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Infant Formula Audit Checklist document sample
Document Sample
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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