Scope of this report
Service* | Provider | Within the scope of this visit |
|---|---|---|
|
Sickle cell and thalassaemia screening laboratory services |
Full blood count: Mersey and West Lancashire Teaching Hospitals NHS Trust
HPLC: Mersey and West Lancashire Teaching Hospitals NHS Trust |
No |
|
Infectious diseases screening laboratory services |
HIV: Mersey and West Lancashire Teaching Hospitals NHS Trust Hepatitis B: Mersey and West Lancashire Teaching Hospitals NHS Trust
Syphilis: Mersey and West Lancashire Teaching Hospitals NHS Trust |
No |
|
Fetal anomaly screening – combined and quadruple screening services |
Dating/NT scan: Mersey and West Lancashire Teaching Hospitals NHS Trust
Screening laboratory: Bolton NHS Foundation Trust |
Yes No |
|
Fetal anomaly screening – NIPT screening laboratory services |
Birmingham Women’s and Children’s Hospital NHS Foundation Trust |
No |
|
Fetal anomaly screening – 20-week screening scans |
Mersey and West Lancashire Teaching Hospitals NHS Trust |
Yes |
|
Diabetic eye screening |
Central Mersey Diabetic Eye Screening Service |
Yes |
|
Newborn and infant physical examination |
Mersey and West Lancashire Teaching Hospitals NHS Trust |
Yes |
|
Newborn blood spot screening laboratory services |
Alder Hey Children’s NHS Foundation Trust
Manchester University NHS Foundation Trust |
No
No |
|
Newborn hearing screening programme |
Bridgewater Community Healthcare NHS Trust (Whiston site)
Mersey and West Lancashire Teaching Hospitals NHS Trust (Ormskirk site) |
Yes
No |
|
Child Health Information Service (CHIS) |
NHS South, Central and West Commissioning Support Unit (Knowsley sub-ICB, St Helens sub-ICB) NHS South, Central and West Commissioning Support Unit (Southport & Formby sub-ICB, South Sefton sub-ICB) HCRG Care Group (West Lancashire sub-ICB) |
Yes
No
No |
Screening laboratories are quality assured by the United Kingdom Accreditation Service (UKAS).
Summary
Quality assurance looks at the antenatal and newborn screening pathways starting with identifying the eligible population of pregnant women and babies. It also includes the relevant screening tests for each programme. For women and babies with screen positive/higher chance results it will also include the pathways for referral, diagnosis and/or treatment.
The findings in this report relate to the quality assurance visit on 4 February 2025 to Mersey and West Lancashire Teaching Hospitals NHS Trust Screening Service which is commissioned by NHS England North West. Any commissioning findings are outside the scope of this report and will be followed up directly with the commissioner.
We use the term ‘woman’ or ‘mother’ to encompass all gender identities and is intended for anyone who is pregnant. Similarly, where the term ‘parents’ is used, this encompasses anyone who has main responsibility for caring for the baby.
Quality assurance purpose and approach
Quality assurance (QA) aims to achieve and maintain national standards, promote continuous improvement in antenatal and newborn (ANNB) screening and support reducing health inequalities. This is to ensure all eligible people have access to a consistent high quality, effective, equitable and safe service wherever they live.
QA visits are carried out by the NHS England Screening Quality Assurance Service (SQAS).
The evidence for this report comes from the following sources:
- monitoring of routine data collected by NHS England
- data and reports from external organisations
- evidence submitted by the provider and external organisations
- discussion with the commissioner in advance of the visit
- information collected during pre-visit interview with the screening coordinator (Ormskirk site) on 31 January 2025 and post-visit interview with the screening support sonographer (Ormskirk site) on 5 February 2025
- information shared with SQAS as part of the visit
The screening service
Mersey and West Lancashire Teaching Hospitals NHS Trust began operations on 1 July 2023 following the acquisition of Southport and Ormskirk Hospital NHS Trust by St Helens and Knowsley Teaching Hospitals NHS Trust. The trust provides healthcare in hospital and community settings to over 600,000 people across Merseyside and West Lancashire.
