1.1
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 1.1
Recommendation · source text
The Health Board should complete and implement its family involvement and engagement strategy at pace and provide a robust mechanism for family feedback that is compatible with the mature engagement approach developed across maternity services. The strategy should be personalised to the needs of women and families using perinatal services and build upon feedback from both current and past service users (1.1).
1.2
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 1.2
Recommendation · source text
Current breastfeeding support should be reviewed to ensure there is sufficient capacity to meet the needs of service users (1.2).
1.3
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 1.3
Recommendation · source text
Peer support networks should be developed for families both within neonatal services and following discharge (1.3).
1.4
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 1.4
Recommendation · source text
The neonatal service should have dedicated psychological provision to support families and staff (1.4).
1.5
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 1.5
Recommendation · source text
A framework for Family Integrated Care should be implemented and its impact evidenced (1.5).
2.1
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 2.1
Recommendation · source text
Health Board governance processes need to demonstrate sustained achievement of improved safety and clinical effectiveness within the neonatal service (2.1).
2.2
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 2.2
Recommendation · source text
The Health Board must improve its ward to Board assurance processes with specific focus on the quality of incident reviews and how any safety-critical findings are identified and shared through the Integrated Locality Group governance structures to the Board. This must demonstrate sustained advances in the safety and effectiveness of neonatal service provision at Prince Charles Hospital (2.2).
2.3
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 2.3
Recommendation · source text
Evidence of detailed discussions taking place regarding clinical outcomes and clinical audit should be provided to the Integrated Locality Group and Health Board committees to ensure Executive level oversight of clinical performance and trajectory (2.3).
2.4
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 2.4
Recommendation · source text
Clinical audit needs to be valued, resourced and utilised at all levels and must be of a high quality to promote confidence in applying findings to developing services (2.4).
3.1
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 3.1
Recommendation · source text
British Association of Perinatal Medicine (BAPM) standards should be adhered to for both nursing and medical workforce provision and structure (3.1).
3.2
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 3.2
Recommendation · source text
Extra consultant time needs to be provided to allow for a consultant of the week pattern from 09:00 - 17:00. All consultants who cover the unit on call should have a minimum of four neonatal service weeks per annum (3.2).
3.3
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 3.3
Recommendation · source text
There should be investment in a Neonatal Unit Senior Nurse position who is in part Matron and part Improvement Lead Nurse to ensure there is a stable senior nursing leadership structure with the specialist ability and leadership experience to know and deliver ‘what good looks like’ (3.3)
3.4
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 3.4
Recommendation · source text
The Advanced Neonatal Nurse Practitioner team should be expanded with clear career progression including protected time for development within the four pillars of advanced practice. Tier 1, Tier 2 and nurse consultant roles should be explored (3.4).
3.5
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 3.5
Recommendation · source text
There should be rotation of nursing and medical teams to exemplar neonatal units to support maintenance of competence in key clinical skills and decision making (3.5).
3.6
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 3.6
Recommendation · source text
Additional investment is required for nursing quality roles. Resilience needs to be developed, for example by ongoing internal rotation of Neonatal Unit staff into these roles (3.6).
3.7
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 3.7
Recommendation · source text
Additional investment is required to enable the nurse in charge role to be supernumerary (3.7).
3.8
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 3.8
Recommendation · source text
There should be adequate provision for Allied Health Professionals for neonatal services in line with national recommendations. These roles should be integrated within the Neonatal Unit permanent workforce (3.8).
3.9
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 3.9
Recommendation · source text
There needs to be an expansion of clinical pharmacist resource dedicated to the neonatal service, including capacity for networking to develop expertise and exemplar practice within the Neonatal Unit (3.9).
3.10
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 3.10
Recommendation · source text
Mandatory training compliance needs to improve across all staff groups. This needs to be facilitated within working hours (3.10).
3.11
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 3.11
Recommendation · source text
Nursing, midwifery and medical Newborn Life Support (NLS) instructors need to be identified within the Health Board to support robustness in NLS local training and simulation training (3.11).
3.12
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 3.12
Recommendation · source text
A specific nurse teaching programme should be developed, linking into network nurse teaching (3.12).
3.13
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 3.13
Recommendation · source text
There should be a robust system for clinical supervision within the workforce linked to annual appraisal and training needs analysis for the Neonatal Unit. This should be provided in a safe and supportive manner (3.13).
3.14
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 3.14
Recommendation · source text
Simulation training should use case examples to support learning in practice as a perinatal multidisciplinary team. Scenarios including intubation with drug preparation must include all levels of nursing and medical colleagues (3.14).
3.15
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 3.15
Recommendation · source text
Simulation training should be joint with all professionals involved within perinatal services locally and the wider perinatal network. Simulations should use case examples to support learning in practice (3.15).
