northern devon healthcare nhs trust - annual audit report … · 2019. 4. 27. · devon supervisory...

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Annual Audit Report Monitoring the Standards of Supervision and Midwifery

Practice

Northern Devon Healthcare NHS Trust

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Local Supervising Authority Audit Report

Northern Devon Healthcare NHS Trust Version number: 1 Audit date: March 16th, 2015 First published: March 21st, 2015 Updated: Prepared by: Helen Pearce (Local Supervising Authority Midwifery Officer) Maria Patterson (Local Supervising Authority Midwife Classification: Official

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Contents Contents ..................................................................................................................... 3

1 Introduction .......................................................................................................... 4

2 Context ................................................................................................................ 7

3 The LSA Audit ..................................................................................................... 8

3.1 Audit aim ........................................................................................................ 8

3.2 Methodology .................................................................................................. 8 3.3 Formal LSA Audit Processes ......................................................................... 8

4 Assessment of the LSA Standards for the Supervision of Midwifery practice .... 10

4.1 Rule 4 .......................................................................................................... 10

4.2 Rule 6 .......................................................................................................... 10 4.3 Rule 7 .......................................................................................................... 12 4.4 Rule 8 .......................................................................................................... 12 4.5 Rule 9 .......................................................................................................... 14 4.6 Rule 10 ........................................................................................................ 15 4.7 Rule 14 ........................................................................................................ 17

5 Appendices ........................................................................................................ 18

5.1 Agenda for audit visit ................................................................................... 18 5.2 Supervisor of Midwives action plan 2014-2015 ........................................... 20 5.3 LSA Audit Tool ............................................................................................. 21

5.4 Lay Auditor Report ....................................................................................... 31 5.5 Peer Supervisor report ................................................................................. 40 5.6 Supervisor of Midwives action plan 2015-2016 ........................................... 41 5.7 Questionairre responses from midwives……………………………………… 42

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1. Introduction to the Local Supervising Authority Annual Audit Overview of Northern Devon Healthcare maternity services. The Northern Devon Healthcare NHS Trust operates across 1,300 square miles and provides both acute hospital care and community services. The North Devon District Hospital in Barnstaple provides a full range of district general hospital services. Northern Devon Healthcare NHS Trust is an aspirant foundation trust. Northern Devon maternity services provides community midwifery across a wide rural area and provides care for approximately 1800 women each year. Northern Devon District Hospital provides a 6 bedded delivery suite facility which caters for high risk women requiring obstetric care and offers midwife led care for low risk women, with two pool rooms being available. The maternity services also provide a 18 bedded antenatal and postnatal ward. There is an available 24/7 theatre located on the delivery suite. There is a special care baby unit providing care for babies who may require level 1 special care additional support (but not intensive care) and are over 30 weeks. The maternity services provide 1-1 care in labour and this is achieved 99% of the time. The maternity services have refurbished their ultrasound suite CQC inspection- Maternity services rated as Good The CQC inspection took place between 2 and 4 July 2014. An unannounced visit also took place on 14 July 2014.The CQC found that maternity services within Northern Devon Healthcare were good. Maternity and family planning services were found to be safe, effective, caring and responsive but required improvement in order to be well-led. The care and support offered to women and their families was detailed as compassionate, kind and informative. The CQC noted that staff referred to a Royal College of Obstetricians and Gynaecologists (RCOG) visit, commissioned by the trust in November 2013, to “obtain an external view of the impact of the medical team working on patient safety”. A report was sent to the trust on 4 March 2014 and an action plan developed by the trust. The developments from this report were needed to address long standing, complex relationship issues around this staff group. The CQC identified that rooms used by sonographers in the antenatal clinic were not big enough to allow for privacy and dignity of women to be maintained without the practitioner having to leave the room. The rooms did not have a system for calling for help in the event of an emergency. The CQC identified that the caesarean section and induction of labour rates were above the national average for a low-risk unit. The maternity staff including supervisors are continually driving forward work to reduce the caesarean section rate , through Listening into Action Methodology and the NHS Innovations Tool kit to promote normal birth with the multi-disciplinary staff groups and to pregnant women. The Head of Midwifery is confident that the Supervisors of Midwives will contribute to ensure the LIA project is maintained and that midwifery practice and good team working continue to promote a safe environment for women to give birth.

