families felt their needs were able to be fully met by the staff working in all areas of the neonatal care service. 'Staff were really helpful they gave me and baby all the care we needed.'

Leaders provided detailed explanation regarding recruitment, evidencing practices that ensured staff were suitably experienced and competent to carry out their roles. For example, we reviewed a comprehensive neonatal clinical skills and competency document designed for new nurses starting in the service. This set out clear competencies to be achieved over a 12 week period. The document also outlined support available for staff to be able to achieve this goal. We heard that where necessary, capability and disciplinary policies were followed in a fair and non-discriminatory way. Leaders were able to clearly articulate the staffing position at the time of assessment. Leaders were aware of the requirements for safe staffing numbers. At the time of our assessment bank staff with appropriate skills and qualifications were used to ensure safe staffing levels and skill mix. We heard about recent and ongoing active recruitment and a planned trajectory for the service to be fully staffed by September 2024. There was evidence of an increase of staffing numbers from the previous year. Leaders were confident that this was a realistic and achievable target. Leaders and staff we spoke to were clear that there was support to attend training that was relevant to the role. Staff had the support they needed to be able to deliver safe care. Staff felt supported to develop within their role and that there were definite routes for progression.

During our assessment we observed staffing levels to be sufficient to meet the needs of babies and families being cared for.

There were clear processes in place for live daily review of staffing levels required to meet the nationally recognised standard according to level of need in the service at any point in time. When staffing did not meet required numbers there was clear escalation guidance in order to ensure continued safety of babies and families using the service. The service worked alongside other regional services in the event that bed areas needed to be closed to ensure safe staffing was maintained.

We saw families and visitors involved in infection, prevention and control (IPC) practices as they entered the unit. All visitors were educated around the importance of hand washing and storing personal belongings appropriately in lockers provided. There were publicly available videos that provided guidance for families and visitors entering the unit including appropriate infection, prevention and control practices to be carried out by all. The infection, prevention and control policy referred in detail to the involvement of families and visitors in maintaining the high standards of the unit.

Leaders told us infection was a consistent and important focus at each daily huddle discussion. Leaders told us about a rolling programme of audit that was carried out and supported constant improvement or change to practices where needed. We understood from staff that babies were protected as much as possible from infection and high expectations were maintained. For example, within the neonatal unit the team had implemented three hourly high touch point cleaning. The outreach team told us they always had sufficient personal and protective equipment (PPE) equipment when working within the community.

During our inspection we observed a consistently high level of IPC practices within the neonatal unit. Staff and visitors adhered to hand hygiene practices. Domestic and housekeeping staff were visibly active in the management of the unit to ensure infection risks were kept to a minimum.

The neonatal service had clearly identified IPC leads with a designated infection team. There were clear processes in place for bespoke audits and constant review of practices. Senior leaders carried our regular walk rounds of the unit. We saw evidence of actions identified as a result of the constant review of practice. The neonatal unit lead consultant for IPC chaired a regional meeting specific to IPC for neonatal services and cross site visits took place with other regional units for shared learning. Good quality data was gathered regarding IPC, for example, an incident report would be completed if an incubator wasn't changed or ventilator circuits not changed at appropriate times. This data supported ongoing learning within the unit. There was an up to date IPC policy in place. The policy was in line with current relevant national guidance. The policy outlined clear processes for communication across agencies where there was transfer of babies. There was clear guidance for families and visitors entering the unit regarding IPC practices.

Staff survey results showed that the service had developed an open incident reporting culture. 95% of staff agreed that incidents were always reported and 88% agreed that actions was taken as a result from learning from incidents. Staff told us they felt supported in their role. They told us they had access to information and tools that supported them in their role, such as information on injectable medicines. The service had an experienced care coordinator that was supernumerary to support junior staff. This had been identified through a quality improvement project and had been received well by staff.

The service monitored and recorded observations of the babies. Records of administered were recorded as per national guidance on paper based records. Weights of babies were recorded and updated regularly. Allergies were recorded. The service monitored the temperature of medicines requiring refrigeration. However we saw instances of fridges being filled beyond capacity which can impact the temperature of the medicines contained within them. Parenteral nutrition was prescribed using a proforma. Records we reviewed showed that the proforma's were completed. Emergency medicines and equipment were accessible by staff.

The service did not have a dedicated specialist pharmacist but were supported by pharmacists from other areas with relevant knowledge and experience including during out of hours. They offered support to each area of the unit, dependent of the needs of the babies. Babies who required more support were reviewed more regularly. The service had a process for the management of controlled drugs. Staff described the process of destroying controlled drugs. The service had a process for uploading information so that paper records could be accessed by other departments. We were not made aware of any concerns around this process. The service had a process for creating bespoke total parenteral nutrition (TPN) if required through the aseptic unit. Staff told us they rarely used this route. The service had a process for reporting and learning from incidents. Information was cascaded down through regular team meetings and engaging posters that were available in the unit and on social media channels. The service had completed monthly medicine management audits. We saw actions around storage of intra-venous (IV) medicines had been taken as a result.