Acute care is provided at Whiston Hospital, Southport District General Hospital and Ormskirk District General Hospital. This includes adult’s and children’s emergency services, intensive care and a range of medical and surgical specialities.
Maternity services are provided at Whiston Hospital, Southport District General Hospital and Ormskirk District General Hospital.
Whiston Hospital and Ormskirk District General Hospital both offer inpatient and outpatient services and level 2 neonatal units. Southport District General Hospital offers consultant-led outpatient services.
Scan clinics are offered additionally at Lowe House community clinic in St Helens and St Helens Hospital and scan and outpatient clinics are offered at Widnes Health Care Resource Centre (HCRC).
Mersey and West Lancashire Teaching Hospitals NHS Trust borders with maternity services at Liverpool Women’s NHS Foundation Trust, Warrington and Halton Hospitals NHS Foundation Trust and Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust.
The newborn hearing screening service for St Helens and Knowsley is provided by Bridgewater Community Healthcare NHS Foundation Trust. The newborn hearing screening service for Southport, Formby and West Lancashire is provided by Mersey and West Lancashire Teaching Hospitals NHS Trust. This service was visited by SQAS in 2022 and was not included in the scope of this visit.
NHS South, Central and West Commissioning Support Unit (SCW CSU) provides the Child Health Information Service (CHIS) across Merseyside including the Knowsley, St Helens, Southport & Formby and South Sefton sub-integrated care boards. HCRG Care Group provides the Child Health Information Service for the West Lancashire sub-ICB. The SCW CSU service for Southport & Formby and South Sefton and the HCRG Care Group service for West Lancashire were visited by SQAS in 2022 and were not included in the scope of this visit.
Findings
Antenatal and newborn screening at Mersey and West Lancashire Teaching Hospitals NHS Trust is a patient focused service delivered by a keen and enthusiastic screening team.
The screening midwives are supported by a wider multi-disciplinary team across the screening programmes. The skilled and dedicated staff seem committed to the care of pregnant women and babies.
There has been a period of transition for the screening team as integration of the two legacy trusts continues. Work has begun to merge the ANNB screening services with ongoing plans to integrate and align systems, processes and communication across the maternity sites. The wider screening team is working hard to manage capacity despite staffing shortages within the context of ongoing change.
Although still early days in the alignment journey there are good foundations in place for the screening team to continue to build on improvements to communication and relationships, sharing learning and focusing on quality improvement.
Immediate concerns
The QA visit team identified no immediate concerns.
High priority findings
The QA visit team identified 9 high priority findings. The main themes included:
- antenatal and newborn screening governance arrangements are not yet aligned cross-site, this includes documented processes for the escalation and management of screening incidents, work to harmonise processes has commenced
- there is no signed off workforce plan for obstetric ultrasound or detailing cover arrangements when the screening coordinator is absent
- identification of the complete antenatal cohort at Ormskirk is not completed timely
- there is no documented failsafe process to make sure that all women accepting screening complete the testing process
- there is no documented fast track pathway for women and/or couples known to be at risk of having a baby with a haemoglobin condition
- the NHSP local manager had capacity issues and had not been able to complete all local manager designated tasks and responsibilities when covering administration and screener They are working to bring all tasks up to date
- CHIS notification to the NHSP team of mover in babies under 8 weeks old with no screening results is not completed timely and the upper parameter does not meet national guidance
Recommendations
The following recommendations are for the provider to action unless otherwise stated.