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The LSA annual audit was undertaken by Helen Pearce LSA Midwifery Officer, Maria Patterson LSA Midwife and Sara Bird LSA Lay Auditor. A peer supervisor was scheduled as part of the audit team however was unable to attend on the day of the audit, the LSA team apologise for this. The audit team was made to feel very welcome and appreciated the hospitality shown. A programme for the visit was agreed in advance, meeting with stakeholders and a tour of the unit and a presentation by the supervisory team. The supervisors presented on the following topic, “Demonstrate how the Supervisory team have taken forward the action plan 2014-2015 highlighting the challenges and triumphs and identifying three key priorities for year ahead. Consider the findings and recommendations from the NMC Extraordinary Review of Guernsey.” The team presented to an audience consisting of the LSA team, Head of Midwifery, Interim Director of Nursing, Non-Executive Directors and student supervisor of midwives. This broad attendance demonstrates the wide support available for the supervisory team. The supervisors presented on their progress in meeting the LSA action plan for 2014-15. The LSA audit team felt that the presentation did not reflect the hard work conducted by the supervisory team over the past twelve months. The presentation had not been prepared or reviewed by the whole supervisory team, which would have been best practice. The presentation failed to cover the findings and recommendations from the NMC Guernsey Extraordinary review. The team agreed to represent their presentation on the 20th April to the LSA Midwifery Officer and LSA Midwife. The presentation on the 20th April was positive; detailing the achievements made by the North Devon supervisory team and how they had carefully considered and benchmarked themselves against the recommendations of the NMC Extraordinary review of Guernsey. The team demonstrated that they had met nine out of eleven recommendations. The two outstanding actions are to achieve 100% completion of the annual supervisory review, which is the NMC expectation, and to audit and evaluate the views of women, midwives and medical staff with regard to complex care planning. There are six supervisors of midwives currently in practise in the Northern Devon supervisory teams with one supervisory on a leave of absence. The supervisory caseloads are currently with a range of between 1-9 and 1:20, with the average being 1:14.7 this is just below the NMC recommended ratio of 1:15. Supervisors described that due to the essential building works surrounding the ultrasound department that it was not always possible to identify a confidential area to be able to meet supervisees and access the LSA database. However the Head of midwifery clarified that there is an office available on Bassett ward for the supervisors to use and that this has been available for supervisors to use throughout the building work.. There are 84 midwives notifying their intention to practise for the year 2014-15. This compares to 90 midwives (2013-14) and 90 midwives (2012-13).

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A member of the LSA team contacted the switchboard but was not able to speak to a supervisor of midwives and had to ask to be put through to the delivery suite. This system needs to be reviewed to ensure that it is accessible. Recommendation: To review information at switchboard concerning contacting the on-call supervisor of midwives.

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2. The Context The Nursing and Midwifery Council (NMC) sets the rules and standards for the function of the Local Supervising Authorities (LSAs) and the supervision of midwives. The Local Supervising Authority Midwifery Officer (LSA MO) is professionally accountable to the Nursing and Midwifery Council. The function of the LSA MO is to ensure that statutory supervision of midwives is in place to ensure that safe and high quality midwifery care is provided to women. Supervisors of Midwives are appointed by the LSA and the LSA function sits within NHS England. The main responsibility of the LSA is to protect the public by monitoring the quality of midwifery practice through the mechanism of statutory supervision for midwives. NHS England and the Nursing and Midwifery Council appoint a LSA MO to carry out the functions of the LSA, which may include visits and inspections of places of midwifery work. This will provide a structured means to oversee the practice and supervision of midwives within South West LSA, to ensure the requirements of the NMC are being met (Rule 11, NMC 2012). The audit is carried out to inform the Local Supervising Authority annual report to the NMC ( Rule 13, NMC 2012). All practising midwives in the United Kingdom are required to have a named Supervisor of Midwives. A Supervisor of Midwives is a midwife who has been qualified for at least three years and has undertaken a preparation course in midwifery supervision (Rule 8, NMC 2012). Each supervisor oversees approximately 15 midwives and is someone that midwives may go to for advice, guidance and support. The Supervisor of Midwives will monitor care by meeting with each midwife annually, (Rule 9, NMC 2012) auditing the midwives’ record keeping and investigating any reports of problems/concerns in practice. They are also responsible for investigating any serious incidents and reporting them to the LSA MO (Rule 10, NMC 2012).

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3. LSA Audit 3.1 LSA Audit Aims The aims of the audit are:-

To review the evidence demonstrating that the standards for supervision are being met.

To ensure that there are relevant systems and processes in place for the safety of mothers and babies.

To review the impact of supervision on midwifery practice

To ensure that midwifery practice is evidence based and responsive to the needs of women.

