Infant Formula Audit Checklist - DOC

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					Application form for
Stage 3 assessment

Maternity
                              UNICEF UK Baby Friendly Initiative

               Application form for Stage 3 assessment - maternity

  Application for assessment for Baby Friendly Initiative accreditation at Stage 3

Introduction

Assessment at Stage 3 focuses on the implementation of the Baby Friendly standards in the
care of pregnant women and new mothers and babies. The assessment itself takes place at the
hospital on a date agreed with the Baby Friendly Initiative office. However, in order for this date
to be booked, written evidence must be submitted of the facility’s readiness for assessment.
When completed, this form provides much of that evidence.

This form may be completed electronically but must be submitted as a signed paper copy. If you
are filling the form in by hand, please use block capitals throughout. To help you to complete the
form, please refer to the Guidance notes for Stage 3 assessment, which provide guidance on
the information required. If you do not have a copy of the guidance notes, you can download one
(together with other information relating to Stage 3 assessment) from the Baby Friendly Initiative
web site, www.babyfriendly.org.uk/stage3. Please provide information which is as full as
possible in relation to each section.

Documents to be made available on the day of the assessment

Certain documents need to be made available on the day of the assessment. These are
mentioned in the relevant section and included in a checklist at the end of the form. Please do
not submit these documents with the application form.

Declaration

The application form should be signed by the Head of Service and submitted to the Baby
Friendly Initiative office at least three months before the planned assessment date, in order to
allow time for full consideration of the audit results and discussion with the key individual/s in the
facility about whether and how any outstanding issues can be addressed within the timescale.
Please note that any decision to re-schedule the date of the assessment is likely to incur costs if
the application form has been received later than three months before the previously agreed
date.

Costs

Information about the cost of assessment can be found on the Baby Friendly Initiative website.
Please note that an invoice will be sent to the address indicated below after the assessment has
taken place, unless you request otherwise.
Cancellation charges: Notice of cancellation or postponement should be informed in writing as soon as possible. No
charge will be incurred if notice of more than 90 days’ notice is provided; we reserve the right to charge 45% of the fee
if less than 90 days’ and more than 60 days’ notice is provided, and 65% of the fee if less than 60 days’ notice is
provided.
                                                           1                                Stage 3 app form mat Jan 2011
Background information



Name of hospital/Trust

Address




Name of Director of Midwifery Services

Job title

Telephone or extension

Email address


Name of member of staff responsible for
co-ordinating implementation of the Baby
Friendly Initiative

Job title

Telephone or extension

Email address

Hours worked by infant feeding lead

Additional hours worked by staff
supporting the infant feeding lead


Name of Finance Director

Address to which invoice
should be sent (if different
from hospital address,
above)




Date of accreditation of the hospital/Trust at Stage 2

                                                2        Stage 3 app form mat Jan 2011
Please provide the following information about the area served by the hospital/Trust:

 Brief description of the
 geographical area served




 Type and mix of
 population served




 Main languages spoken
 other than English
 (if there is a significant non-
 English-speaking population)




 Number of maternity units to be included in the assessment


Please complete a separate copy of the next page for each maternity unit which is to form part of
the assessment.


Please give details of antenatal clinics held on hospital premises:

                                           Where held                 Additional information
  Day and time of clinic
                                   (please specify at which unit)      (e.g. diabetic focus)




                                                   3                       Stage 3 app form mat Jan 2011
 NAME OF MATERNITY UNIT

 Type of care delivered (e.g. high risk /
 midwife-led)

 Name of Midwifery Manager responsible
 for the day-to-day running of the unit

 Job title

 Telephone or extension

 Email address




Size of unit

 Antenatal beds

 Postnatal beds

 Delivery beds

 Special/neonatal care cots




Birth and inpatient data

 Births in the last year

 Caesarean Section rate (%)

 Home birth rate (%)

 Births to mothers who received antenatal care from another Trust (%)

 Mothers transferred in for postnatal care, following delivery in a unit
 which will not form part of this assessment (%)

 Average length of in-patient stay postnatally




Remember to complete a separate copy of this page for each maternity unit which is to form part
                                   of the assessment.


                                                  4                        Stage 3 app form mat Jan 2011
Breastfeeding statistics

Do you use the same categories and definitions as those recommended by
the Department of Health (see Stage 3 guidance document)?                                     Yes/No

If no, please use the grid below to explain what categories you use to record infant feeding.


 Category name                             Definition




Is this information collected separately for each unit?                                       Yes/No

If statistics are collected separately and are not collated together, please complete a separate
copy of the next page for each maternity unit which is to form part of the assessment.




                                                 5                         Stage 3 app form mat Jan 2011
Breastfeeding statistics (cont)

Please complete the table below with your most recent infant feeding statistics:

                            Feeding category (e.g. full, partial etc.) as per
    Age/stage collected                                                                     Rate (%)
                            definitions confirmed above

    Initiation




These figures cover the 12-month period from …………………………… to ………………………..