No. | Recommendation | Reference | Timescale | Priority | Evidence required |
|---|---|---|---|---|---|
|
Governance and leadership | |||||
|
01 |
Complete the planned work for ANNB |
Section 7a |
3 months |
High |
Organisational structure |
|
|
screening governance across the whole trust footprint, making sure that ANNB screening is visible to senior leadership and that escalation processes are documented and available for staff |
screening service schedule 2 no: 15, 16, 17, 18, 19, 20, 21 2024 – 2025 |
|
|
chart (that is signed off)
Escalation process (that is signed off) |
|
|
|
Antenatal and |
|
|
|
|
|
|
newborn |
|
|
|
|
|
|
screening |
|
|
|
|
|
|
pathway |
|
|
|
|
|
|
requirements |
|
|
|
|
|
|
specifications |
|
|
|
|
|
|
2021 |
|
|
|
|
02 |
Update the terms of reference of the ANNB Steering Group to reflect the trust’s joint footprint and include |
Section 7a screening service schedule 2 no: 15, 16, 17, 18, 19, 20, 21 2024 – 2025
Antenatal and newborn screening |
3 months |
Standard |
Terms of reference signed off by the ANNB Steering Group |
|
|
standing agenda items and consistent |
|
|
| |
|
|
reporting from all sites, including risks |
|
|
| |
|
|
and incident management |
|
|
| |
No. | Recommendation | Reference | Timescale | Priority | Evidence required |
|---|---|---|---|---|---|
|
|
|
pathway requirements specifications 2021 |
|
|
|
|
03 |
Improve links between maternity and |
Section 7a |
6 months |
Standard |
Escalation process (that |
|
|
the newborn hearing screening programme to make sure that issues and risks are shared |
screening service schedule 2 no: 15, 16, 17, 18, 19, 20, 21 2024 – |
|
|
is signed off)
Minutes of meetings |
|
|
|
2025 |
|
|
|
|
|
|
Antenatal and |
|
|
|
|
|
|
newborn |
|
|
|
|
|
|
screening |
|
|
|
|
|
|
pathway |
|
|
|
|
|
|
requirements |
|
|
|
|
|
|
specifications |
|
|
|
|
|
|
2021 |
|
|
|
|
04 |
Document the process for the |
Section 7a |
3 months |
High |
Escalation and |
|
|
escalation and management of screening incidents (and share this with staff) |
screening service schedule 2 no: 15, 16, 17, 18, 19, 20, 21 2024 – |
|
|
management process (that is signed off) |
|
|
|
2025 |
|
|
|
|
|
|
Antenatal and |
|
|
|
|
|
|
newborn |
|
|
|
|
|
|
screening |
|
|
|
|
|
|
pathway |
|
|
|
|
|
|
requirements |
|
|
|
No. | Recommendation | Reference | Timescale | Priority | Evidence required |
|---|---|---|---|---|---|
|
|
|
specifications 2021 |
|
|
|
|
05 |
Make sure guidelines refer to managing safety incidents in NHS screening |
Managing safety incidents in NHS screening programmes updated 2024 |
12 months |
Standard |
Guideline (that is signed off) |
|
|
programmes and the link to the NHSE |
|
|
| |
|
|
screening incident assessment form |
|
|
| |
|
|
(SIAF) is updated |
|
|
| |
|
06 |
Make sure that the screening health |
Section 7a |
6 months |
Standard |
Minutes of meetings |
|
|
inequality audit is presented within the trust and that there is a monitored action plan to address findings |
screening service schedule 2 no: 15, 16, 17, 18, 19, 20, 21 2024 – |
|
|
Action plan including timescales |
|
|
|
2025 |
|
|
|
|
|
|
Antenatal and |
|
|
|
|
|
|
newborn |
|
|
|
|
|
|
screening |
|
|
|
|
|
|
pathway |
|
|
|
|
|
|
requirements |
|
|
|
|
|
|
specifications |
|
|
|
|
|
|
2021 |
|
|
|
|
07 |
Make sure women have consistent access to translation services for ANNB screening services cross-site, including |
Section 7a screening service schedule 2 no: 15, 16, 17, 18 2024 – 2025 |
12 months |
Standard |
Confirmation of updated guideline and plan to audit within 12 months |
|
|
when face to face interpreters and |
|
|
| |
|
|
telephone translation services are not |
|
|
|
No. | Recommendation | Reference | Timescale | Priority | Evidence required |
|---|---|---|---|---|---|
|
|
available and in alternative formats to written information |