3.2 Methodology

The process for the audit of the LSA standards continues to be a self/peer review approach with verification of evidence by the LSA audit team employing a targeted sampling technique. Self/peer review is recognised as a powerful tool that stimulates professional development and decentralises power creating awareness of personal accountability. A profile of the maternity service and the completed assessment tool listing the supporting evidence and any comments and recommendations the supervisors wished to make was sent to the LSA office prior to the audit.

3.3 Formal LSA Audit Processes

Programme for Audit visit The programme was sent in advance to the audit team.

Self-audit tool The tool was completed before the audit and sent to the LSA MO.

Evidence The supervisors had prepared evidence for each standard similar to a CNST audit. Where possible evidence was sent electronically to the LSA in advance of the formal audit.

3.4 LSA audit and how the standards are met The audit methodology requires that LSA auditors should make judgments based on evidence provided to them about the quality and effectiveness of the supervision of midwives in meeting the LSA standards. The LSA auditors made judgements on the following basis: “Met” Standards are in place across the LSA and they are met within this team’s area. The LSA enables supervisors of midwives and midwives to achieve stated

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rules and standards. Audit standards have been met without the need for specific improvements.

“Requires improvement” The LSA enables supervisors of midwives and midwives to comply with the midwives rules and standards. However improvements are required to address specific processes to enhance assurance for public protection.

“Not met” The team does not meet the requirements necessary for ensuring that the LSA is compliant with the midwives rules and standards. Significant and urgent improvements are required in order that public protection can be assured and the standards are met.

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4 NMC (Midwives) Rules (2012) Summary The Supervisors of Midwives based at North Devon Hospitals met in full the standards for statutory supervision of midwives set by the Nursing and Midwifery Council and cited in The Midwives’ Rules and Standards (NMC, 2012) for Rules 7,9,10 and 14. Improvements are required to address specific processes to enhance assurance for public protection for Rules 4, 6 and 8. These areas have been identified and recommendations have been made. The expectation is that supervisors will write an action plan in response to this audit and develop supervisory practices in these areas. 4.1 Rule 4: Notifications by LSA: Requires Improvement 1.1 Intention to practise notifications are sent to the NMC by the annual submission date specified by the Council 1.2 Intention to practise notifications received after the annual submission date are sent to the NMC as soon as reasonably practicable. Intention to Practice The LSA midwife reviewed the current Northern Devon maternity establishment and cross checked against the LSA database, to ensure that all midwives employed at the Trust had a current Intention to practice (ITP). It was identified that two midwives who had recently started work at the Trust had had their intention to practice entered for the forthcoming practice year but not for the current year. For one new starter there was a three month delay due to the ITP having been entered for the incorrect year. This was due to human error and was rectified on the day of the audit; the midwives had submitted the correct Intention to Practice form. This issue requires highlighting to supervisors to ensure that the error does not occur again. The dates of two additional new starters to the Trust were cross checked against the date that the ITP had been entered. For two midwives their ITP was entered within three or four days of commencing work at the Trust, it is not clear if this was prior to clinical practice being commenced. The supervisors described that all new midwives joining the Trust are now sent a letter from the supervisory team as part of the trust recruitment pack. The supervisors have also devised a new starter checklist and a letter to be sent to midwives from the supervisors once they start work. This is good practice and evidence of proactive supervision, it would appear that the wrongly entered ITP forms were human error and the team should be reminded to check the year date when submitting an ITP. The supervisors shared as evidence an ITP poster that they have displayed around the unit to remind midwives to submit their ITP forms for the forthcoming practice

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year. Each midwife also has a personnel email from the supervisory team as a personnel reminder. Recommendation: The supervisory team to review their processes with regard to uploading the ITP’s of new starters at the end of the practice year. Annual Reviews In order to provide assurance that midwives are meeting the NMC requirements to maintain their midwifery registration supervisors of midwives must complete an annual review to provide assurance that midwives are meeting the NMC requirements for midwifery practice. The annual review should be completed prior to the ITP form being signed. The North Devon supervisors have completed 92% of annual reviews for this current practice year. This percentage has failed to meet the 100% completed annual reviews target expected by the NMC (excluding maternity leave and sick leave). The annual review paperwork used by the North Devon supervisors is being piloted across the South West LSA and ensures a robust and consistent approach. However it is rather lengthy and repetitive and will be reviewed by a working group from across the LSA. A representative from North Devon will be on this group. The paperwork seeks assurance in relation to how the midwife has met the NMC PREP requirements of 35 hours learning activity (CPD) and 450 hours of registered practice in each 3 year Notification of Practice (NoP) cycle.

