CHILD & ADOLESCENT SERVICES REPORT
January 2007 – September 2007
Aims of this report:
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To give a formal update on child and adolescent services to the Trust
Executive Committee and the Trust Board.
Key achievements – January 2007 – September 2007
 Recruitment of a Paediatric Psychologist
 Environmental changes made to the main paediatric ward and education
service room
 Securing funds and developing plans to create purpose built rooms within
the paediatric main wards for private paediatric patients to be fully integrated
 Establishing Child Branch Nurse rotation to the Private Patient Unit
 Recruiting a paediatric Lead Nurse to the Alan Bray Unit
 Establishing a Child Branch Nurse rotation to the Alan Bray Unit
 Increasing the number of Play specialists from one to three part-time
 Raising the profile of child protection and increasing the number of
professionals who have received mandatory training
 Establishing pain assessment tools and using them for all paediatric patients
who are experiencing pain
 The Matron and Paediatric Ward Managers have presented RNOH
children’s service improvements at the Royal College of Nursing conference
 Significantly increasing the percentage of Child Branch trained nurses
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1. Background
Children’s tertiary healthcare services such as those provided at the RNOH, treat
relatively uncommon and often complex conditions. Patients from across the UK
as well as from abroad are treated either under NHS criteria or as private patients.
The RNOH sees children and adolescents, many of whom have congenital (birth)
musculo-skeletal abnormalities, suffered injury or musculo-skeletal tumours. Many
of these children and young people require a series of complex surgical and
medical procedures to be performed, often over many years. Children and
Adolescent patients make up 24% of the total percentage of patients seen at the
RNOH and 26.4% of the annual income.
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Children’s Services Report – October 2007. S. McCabe on behalf of the Children’s
Services Strategic Group.
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1.1 The Hospital Standard of the Children’s National Service Framework:
The most recent document guiding the provision of hospital child and adolescent
services is the Hospital Standard Children’s National Service Framework 2003.
The main 10 dimensions of the standard are:
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In-patient surgical services on free standing sites must ensure clinical safety
is consistent 24/7 not only for the specialist needs of patients but also
general medical healthcare needs (suitable medical presence and or
transfer arrangements made through Service Level Agreements)
Separate care facilities for young children and privacy for adolescents
Education support integral to the day to day provision of care
Dedicated children’s units in A&E departments
Kids and adolescents meal menus
Regular security reviews to ensure that access to children’s wards is limited
Specialist training for staff dealing with children (particularly child protection
training)
Play specialists who help children cope with the distress of being in hospital
Appropriate staff and services to address the mental health and
psychological well-being of children and young people
Surveys of children and their parents to help inform service development
and the new Commission for Healthcare Audit and Inspection.
An initial benchmark was carried out in the Trust - December 2003 against the
children’s NSF and since then the three key aspirations have served as a
foundation for improving children’s hospital services:
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Child-centred Hospital Services
Quality and Safety of care provided
Quality of setting and environment
The Trust will be undertaking a table top benchmarking exercise to further audit
ourselves against the hospital standard of the children’s NSF. This is using an
audit tool which is also used at Great Ormond Street Hospital and will be
completed by the end of November 2007.
1.2 The RNOH Children’s Services Strategic Development group and action plan
2005 – 2010 (appendix 1)
The action plan sets out the standards that the RNOH needs to work towards from
the NSF hospital services for children as well as the recommendations from both
external reviews -The Sir John Temple and Alison Arnfield – July 2005. The action
plan sets out the current position of the Trust against the various standards and
progress is categorised in two stages 2005 – 2008 and in the new hospital at 2010.
The Group is chaired by Sheila Puckett – Director of Operations and Service
Improvement. The strategic action plan was written in anticipation of the new
hospital rebuild on site at Stanmore. However, the service developments
envisaged for 2010 are still applicable as they are based on relevant
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Children’s Services Report – October 2007. S. McCabe on behalf of the Children’s
Services Strategic Group.
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recommendations from key national documents and represent excellence in
hospital care for children.
Steccia Laddie has been assigned as the Trust Board Non-Executive Director with
a remit for children. She has been attending the Children’s Services Strategic
Development Group monthly meetings and (in conjunction with Sheila Puckett),
representing children’s services matters at Board level.
1.3 The overall aim of the Sir John Temple review:
“ To advise on the clinical issues that arise from the proposals to rebuild
[RNOH] as a stand-alone site”. (page 4)
The fundamental principle to be addressed was whether a single stand-alone
specialty directed site could provide the necessary inter-related level of general
care which can be found within a large District General Hospital. Whether the
level, safety and quality of general medical, nursing and therapeutic care for
patients at the RNOH can be guaranteed, be they very young, adult or elderly.