Antenatal screening pathway requirements specifications 2021 |
|
|
|
|
08 |
Make sure that current clinical practice |
Section 7a |
12 months |
Standard |
Audit of current clinical |
|
|
complies with national policy and guidelines, policies and SOPs are appropriately updated to reflect this, including, SCT pathway for abnormal paternal results, updated NIPE pathway |
screening service schedule 2 no: 15, 16, 17, 18, 19, 20, 21, 22 2024 – 2025 |
|
|
practice against guideline
Guidelines (that are signed off) |
|
|
for testes, NIPE timeframe for hip scans |
Antenatal and |
|
|
|
|
|
|
newborn |
|
|
|
|
|
|
screening |
|
|
|
|
|
|
pathway |
|
|
|
|
|
|
requirements |
|
|
|
|
|
|
specifications |
|
|
|
|
|
|
2021 |
|
|
|
|
09 |
Make sure harmonised guidelines |
Section 7a |
12 months |
Standard |
Guidelines (that are |
|
|
clearly reflect any site specific differences and pathways |
screening service schedule 2 no: 15, 16, 17, 18, |
|
|
signed off) |
|
|
|
19, 20, 21, 22 |
|
|
|
|
|
|
2024 – 2025 |
|
|
|
|
|
|
Antenatal and |
|
|
|
|
|
|
newborn |
|
|
|
|
|
|
screening |
|
|
|
No. | Recommendation | Reference | Timescale | Priority | Evidence required |
|---|---|---|---|---|---|
|
|
|
pathway requirements specifications 2021 |
|
|
|
|
10 |
Implement a trust wide governance |
Section 7a |
12 months |
Standard |
List of planned audits |
|
|
plan for audit of ANNB screening |
screening service schedule 2 no: |
|
|
|
|
|
|
15, 16, 17, 18, |
|
|
|
|
|
|
19, 20, 21 2024 – |
|
|
|
|
|
|
2025 |
|
|
|
|
|
|
Antenatal |
|
|
|
|
|
|
screening |
|
|
|
|
|
|
pathway |
|
|
|
|
|
|
requirements |
|
|
|
|
|
|
specifications |
|
|
|
|
|
|
2021 |
|
|
|
|
11 |
Demonstrate that feedback (including |
Section 7a |
12 months |
Standard |
Meeting minutes |
|
|
complaints) from service users, including those with protected characteristics or from underserved groups is used to develop and/or improve service delivery for antenatal |
screening service schedule 2 no: 15, 16, 17, 18, 19, 20, 21 2024 – 2025 |
|
|
confirming user feedback findings and action plan discussed at the ANNB Steering Group |
|
|
and newborn screening |
Antenatal |
|
|
|
|
|
|
screening |
|
|
|
|
|
|
pathway |
|
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requirements |
|
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|
|
|
specifications |
|
|
|
|
|
|
2021 |
|
|
|
No. | Recommendation | Reference | Timescale | Priority | Evidence required |
|---|---|---|---|---|---|
|
Infrastructure | |||||
|
12 |
Ensure there is resilience in the service |
Section 7a |
3 months |
High |
Confirmation of cross |
|
|
to maintain delivery of screening |
screening service |
|
|
cover arrangements |
|
|
functions when key members of staff, |
schedule 2 no: |
|
|
|
|
|
including the LCO, are absent |
15, 16, 17, 18, |
|
|
|
|
|
|
19, 20, 21 2024 – |
|
|
|
|
|
|
2025 |
|
|
|
|
|
|
Antenatal |
|
|
|
|
|
|
screening |
|
|
|
|
|
|
pathway |
|
|
|
|
|
|
requirements |
|
|
|
|
|
|
specifications |
|
|
|
|
|
|
2021 |
|
|
|
|
13 |
Make sure there is resilience in the ultrasound service by implementing a collaborative and sustainable workforce plan across all sites, this could also include utilising cross-site training opportunities |
Section 7a screening service schedule 2 no: 16 2024 – 2025
Fetal anomaly screening pathway requirements specification 2021 |
6 months |
High |
Workforce plan (that is signed off) |
|
14 |
Implement and monitor a process for ongoing training and continuing professional development for health professionals involved in screening |
Section 7a screening service schedule 2 no: 15, 16, 17, 18, |
12 months |
Standard |
Confirmation of training log / completion of NHS Screening e-Learning resource |
No. | Recommendation | Reference | Timescale | Priority | Evidence required |