Recommendation: Supervisors to ensure that 100% of annual reviews are completed to ensure compliance with the NMC midwives rules. 4.2 Rule 6: Records –Requires Improvement The NMC (Midwives) Rules 2012 require midwives to ensure that there are ‘all records relating to the care of the woman or baby must be kept securely for 25 years. This includes work diaries if they contain clinical information’ and the .NMC Code (2014) ‘47 You must ensure all records are kept securely.’

The supervisors confirmed that they have no agency midwives or independent midwives who work within the organisation. The LSA team reviewed the storage of supervisory records. The majority of supervisory records are stored electronically. Any paper supervisory records are stored in a locked filing cabinet in a locked room. This meets the requirements for the safe storage of records. Following the NMC extraordinary review of Guernsey, the supervisory team have reviewed the system for the storage of community midwifery diaries. As a result of this review, the community diaries are now being bought into the Trust for safe storage. This is good practice, ensuring compliance with rule 6 of the NMC rules. It is recommended that this practice is incorporated into the Trust policy for the storage of medical records.

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Recommendation: Trust record storage policies to detail the procedure for the safe storage of community diaries. The maternity records within the units are stored within staff offices that are securely locked with key pads. The clinical maternity notes on Bassett ward are stored in a notes trolley which is not locked and within the labour ward notes are stored in a cupboard that is not locked. The community matron has advised that lockable notes trolleys have been ordered to ensure the security of patient records. Recommendation: Lockable notes trolleys should be utilised to ensure the safety and security of patient records. Recommendation: Supervisors to audit the safe storage of records on a regular basis 4.3 Rule 7: The Local Supervising Midwifery Officer- met

The LSA has conducted an annual audit in 2014, which was shared with the Trust in the autumn. A service user is a key part of the audit process, meeting with women to seek their experiences of the maternity service, the service user views and recommendations are included with the report. The audit report and recommendations was presented by the contact supervisor at the Quality Assurance Committee. The minutes highlight that the contact supervisor reminded the board of the key supervisory functions, the progress on the previous year’s action plans. The board requested assurance that the all key recommendations would be allocated to a named supervisor and there was a discussion relating to the supervisor’s role in reducing the caesarean section rate. This is excellent evidence of supervisor’s raising the profile of supervision at board level. The audit report is also available on the supervisory webpage for members of the public or midwives to access. This is an excellent achievement.

Minutes of the supervisory meetings were reviewed by the LSA audit team and it was evident that the audit action plan was a standing agenda item at each supervisory meeting. The team have made significant progress against their action plan via delivering nine out of eleven recommendations. This achievement demonstrates the hard work of the North Devon supervisory team and their commitment to supervision. In addition to the promotion of supervision within the Trust the supervisors have also been involved in articles for local newspaper regarding how supervision can support women and their families.

4.4 Rule 8: Supervisors of Midwives- requires improvement

There was compliance with the LSAMO Forum UK guideline for the recruitment and retention of supervisors of midwives.

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The supervisory team described how they met the guideline for recruitment by sending every midwife an email inviting them to apply to become a supervisor of midwives. The supervisory team articulated that they received a positive response, with four midwives being interested. The NMC requirements were met and LSA process was followed. Three candidates were interviewed. Two candidates were selected. The interview panel included the LSAMO, the LME, the LSA lay user and the contact supervisor of midwives. Both POSOM students have been allocated a mentor who is eligible to be a sign off mentor and is on the mentor register. There has been additional interest expressed from midwives for this year’s PoSoM course should funding be available. This is indicative that supervision is viewed positively within the unit. Meeting with Lead Midwife for Education The LME was able to provide assurance that there were appropriate sign off mentors for the PoSoM students and that there was a list of sign off mentors and that the university would be reviewing their mentor database. The LME suggested that the supervisory team would benefit from greater understanding and knowledge of external influences. The model of cascading information from the Kirkup report was excellent and should be considered by the team for other national reports and information from supervision. The second presentation in April demonstrated greater understanding and this will be further strengthened by the Head of Midwifery re-joining the supervisory team. The LME has offered to attend a supervisory meeting and the LSA will also arrange to attend a meeting within the next 3 months. Recommendation: For the LME and LSA to support the supervisory team by providing relevant and timely national information and attendance at a SoM meeting All supervisors of midwives have completed the required six hour PREP activity specified by the NMC. However, only three supervisors have completed the supervisor’s self-assessment competency document which is required by the LSA to identify if supervisors feel able to undertake their role or require additional support. Recommendation: 100% of supervisors to complete the supervisor’s competency document. There are five sign of mentors amongst the supervisory team which facilitates the support, training and assessment of PoSoM students.

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No complaints were raised in relation to a North Devon supervisor of midwives in this practice year.