4.1
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 4.1
Recommendation · source text
Learning from incidents needs to ensure the context of the incident and potential for human factors are considered and explored (4.1).
4.2
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 4.2
Recommendation · source text
Work to better understand and develop a culture focused on safety, awareness and communication across the perinatal multidisciplinary team needs to be undertaken (4.2).
4.3
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 4.3
Recommendation · source text
Reflective practice must be included within unit learning and incident reviews. This can be both personal and multidisciplinary (4.3).
5.1
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 5.1
Recommendation · source text
The clinical team must ensure completeness and accuracy of Neonatal Unit data (5.1).
5.2
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 5.2
Recommendation · source text
Neonatal dashboards should encompass a range of performance and quality metrics, supplemented with a narrative highlighting key points and identifying trends. The responsibility for this lies with the senior clinical team (5.2).
6.1
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 6.1
Recommendation · source text
There needs to be joint ownership of assurance and governance of aspects of care that are co-dependent on neonatal and maternity services via the Integrated Locality Group governance processes (6.1).
6.2
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 6.2
Recommendation · source text
The working arrangements of the Neonatal and Maternity Improvement Teams should be reviewed to ensure effective joint working which addresses current issues related to silo working in clinical care (6.2).
6.3
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 6.3
Recommendation · source text
Neonatal and maternity teams must work together at all levels to support changes in service delivery. These include appropriate place of delivery, reducing term admissions and developing Transitional Care provision; specified consultant staff should have named responsibility for each of these elements and should be led in conjunction with designated members of the nursing and midwifery teams (6.3).
6.4
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 6.4
Recommendation · source text
All developments across perinatal care must involve an appropriately diverse service user voice at national, network and local levels (6.4).
7.1
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 7.1
Recommendation · source text
Communication with families on the Neonatal Unit must be timely, open and honest and comprehensively documented (7.1).
7.2
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 7.2
Recommendation · source text
Support is required from tertiary neonatal services to support immediate clinical decision making in cases where infants require short term stabilisation and intensive care. There should be clear escalation processes in place and a trigger list to support early recognition of the need to refer (7.2).
7.3
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 7.3
Recommendation · source text
Prescribing standards must be improved with a continued focus at identifying, resolving and minimising prescription errors. There needs to be clear accountability for all staff involved in prescribing and administering medicines and should be supported through the additional pharmacy support on a daily basis (7.3).
7.4
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 7.4
Recommendation · source text
Management of therapeutic hypothermia should be supported with robust guidance in line with national best practice frameworks (7.4).
7.5
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 7.5
Recommendation · source text
Standards of formal radiology reporting pertaining to the neonatal services should be audited (7.5).
7.6
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 7.6
Recommendation · source text
Documentation standards must be improved in line with GMC/NMC requirements and there must be senior medical oversight of discharge summaries (7.6).
7.7
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 7.7
Recommendation · source text
The incident reporting trigger list should be followed to ensure reporting and subsequent multidisciplinary review of all significant events, for example babies requiring therapeutic hypothermia (7.7).
7.8
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 7.8
Recommendation · source text
There are several areas of focus for local quality improvement projects including reducing unplanned extubation and optimising perinatal care. National toolkits should be used locally, and multidisciplinary involvement is required for success in these areas (7.8).
7.9
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 7.9
Recommendation · source text
External support should be used to ensure standards of robust review that support local learning and improvement (7.9).
7.10
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 7.10
Recommendation · source text
Review should take place of the remaining 22 clinical cases from 2020 identified to the review team as fulfilling criteria for assessment, as only a representative sample (25 of 47) was examined (7.10).
7.11
Addressed to: Cwm Taf Morgannwg University Health Board
No Response Published
Link to recommendation 7.11
Recommendation · source text
Clear documentation of uncertainty and reflection within clinical decision-making should be encouraged and accepted as standard practice (7.11).
8.1
Addressed to: the Welsh Government
No Response Published
Link to recommendation 8.1
Recommendation · source text
A review of neonatal critical care services in Wales is suggested. This should include capacity, patient flows, transport services and the network role within operational consistency and assurance (8.1).
8.2
Addressed to: Healthcare providers and commissioners
No Response Published
Link to recommendation 8.2
Recommendation · source text
Healthcare providers and commissioners need to actively look at high risk clinical services and seek assurance that outcomes are in line with national standards and that services are safe. Where standards cannot be met, this should be shared transparently within an organisation and escalated so that services can be supported to improve (8.2).
8.3
Addressed to: Maternity and Neonatal Networks
No Response Published
Link to recommendation 8.3
Recommendation · source text
Maternity and Neonatal Networks should be responsible for oversight of outcomes and key safety metrics (8.3).
8.4
Addressed to: The Welsh Government
No Response Published
Link to recommendation 8.4
Recommendation · source text
The Welsh Government may wish to consider the applicability of the recommendations made within this report to other neonatal services.