|---|---|---|---|---|---|
|
|
|
19, 20, 21, 22 |
|
|
|
|
2024 – 2025 | |||||
|
Antenatal and | |||||
|
newborn | |||||
|
screening | |||||
|
pathway | |||||
|
requirements | |||||
|
specifications | |||||
|
2021 | |||||
|
Identification of cohort (antenatal) | |||||
|
15 |
Make sure that weekly checks are in |
Section 7a |
3 months |
High |
Tracking process which |
|
|
place for the timely identification of the |
screening service |
|
|
shows weekly (as a |
|
|
complete antenatal cohort at Ormskirk |
schedule 2 no: |
|
|
minimum) tracking |
|
|
|
15, 16, 17, 18 |
|
|
|
|
|
|
2024 – 2025 |
|
|
|
|
|
|
Antenatal |
|
|
|
|
|
|
screening |
|
|
|
|
|
|
pathway |
|
|
|
|
|
|
requirements |
|
|
|
|
|
|
specifications |
|
|
|
|
|
|
2021 |
|
|
|
|
16 |
Make sure processes are documented |
Section 7a |
3 months |
High |
Documented processes |
|
|
for the failsafe of the antenatal |
screening service |
|
|
(that are signed off) |
|
|
screening programmes |
schedule 2 no: |
|
|
|
|
|
|
15, 16, 17, 18 |
|
|
|
|
|
|
2024 – 2025 |
|
|
|
No. | Recommendation | Reference | Timescale | Priority | Evidence required |
|---|---|---|---|---|---|
|
|
|
Antenatal screening pathway requirements specifications 2021 |
|
|
|
|
17 |
Make sure processes are documented for the management of screen positive results for women who miscarry or terminate their pregnancy and they are followed up as required |
Section 7a screening service schedule 2 no: 15, 16, 17, 18 2024 – 2025
Antenatal screening pathway requirements specifications 2021 |
6 months |
Standard |
Documented processes (that are signed off)
Tracking system Letter templates |
|
Sickle cell and thalassaemia screening | |||||
|
18 |
Monitor the action plan to meet the acceptable threshold for standard/key performance indicator SCT-S02/ST2 – the proportion of pregnant women having antenatal sickle cell and thalassaemia screening for whom a screening result is available before or at 10 weeks + 0 days gestation |
Section 7a screening service schedule 2 no: 18 2024 – 2025 Sickle cell and thalassaemia screening pathway |
12 months |
Standard |
Action plan that is agreed and monitored by the ANNB Steering Group
Submission of data for standard/key performance indicator SCT-S02/ST2 |
No. | Recommendation | Reference | Timescale | Priority | Evidence required |
|---|---|---|---|---|---|
|
|
|
requirements specification 2021
Standards 2018 SCT-S02 |
|
|
|
|
19 |
Make sure staff providing counselling to women/couples at risk of sickle cell and thalassaemia undertake the accredited genetic risk assessment and counselling module |
Section 7a screening service schedule 2 no: 18 2024 – 2025
Sickle cell and thalassaemia screening pathway requirements specification 2021
Standards 2018 SCT-S02 |
12 months |
Standard |
Confirmation of completion of accredited genetic risk assessment and counselling module |
|
20 |
Implement a documented process for the fast track of women and/or couples known to be at risk of having a baby with a haemoglobin condition and for women with assisted pregnancies |
Section 7a screening service schedule 2 no: 18 2024 – 2025
Sickle cell and thalassaemia screening pathway requirements specification 2021 |
3 months |
High |
Documented process (that is signed off) |
No. | Recommendation | Reference | Timescale | Priority | Evidence required |
|---|---|---|---|---|---|
|
Infectious diseases in pregnancy screening | |||||
|
21 |
Improve awareness of staff and the promotion to women of the ‘negative now’ message in IDPS testing |
Section 7a screening service schedule 2 no: 15 2024 – 2025
Infectious diseases in pregnancy screening pathway requirements specifications 2021 |
6 months |
Standard |
Confirmation of inclusion in the updated guidance
Confirmation of staffing update |
|
22 |