The review was conducted on three visits to the RNOH and a variety of clinical and
non-clinical staff were interviewed. A range of Trust documents as well as a
literature review were accessed. Comparisons were made with other UK and
European units.
The External Review conducted by Sir John Temple in July 2005 made 14
recommendations. The Trust’s Children Services Strategic Working Group meets
each month to monitor and report on improvements made in the provision of
children’s services. Attached at appendix 2 is a summary of our progress against
the Sir John Temple recommendations.
1.4 External Review of Children’s Nursing Services:
As an adjunct to the review conducted by Sir John Temple, he commissioned a
rapid review of the extent of R.S.C.N / child Branch trained nurses and roster
arrangements on the paediatric/adolescent wards (and trust-wide wherever
children are admitted or access RNOH services).
The formal aim of the review was:
“To assess the adequacy of paediatric training and the experience of nursing staff
at RNOH’. (page 3)
Nursing qualifications, post qualification training/experience and daily rosters (for
RSCN to RGN ratios and cover each shift) was examined (in conjunction with the
Trust’s Paediatric Workforce Group) for the following areas:
 ITU/HDU
 Private Patient wards (Iain Munro and Philip Newman)
 Coxen Ward
 Adolescent Ward
 Theatre and Recovery
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Children’s Services Report – October 2007. S. McCabe on behalf of the Children’s
Services Strategic Group.
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Plaster Theatre
Out-patient departments at Stanmore and Bolsover St.
In addition, the report also focused on how the Trust is progressing towards the
implementation of the NSF for children and young people.
Alison Arnfield made recommendations and these have been amalgamated into an
RNOH action plan for the strategic development of children’s services. It is
monitored through the Children’s Services Strategic Development Group.
1.5 Progress to date Paediatric Ward Nurses
Recruitment to nursing posts is now complete and the wards are fully staffed.
The nurses on the ward have a full programme of teaching and clinical training.
They have attended several conferences nationally and internationally to share
their specialist knowledge and work.
The unit strives to lead in implementing new initiatives that benefit patient care and
nursing practice. The team is committed to clinical audit and action planning
improvement related to audit outcomes.
Student nurses on placement give excellent feedback of their learning experience
and often request the paediatric wards as their final 2 week placement.
A rotation programme has been put in place and provides one experienced
Paediatric trained nurse in the HDU for a period of four months. This supports
local staff to care for children and increases their nursing skills to care for the high
dependent patient. The long term aim is to enable children to return to the ward
straight from theatre and be cared for on the ward by nurses who are skilled at
caring for a highly dependent post-operative patient.
A nurse has been recruited to provide paediatric nursing care on the Private
Patients unit and thus increases the amount of hours of children’s nursing available
weekly in the unit.
Overall, the paediatric nursing team is motivated and provides a high standard of
patient care, morale is high and there is good job satisfaction for staff working on
the ward.
2. The Children’s Ward Core Standards audit - January 2007
The tool is set out under 4 domains of the Standards for Better Health, DoH July
2004 and each section has a detailed set of standards with prompts and a traffic
light scoring system:
 Green
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Compliant
Amber
Partially Compliant
x
Red
Not Compliant
(>75%)
(>15%)
(<15%)
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Children’s Services Report – October 2007. S. McCabe on behalf of the Children’s
Services Strategic Group.
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The 4 Domains:
Patient Focus
Safety
Clinical and Cost
Effectiveness
Governance
‘Standards for Better Health’ set out two key principles:
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To provide a common set of requirements across all healthcare
organisations
To provide a framework for continuous improvement in the quality of care
patients receive.
The standards cover the following:
Safety:
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Clinical cost and Effectiveness:
Patient Focused:
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Environment
Kitchens
Linen
Waste
Sharps
Equipment
Hand Hygiene
Clinical Practice
Protective equipment
Care Delivery
Complaints
Patient’s views
Courtesy, Kindness and
Professionalism
 Patient Environment
 Food & Nutrition
 Privacy & dignity
Evidence Based Care
Skill Mix
Temporary Staff
Recruitment and Retention
Documentation
Handover
Rota Management
Acuity Tracking
Length of in-patient stay
Roles & Responsibilities
Staff Sickness >4%
Governance:
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Education & Training
Performance Management
Students & Learners
Multi-disciplinary Team
Working
 Communication
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Children’s Services Report – October 2007. S. McCabe on behalf of the Children’s
Services Strategic Group.