These figures relate to …………… % of the population covered by the facility.

     If figures are not collated for the whole Trust, remember to complete a separate copy of this
                  page for each maternity unit which is to form part of the assessment


Local demographics
Please give a brief description of local demographics




.



                                                  6                             Stage 3 app form mat Jan 2011
 Section 1 – Antenatal care


This section applies to the whole of the hospital/Trust which is the subject of the assessment.
Please refer to section 2 of the guidance document when completing this section. The numbered
headings below relate to the numbered sections of the guidance document.
Please delete Yes or No, where applicable.

1.1    Antenatal information on breastfeeding

       Are all pregnant women given information on:
           The health benefits of breastfeeding?                                          Yes/No
           The importance of exclusive breastfeeding?                                     Yes/No
           The importance of skin-to-skin contact at delivery?                            Yes/No
           The importance of effective positioning and attachment for breastfeeding?      Yes/No
           The importance of keeping mother and baby close/rooming-in?                    Yes/No
           The importance of baby-led/demand feeding?                                     Yes/No
           The importance of avoiding teats and dummies during the establishment
            of breastfeeding?                                                              Yes/No


       How is this information provided?
        Discussion  Written materials       Parent education class

       When, during a woman’s pregnancy, is this information given?

              Discussion, Parent education class or Leaflet
                                                                            When given
                      (please give details of leaflet)




       Please ensure that copies of all written materials in current use are available for the
       assessors to see on the day of the assessment.

                                               7                        Stage 3 app form mat Jan 2011
      Is a checklist used to prompt/document the giving of this information?                  Yes/No

      If yes, please ensure that a copy of the checklist is available for the assessors to see on
      the day of the assessment.

      If no, please describe, in the box below, how the giving of information antenatally is
      recorded in the woman’s notes:




      Are pregnant women routinely shown how to make up a bottle of infant
      formula?                                                                                Yes/No

1.2   Results of audit of antenatal care

      Please use the results of your most recent audit to complete the table below:

                                                                               % giving desired
      Pregnant women who …
                                                                               response

      Can recall basic information about what skin contact is and why it
      is beneficial

      Can recall basic information about the importance of keeping the
      baby close for breastfeeding

      Can recall basic information about how often her baby will feed
      and what signs to look out for

      Can recall basic information about why it is important not to give
      formula or water to a breastfed baby

      Can recall basic information about why positioning and
      attachment matter for breastfeeding

      Can recall basic information about at least two of the above
      management topics

      Can name at least two health benefits of breastfeeding

      Confirm that they have not been given instruction in how to make
      up a bottle of infant formula during this pregnancy


                                               8                           Stage 3 app form mat Jan 2011
1.3   Written materials for pregnant women

      Please ensure that copies of all written materials listed in section 1.1, above, are
      available for the assessors to see on the day of the assessment.

      Are any promotional materials (e.g. Bounty bags) distributed to pregnant
      women?                                                                               Yes/No

      If yes, please ensure that samples of all these materials are available for the assessors
      to see on the day of the assessment.




                                              9                         Stage 3 app form mat Jan 2011
 Section 2 – Postnatal care


This section applies to the whole of the hospital/Trust which is the subject of the assessment.
Please refer to section 3 of the guidance document when completing this section. The numbered
headings below relate to the numbered sections of the guidance document.
Please delete Yes or No, where applicable.

2.1    Mother and baby contact – at birth

       Please use the results of your most recent audit to complete the table below:

       New mothers whose babies were able to be with them on the               % giving desired
       postnatal ward who …                                                    response

       Confirm that they had skin-to-skin contact with their baby as soon
       as possible after delivery

       Confirm that this skin contact lasted at least one hour (longer if
       the mother wished) or until the baby has breastfed.

       Were offered help, support or encouragement to give their baby a
       first breastfeed soon after delivery



2.2    Mother and baby contact – later

       Please use the results of your most recent audit to complete the table below:

       New mothers whose babies were able to be with them on the               % giving desired
       postnatal ward who …                                                    response

       Roomed-in with their baby throughout their hospital stay, without
       unwarranted separation

       Are there any policies (other than the breastfeeding policy) which are relevant
       to mother and baby contact, e.g. a bed sharing policy?                                  Yes/No

       If yes, please ensure that a copy of each of these is available for the assessors to see on
       the day of the assessment.