Make sure that there is an agreed process for the establishment of a formal IDPS MDT when this is required |
Section 7a screening service schedule 2 no: 15 2024 – 2025
Infectious diseases in pregnancy screening pathway requirements specifications 2021 |
6 months |
Standard |
Documented process (that is signed off) |
|
23 |
Make sure each woman who declines the initial offer of IDPS screening (HIV, |
Section 7a screening service |
6 months |
Standard |
Documented process (that is signed off) |
No. | Recommendation | Reference | Timescale | Priority | Evidence required |
|---|---|---|---|---|---|
|
|
Hepatitis B and/or syphilis) is identified, tracked and re-offered screening by 20 weeks of pregnancy or within 2 weeks if booked after 20 weeks gestation |
schedule 2 no: 15 2024 – 2025
Infectious diseases in pregnancy screening pathway requirements specifications 2021 |
|
|
|
|
Fetal anomaly screening | |||||
|
24 |
Make sure processes are documented, including site specific variations, for booking ultrasound appointments, undertaking a clinical review when a baby is born unexpectedly with one of the physical conditions screened for, IT downtime for maternity ultrasound, induction of new/agency sonographers, ensuring women scanned in EPAU do not miss the opportunity for first trimester screening |
Section 7a screening service schedule 2 no: 15, 16, 17, 18, 19, 20, 21 2024 – 2025
Antenatal and newborn screening pathway requirements specifications 2021 |
3 months |
Standard |
Documented processes (that are signed off) |
|
25 |
Make sure the SSS at Whiston is supported in carrying out the functions |
Section 7a screening service |
6 months |
Standard |
Rostered time |
No. | Recommendation | Reference | Timescale | Priority | Evidence required |
|---|---|---|---|---|---|
|
|
of the role including capacity to provide feedback on 6-monthly DQASS reports to individual practitioners |
schedule 2 no: 16 2024 – 2025
Fetal anomaly screening pathway requirements specification 2021
Fetal anomaly screening programme handbook 2024 |
|
|
Confirmation that feedback to individual ultrasound practitioners is being completed |
|
26 |
Audit the FASP screening pathway including quadruple rate, inadequate samples (FA4) and repeat 20 week scans. The audit should be included on the organisation’s audit schedule with an agreed timeline and the findings and associated actions shared into the ANNB Screening Group. |
Section 7a screening service schedule 2 no: 16 2024 – 2025 Fetal anomaly screening pathway requirements specification 2021
Fetal anomaly screening programme handbook 2024 |
12 months |
Standard |
FASP audit schedule
Minutes from ANNB Screening Group |
|
27 |
Make sure contact details are updated with the National Congenital Anomaly |
Section 7a screening service |
3 months |
Standard |
Confirmation of contact details provision, |
No. | Recommendation | Reference | Timescale | Priority | Evidence required |
|---|---|---|---|---|---|
|
|
and Rare Disease Registration Service (NCARDRS), that data is submitted timely and all aspects of the process are documented. |
schedule 2 no: 16, 17 2024 – 2025
Fetal anomaly screening pathway requirements specification 2021 |
|
|
NCARDRS data submission and documented processes |
|
Diabetic eye screening in pregnancy | |||||
|
28 |
Implement and monitor a process to track all eligible women into DESP including women from out of area (Whiston), and report into the ANNB Steering Group |
Section 7a screening service schedule 2 no: 22 2024 – 2025 Diabetic eye screening pathway requirements specification 2021 |
3 months |
Standard |
Confirmation of a tracking process
Attendance at ANNB Steering Group by DES representative |
|
Newborn hearing screening | |||||
|
29 |
Make sure that the NHSP local manager has sufficient capacity to complete their local manager designated tasks and responsibilities and to attend the ANNB Steering Group |