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Assessment Summary
Domain
Safety
Clinical and
Cost
Effectiveness
Governance
Patient
Focus
Compliant
Green
Amber
Compliant
Partially
Compliant
(>75%)
(>15%)
Compliant
8%
(<15%)
11%
12%
17%
8.5%
89%
80%
83%
79%
12.5%
Red
Not
Yes
Part
No
√
√
√
√
77%
78%
90%
91%
72%
17%
22%
5%
9%
10%
6%
5%
√
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18%
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84%
6.25%
9.75%
√
The tool was completed by a team comprising of the Matron, Ward Manager,
another Ward Manager from another ward area, a member of the environmental
team and a member of infection control team (and the ward infection control link
nurse).
2.1 The Assessment
The actual assessment took approximately 4 hours. The assessment day
included:
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Tour of the ward/clinical area
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Reading of evidence e.g. policies, logs, records
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Clinical area observations of care for at least 60 minutes
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Spot audits of at least 6 patients’ documentation
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Discussion with at least 6 patients
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Individual interviews with at least 4 members of staff
2.2
Assessment main findings – February 2007
The audit (full report attached as appendix 3) found that all aspects were compliant
(green); however, there was one domain that was only partially compliant:
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Children’s Services Report – October 2007. S. McCabe on behalf of the Children’s
Services Strategic Group.
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o There is a notice clearly displayed outlining the Trust Zero Tolerance Policy The ward has no problem with patient or family behaviour and had decided not
to display these warning posters in the ward environment.
o Where appropriate user representatives are included in the development of new
initiatives/protocols – There is no separate Paediatric Patient forum, inclusion
comes from the Trust wide Patient forum.
o There is information available to the PALS service - There were no easily
accessible information on how to contact PALS, this is now resolved and flyers
are on display in the ward area
o Staff are aware of the Trust annual survey of patients views and an associated
action plan – This has since been made available for staff to review and
discussed at ward meetings.
o There is information readily available with details of the Trust, local patient
forums, members councils etc –This was not readily available at the time of the
audit but information is now in place on the ward.
o Results of food satisfaction surveys are fed back to ward staff – There have
been no complaints regarding food, since the audit the Facilities manager
comes to the ward manager meeting to feed back the food survey results and
the ward managers disseminate findings to their staff.
o Hand Hygiene – Due to alcohol gel hand dispensers not being available at each
patient’s bedside. This has been further assessed and alcohol gel hand
dispensers being placed at the entrance to each bed bay.
o Staff sickness - the Trust percentage was 8%, however, the NHS target is 4%.
This was due to 3 staff being on long term sickness. This has now been
completely resolved and the sickness level is below 3%.
3. Healthcare Commission standards and audit findings – March 2007
The Healthcare Commission has developed a new system for assessing public and
private health services in England. It involves the Trust conducting an annual selfassessment against key core standards to demonstrate how we are achieving
them. A declaration and self-assessment were submitted originally in October
2005 (this was presented to the Trust Executive Committee and Trust Board in
September 2005 by Anthony Palmer). A further self assessment was undertaken
and submitted in March 2007.
3.1 Key findings
The Trust’s original submission highlighted known key shortfalls in our paediatric
services and actions are underway through the Children’s Strategic Services
Development group. The areas of shortfall were:
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Insufficiently skilled paediatric trained staff in HDU and ITU
Environmental shortcomings in areas where children and adolescents are
cared for
Poor attendance of key staff groups e.g. medical staff, at child protection
training
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Children’s Services Report – October 2007. S. McCabe on behalf of the Children’s
Services Strategic Group.
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Relatively low numbers of staff trained in Advanced Paediatric Life Support
(APLS)
The absence of a pain management service specifically for paediatric
patients
There is only one Play Specialist and her remit is Trust-wide. In her
absence, there is no cover arrangement
3.2 Progress to date against the original 2006 self assessment findings
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A Lead Nurse has been appointed who has qualified as a Child Branch
trained nurse (January 2007)
Environmental upgrades have been carried out on the Adolescent Ward
and Coxen Ward
Attendance at mandatory Child Protection training has improved.
Attendance at Advance Paediatric Life Support has improved.
The pain management tool has been put into use and 100% of nursing
have been trained to use it with children and it has been used for each
patient since January 2006
A pain management assessment tool has been devised and has been
used for each patient (January 2007)
A pain specialist Sister has been appointed and she holds the
Registered Sick Children’s Nursing qualification
The Play Specialist service has been reviewed and (2.3 wte) three parttime Play Specialists have been employed with varying skill levels
Findings from the audit carried out in March 2007
The key areas we have improved on are:
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22 of our trained nurses out 34 are now Registered Child Branch nurses.