                                               10                           Stage 3 app form mat Jan 2011
2.3   Help and support for breastfeeding on the postnatal ward

      Please use the results of your most recent audit to complete the table below:

      Breastfeeding mothers whose babies were able to be with               % giving desired
      them on the postnatal ward who …                                      response

      Were offered further help with breastfeeding within 6 hours of
      delivery

      Were shown how to position and attach their baby for
      breastfeeding

      Can correctly describe effective positioning and attachment


      Were shown how to express their breastmilk by hand

      Were able to describe how they would recognise effective milk
      transfer

      Were advised to feed their baby on demand (or otherwise, if
      appropriate to the baby) and aware of feeding cues

      Confirm that their baby has not been fed using a bottle and teat
      (except in the case of fully informed choice)

      Confirm that their baby has not been given a dummy
      (except in the case of fully informed choice)



2.4   Exclusive breastfeeding on the postnatal ward

      Please use the results of your most recent audit to complete the table below:

      Breastfeeding babies on the postnatal ward who have                   % giving desired
      received …                                                            response

      Only breastmilk


      Supplement(s) as a result of a fully informed maternal choice


      Supplement(s) as a result of clear clinical/medical indication

      Supplement(s) which were clinically indicated but which may have
      been avoided if earlier care had been better

      Supplement(s) suggested by staff for non-clinical reason(s)

                                              11                         Stage 3 app form mat Jan 2011
      Is there a hypoglycaemia policy and/or a policy/guidelines for the
      management of babies who are reluctant to feed?                                         Yes/No

      Are there other policies which are relevant to the maintenance of
      exclusive breastfeeding (e.g. management of jaundice)?                                  Yes/No

      If yes, please ensure that a copy of each of these is available for the assessors to see on
      the day of the assessment.


2.5   Support for mothers with babies in the Special Care/Neonatal Unit

      Please use the results of your most recent audit to complete the table below:

      New mothers whose babies are in the Special Care/Neonatal               % giving desired
      Unit who …                                                              response

      Were offered help to express their breastmilk as soon as possible
      after delivery

      Were shown how to express by both hand and pump

      Were advised to express at least 8 times in 24 hours, including at
      night



2.6   Ongoing support for breastfeeding mothers

      Please describe, in the box below, the support that is provided by the maternity service
      for breastfeeding mothers once they have left the hospital:




      Are mothers advised how to contact a midwife for help with breastfeeding
      on (or before) discharge from hospital?                                                 Yes/No



                                              12                           Stage 3 app form mat Jan 2011
      Are there any breastfeeding support groups in the local area?                          Yes/No

      If yes, please give details in the box below:




      Are mothers provided with contact details for the these groups on (or
      before) discharge from hospital?                                                       Yes/No

      Are mothers provided with contact details for the national telephone helpline          Yes/No

      Are mothers provided with information about the national voluntary
      breastfeeding support organisations?                                                   Yes/No


      Please use the results of your most recent audit to complete the table below:

                                                                              % giving desired
      Breastfeeding mothers who …
                                                                              response

      Confirm that they were given information, on or before discharge
      home from the maternity unit, about how to contact a midwife and
      both national and local a voluntary sources of support

      Is this information provided as part of a standard pack of information and/or
      materials that is given to all breastfeeding mothers on transfer home?                 Yes/No

      If yes, please ensure that a sample of this pack is available for the assessors to see on
      the day of the assessment.


2.7   Information for mothers who have chosen to formula feed

      Are mothers who have chosen to formula feed their babies shown
      how to make up feeds in the postnatal period?                                          Yes/No

      Please use the results of your most recent audit to complete the table below:

                                                                              % giving desired
      Formula-feeding mothers who …
                                                                              response

      Confirm that they have been shown, postnatally, how to make up
      a formula feed, or that a member of staff has confirmed that they
      know how to do this

                                               13                         Stage 3 app form mat Jan 2011
2.8   Written materials for new mothers

      Is written information provided for new mothers?                                       Yes/No
      [If yes] When, during the postnatal period, is this information given?

                   Leaflet / pack                      To whom given              When given




      Remember to include information given to mothers whose babies are in the NNU/SCBU
      and those who have chosen to formula feed.

      Please ensure that copies of all written materials in current use are available for the
      assessors to see on the day of the assessment.

      Are any promotional materials (e.g. Bounty bags) distributed to new mothers?           Yes/No

      If yes, please ensure that samples of all these materials are available for the assessors
      to see on the day of the assessment.


2.9   Recording of postnatal care and information-giving

      Is a checklist used to prompt/document the giving of information and care
      to mothers postnatally?                                                                Yes/No

      If yes, please ensure that a copy of the checklist is available for the assessors to see on
      the day of the assessment.

      If no, please describe, in the box below, how the giving of information and care
      postnatally is recorded in the woman’s/baby’s notes:




                                              14                          Stage 3 app form mat Jan 2011
 Declaration by Head of Service



I certify that the information given on this form is correct, to the best of my knowledge.


I request an assessment at:


 Name of hospital or Trust


on or soon after:

 Anticipated date of readiness
 for assessment


I confirm that


 Name of Trust / organisation


will pay the invoice for the above assessment visit within 30 days of receipt; I note and agree to
the cancellation charges (see page 1).




 Signature (Head of Service)

 Job title

 Date




                                                 15                          Stage 3 app form mat Jan 2011

				
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