Section 7a screening service schedule 2 no: 20 2024 – 2025
Newborn hearing screening pathway |
3 months |
High |
Confirmation that local manager tasks are up to date
Attendance at ANNB Steering Group by NHSP representative |
No. | Recommendation | Reference | Timescale | Priority | Evidence required |
|---|---|---|---|---|---|
|
|
|
requirements specification 2021 |
|
|
|
|
30 |
Make sure that NHSP processes are fully documented in guidelines and standard operating procedures (SOPs) |
Section 7a screening service schedule 2 no: 20 2024 – 2025
Newborn hearing screening pathway requirements specification 2021 |
12 months |
Standard |
Guidelines and policies (that are signed off) |
|
31 |
Make sure aetiological investigation data for babies with PCHI is added onto S4H |
Section 7a screening service schedule 2 no: 20 2024 – 2025 Newborn hearing screening pathway requirements specification 2021 |
6 months |
Standard |
Meeting minutes confirming update provided to ANNB Steering Group |
|
32 |
Implement and monitor a plan to meet the acceptable threshold for standards NHSP-S01 (KPI NH1), NHSP-S02, NHSP-S03 and NHSP-S05 (KPI NH2) |
Section 7a screening service schedule 2 no: 20 2024 – 2025
Newborn hearing screening |
12 months |
Standard |
Action plan that is agreed and monitored by the ANNB Steering Group as well as through audiology directorate processes |
No. | Recommendation | Reference | Timescale | Priority | Evidence required |
|---|---|---|---|---|---|
|
|
|
pathway requirements specification 2021 Standards 2022 NHSP-S01 Standards 2022 NHSP-S02 Standards 2022 NHSP-S03 Standards 2022 NHSP-S05 |
|
|
Submission of data for standard/key performance indicators for NHSP-S01 (KPI NH1), NHSP-S02, NHSP-S03 and NHSP- S05 (KPI NH2) |
|
33 |
CHIS to make sure that notification of missing results to NHSP is timely to ensure all eligible babies are included and the upper parameter meets national guidance |
Section 7a screening service schedule 2 no: 20 2024 – 2025
Newborn hearing screening pathway requirements specification 2021 |
3 months |
High |
Updated failsafe report for NHSP |
|
Newborn and infant physical examination | |||||
|
34 |
Implement and monitor a process to support the continuing professional development of practitioners undertaking NIPE |
Section 7a screening service schedule 2 no: 21 2024 – 2025 |
6 months |
Standard |
Training log / completion of NIPE e-Learning resource each year (with dates) |
|
No. |
Recommendation |
Reference |
Timescale |
Priority |
Evidence required |
|
|
|
Newborn and infant physical examination screening pathway requirements specification 2021
Newborn and infant physical examination programme handbook 2024 |
|
|
|
|
35 |
Implement and monitor a plan to meet NIPE standards NIPE-S02, NIPE-S03, NIPE-S04 (KPI NP4) and NIPE-S05 (making sure that only NIPE defined reportable conditions are documented for referral on S4N) |
Section 7a screening service schedule 2 no: 21 2024 – 2025 Newborn and infant physical examination screening pathway requirements specification 2021
Standards 2024 NIPE-S02, NIPE- S03, NIPE- S04/NP4, NIPE- S05 |
12 months |
Standard |
Action plan that is agreed and monitored by the ANNB Steering Group
Submission of data for standard/key performance indicators for NIPE-S02, NIPE-S03, NIPE-S04 (KPI NP4) and NIPE-S05 Quarterly data quality report from S4N |
No. | Recommendation | Reference | Timescale | Priority | Evidence required |
|---|---|---|---|---|---|
|
36 |
Audit the process for NIPE referrals to ensure that secondary check by medical staff does not cause delays in the referral pathway |
Section 7a screening service schedule 2 no: 21 2024 – 2025
Newborn and infant physical examination screening pathway requirements specification 2021