This is an improvement on the 8 out of 28 trained nurses last year (2006).
The Paediatric MDT now includes a Basic grade Hospital Play Specialist
(HPS), a part time Senior 2 HPS and a full time Senior 1 HPS as well as a
part-time Paediatric Clinical Psychologist.
However, the key areas we continue to be weak on are:
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Only 3 Consultant Surgeons attended child protection training (out of a
possible 32 Consultants who treat / operate on children and adolescents).
This compares less favourably with last years submission where 4
Consultants attended out of a possible 32.
The number of anaesthetists who have attended Paediatric Life Support or
Advanced Paediatric Life Support is low being 3 out of 19. This is the same
number as was submitted last year.
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Children’s Services Report – October 2007. S. McCabe on behalf of the Children’s
Services Strategic Group.
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4. Child Protection update
The RNOH needs to ensure that all staff that work with or provide treatment to
children, adolescents and their families has experience and or training in child
protection. The RNOH has a responsibility to have robust child protection systems
in place. This includes ensuring that there are designated child protection staff, up
to date policies/procedures and a rolling programme of training for all levels of
staff. In addition, the Trust needs to have systems in place to regular monitoring
working practices aimed at providing child protection and firm plans towards the
implementation of the recommendations from the Laming Inquiry (into the death of
Victoria Climbie, January 2003).
There is designated staff in the Trust with responsibility for conducting a variety of
child protection training to all staff:
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Siobhan Lalor McTague - The Paediatric Specialist Nurse/Named nurse for
Child Protection
Dr Benjamin Jacobs – The named Doctor for Child Protection
One of the key recommendations from the Hospital standard of the Children’s NSF
is:
“… Children and young people should receive appropriate high quality,
evidence-based hospital care, developed through clinical governance and
delivered by staff that has the right set of skills…”
4.1 Key aspects provided by the child protection lead staff:
Advice and support
Creation and maintenance of an up to date C.P library
C.P supervision – to Nursing staff - (groups)
C.P Trust Training (maybe in conjunction with NPH) programmed
and reporting back
Conducting Audits (in conjunction with the Trusts Audit and Clinical
Governance team)
Policies and procedures
Attendance at Harrow Safeguarding Committee and sub-groups
The importance of training is highlighted to new staff during the monthly corporate
induction. New Medical staff who commence in the Trust have an update training
session at the Trust induction. Training is also provided to new staff (including
SHOs) during the monthly corporate induction and focuses on the following:
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The need for awareness of Child Protection Issues (including Laming/Climbie)
The CP Team for RNOH
Individual & Organisational Responsibilities
The location and content of the RNOH CP Policy
These sessions are for all new staff across the Trust, regardless of profession
Communicating with children and young people
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Children’s Services Report – October 2007. S. McCabe on behalf of the Children’s
Services Strategic Group.
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Level 1 Child protection training is now mandatory for all staff who work in the
Trust. Level 2 Child Protection training is mandatory for all staff whose work brings
them into contact with children.
4.2 Attendance at Child Protection Training January 2007 – September 2007
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251 Trust staff have attended level 1 child protection training. 279 Staff
have attended level 2 child protection training (January – September 2007).
Attendance will continue to be monitored to ensure we significantly increase
the numbers of medical staff who receive training on child protection.
5. Other key achievements in children’s services this year
5.1 Paediatric Nutrition
A part-time paediatric focused Dietician is being recruited
5.2 Paediatric Psychology
A part-time (18hrs per week) Paediatric Psychologist has been recruited and
commenced in January 2007. Monica Korpershoek works part-time with us and
part-time with The Tavistock Clinic. She works closely with our Paediatric
Psychiatrist, nursing team, the Paediatricians and the wider multi-disciplinary team.
5.3 RNOH Children’s Education Service - update
A Service Review was carried out (February 2007) by the Education Service
Managers from Harrow. The review looked at the changing needs of the Service
alongside RNOH changes on the Paediatric Unit.
The Review was very positive and acknowledged the excellent work, experience
and dedication of the staff. Funding has been provided to refurbish the schoolroom
to make it more accessible, spacious and adolescent friendly. This should be
completed by December 2007.
There have also been some staff changes. The Primary Ward Teacher left at the
end of May and is still to be replaced. Existing staff are providing cover. The
Administrative Assistant, who worked 3 days a week, is now working full time at the
Harrow Tuition Service. A new Administrative Assistant has been appointed to
work 2 mornings each week.
We have continued to develop our School Outreach Visits from representatives of
Museums and Art Galleries in London, which greatly benefits and enhances the
children’s learning and for which we achieved an ‘Excellent’ Commendation by the
OFSTED Inspector last year. We now have regular visits from:
o The Museum of London
o The Imperial War Museum
o HMS Belfast
o The Museum of Childhood
o The National Art Gallery
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Children’s Services Report – October 2007. S. McCabe on behalf of the Children’s
Services Strategic Group.
o ‘POD’ Children’s Entertainers (This is a charity organisation for
children in hospital)
After having successfully achieved our ‘Healthy Schools Award’ last year, we are
now embarked on our “2nd year, and have set up two interesting projects for the
sections on ‘Emotional Health and Wellbeing’, working alongside the Paediatric
Psychiatrist and Psychologist, and ‘Physical Education’ working with the
Paediatric Physiotherapists in providing 2x 1hr lessons of appropriate, adapted,
physical games and sports on the ward, for all the school aged children. This will
meet the new requirements. If possible, one of our ideas is to look into setting up
the first ever ‘Children’s Hospital Olympics’ in the UK. An article will be placed in
the Trust magazine - ‘ Articulate’.
If any members of the Board would like to visit the RNOH Education Service
Please email the Teacher in Charge Gail Burgess at: gail.burgess@rnoh.nhs.uk
5.4 Speech and Language Therapy
The paediatric Speech and Language therapy Service has continued to support
children and young people with communication and/or eating and drinking
difficulties during their admission to RNOH.
Key Achievements:
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The passport service is now established for all children / young people
identified for pre-operative assessment, to ensure that information about the
patient’s skills and difficulties and strategies to support their difficulties is
shared amongst staff working in RNOH. This service was recently audited,
and preliminary findings show that 100% of families and staff reported that
the passports helped staff to care for the child / young person during
admission.
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The Speech and Language Therapy Service has worked alongside the pain
service looking at identification of appropriate pain management tools for
children / young people with special needs / communication difficulties
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Development of a service to support the admission of children / young
people with autistic spectrum disorder – this has been a multi-disciplinary
service development with the paediatric team.
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Presentation of a joint poster with the Play Specialist Team at the National
Conference for Hospital Play Specialists
Paediatric Speech and Language service objectives:
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To identify and support all children / young people with communication and
/or eating and drinking difficulties – a pilot process for identifying all patients
has been agreed with the paediatric and surgical teams and is currently in
the process of being rolled out
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Children’s Services Report – October 2007. S. McCabe on behalf of the Children’s
Services Strategic Group.
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Provision of accessible information to ward staff around identifying and
supporting children / young people with communication difficulties
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Development of clear guidance / policies around the management of eating
and drinking difficulties in liaison with adult SLT / dietetics
6. Conclusion
Following the intense external scrutiny of paediatric and adolescent services,
significant progress has been made: The paediatric multi-disciplinary team has
been enhanced by the appointment of a paediatric psychologist who commenced
in January 2007. The improvements to the environment such as re-locating the
nurses station has enabled ward nurses to be placed centrally within the paediatric
unit to improve accessibility to patients, parents and carers. The recent
improvements to the Coxen bathroom and the creation of a ‘milk kitchen’ and
parent toilet have significantly enhanced the patient experience. The Child Branch
nurse rotations to the Private Patient’s Unit and the Alan Bray Unit have also
enabled children and adolescents to be cared for by appropriately trained staff.
The expansion of the Play Specialist team has really brought the benefits of play to
each patient and has benefited children’s ability to relax during what is often a
stressful, uncertain time in their lives.
However, implementing sustainable change continues to require a firm
commitment from all levels within the organisation. In the future we will continue to
ensure that a comprehensive approach to caring for children and adolescents
whenever they are admitted is maintained. There are key environmental aspects
pertaining to the implementation of the Hospital Standard of the Children’s NSF
particularly around ensuring there is clear separation of children and adults. There
is still work to be done to explore the options around implementing this in our High
Dependency Unit in a flexible way. Attendance at Child protection training needs
to increase significantly. The Paediatric Matron and Named Nurse will continue to
undertake training and closely monitor attendance by all professional groups. The
RNOH has many network links to peer organisations and these need to be
maintained through proactive involvement. The achievement of a rebuild on the
Stanmore site is a goal worth striving towards and it gives a clear reward and
incentive to continue to modernise our services and improve patient care.
Shane McCabe
General Manager
October 2007
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Children’s Services Report – October 2007. S. McCabe on behalf of the Children’s
Services Strategic Group.