Newborn and infant physical examination programme handbook 2024 |
6 months |
Standard |
Share audit findings at the ANNB Steering Group Submission of data for standards/key performance indicators for NIPE-S03, and NIPE-S04 (KPI NP4) |
|
Newborn blood spot screening | |||||
|
37 |
Implement and monitor a plan to meet the acceptable threshold for standard NBS-S06 (KPI NB2) – the proportion of first blood spot samples that require repeating due to an avoidable failure in the sampling process |
Section 7a screening service schedule 2 no: 19 2024 – 2025
Newborn blood spot screening pathway requirements specification 2021 |
12 months |
Standard |
Action plan that is agreed and monitored by the ANNB Steering Group
Submission of data for standard/key performance indicator for NBS-S06 (KPI NB2) |
No. | Recommendation | Reference | Timescale | Priority | Evidence required |
|---|---|---|---|---|---|
|
|
|
Standards 2021 NBS-S06 |
|
|
|
|
38 |
CHIS to develop a process to notify GPs of missing NBS results/ unscreened babies at 1 year old |
Section 7a screening service schedule 2 no: 19 2024 – 2025
Newborn blood spot screening pathway requirements specification 2021 |
6 months |
Standard |
Confirmation of process in place |
Next steps
The screening service is responsible for developing an action plan in collaboration with the commissioners to complete the recommendations contained within this report.
SQAS will work with commissioners to monitor activity and progress of the recommendations for 12 months after the report is published. After this point SQAS will send a letter to the provider and commissioners summarising progress made and will outline any further action(s) needed.
Screening standards/KPI data
Appendix A: SCT screening standards/KPI data – St Helens & Knowsley / Southport & Ormskirk
Appendix B: IDPS screening standards/KPI data St Helens & Knowsley / Southport & Ormskirk
Appendix C: FASP screening standards/KPI data St Helens & Knowsley / Southport & Ormskirk
Appendix D: NHSP screening standards/KPI data Bridgewater service only
Appendix E: NIPE screening standards/KPI data St Helens & Knowsley / Southport & Ormskirk
Appendix F: NBS screening standards/KPI data
Appendix G: References
- NHS Section 7a screening service schedules 2 and 4 2024-25
- NHS population screening: pathway requirements specifications and learning from screening incidents
- NHS population screening standards
- NHS population screening: reporting data definitions for key performance indicators
- NHS Managing Safety Incidents in NHS Screening Programmes (last updated 2024)
- NHS England (2022) Patient Safety Incident Response Framework
- NHS Sickle cell and thalassaemia screening programme handbooks (last updated 2022)
- NHS Infectious diseases in pregnancy screening programme clinical guidance (last updated 2023)
- NHS Fetal anomaly screening programme handbook (last updated 2024)
- NHS Newborn hearing screening programme operational guidance (last updated 2024)
- NHS Newborn and infant physical examination: programme handbook (last updated 2024)
- NHS Newborn blood spot screening guidance (last updated 2023)
- NHS England population screening: pathway requirements specification Diabetic eye screening pathway requirements specification
- NHS Screening inequalities strategy
- Department of Health and Social Care Public Health Profiles
- The Society and College of Radiographers and The Royal Collage of Radiologists (2017) Standards for the provision of an ultrasound service
- UK Health Security Agency Immunisation against infectious disease (last updated 2024)
- Hinton et al (2023). A qualitative study of the dynamics of access to remote antenatal care through the lens of candidacy
- Hinton et al (2022) Quality framework for remote antenatal care
View more detailed information on individual screening programmes.