4.5 Rule 9: Local Supervising Authorities Responsibility for Supervision of Midwives: met

The contact supervisor of midwives has attended 100% of the contact supervisor meeting this year; this is very positive and ensures clear communication between the LSA and the supervisory team.

The supervisory caseloads were reviewed to demonstrate equitable, effective supervision for all midwives working within Northern Devon Healthcare Trust. The supervisory caseloads range from between 1:10 and 1:18, however one supervisor is currently off sick. During the audit the team discussed succession planning and how to broaden the skills within the team. It was agreed that the Head of midwifery would join the team as a supervisor of midwives which would reduce the caseload numbers for each supervisor. This is good evidence of supervisors reviewing their caseloads and skill mix to ensure the team is succession planning and productive. There is evidence from the supervisory meeting minutes that caseloads are regularly reviewed and updated. This is good practice. Two new supervisors are due to qualify in September which will further reduce the caseloads. The Head of Midwifery is keen to re-join the supervisory team and has discussed with the LSA how she would manage the role alongside her substantive position. She is keen to be develop supervisory links with students, this would be a good use of her experience and expertise. Recommendation: The Head of Midwifery to re-join the supervisory team. The contact supervisor informed the LSA that all student midwives have access to a supervisor of midwives. An e mail was shared as evidence to demonstrate that a cohort of students had been contacted by their named supervisor of midwives who advised them that she could be contacted. The LSA team spoke with three student midwives who confirmed that they were allocated a named supervisor of midwives. The students described that they are required to meet with a supervisor of midwives to complete their annual assessments.

The supervisory team articulated that they are appropriately allocated time to undertake their supervisory role. This is assuring for the LSA, demonstrating that the North Devon supervisors are fulfilling their statutory function as per NMC midwives rules and standards.

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4.6 Rule 10: Supervisory Investigations- Met There is good evidence that the supervisors comply with the LSA investigation policy. The supervisory team has undertaken six supervisory investigations in the previous practice year, which have involved eight midwives. The investigations have been entered onto the LSA database and the correct processes and documentation have been used. The LSA is assured that the investigations were conducted with a transparent approach and demonstrated robust decision making. Two investigations were delayed due to annual leave and one due to workload. The investigations have recommended the following; one midwife required local resolution, four midwives required a local action plan and two midwives have required the support of an LSA practice programme. One investigation remains ongoing. The supervisors have communicated regularly with the LSA throughout the course of the investigations and sought advice or assistance as required. The LSA requires all serious incidents to be reviewed by a supervisor to ensure compliance with the midwives rules. There have been seventeen STEIS cases reported by maternity services within 2013-14. All serious incidents are now reported to the contact SOM and a supervisor now attends the serious incident review to provide clinical advice and support for the midwives. The LSA has evidence that all STEIS cases have been proactively reviewed by a supervisor using a decision tool, this is assuring. The supervisors articulated that all decision tools are discussed during the supervisory meeting which promotes learning stimulates debate and identifies trends.

After completion of several DMT’s the SOM team noticed a trend with regards to reduced fetal movements. The supervisors responded to this risk by developing leaflets and posters for woman and also posters for professional informing them of what action to take at each gestation in pregnancy. The supervisors have also contributed to the redevelopment of the reduced fetal movement’s guideline. A supervisor of midwives now attends the risk meeting and completes a proforma for detailing the discussion from the meeting which is stored on the G drive for access by all supervisor of midwives. This is a good achievement. This is excellent evidence of supervisors complying with rule ten and challenging poor midwifery practice. On the day of the LSA audit three sets of STEIS cases had been requested for review by the LSA team using a supervisory decision tool. The audit team reviewed each case alongside the completed decision tool and were assured that the appropriate supervisory action had been taken. The Contact SOM met with Director of Nursing on two occasions however the Director of Nursing has resigned and an Interim Director of Nursing has recently been appointed. The Contact supervisor plans to commence regular meetings with

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the Interim Director of Nursing. The contact supervisor meets regularly with the Head of Midwifery to ensure good communication between supervision and management. The Maternity Risk Manager was able to provide assurance about the collaborative and effective working relationships that he had with all of the supervisors of midwives. He felt that whilst information was shared this was principally through informal routes. It was therefore agreed that he would agree a short briefing highlights template that the supervisors could complete for the governance meetings Recommendation: For the supervisors to agree with the Maternity Governance Manager, a short briefing template highlighting key supervisory activities / outcomes to be shared through Trust governance systems Meeting with Director of Nursing The LSA team met the Interim Director of Nursing who was able to provide assurance that there she would support a quarterly meeting with the Contact Supervisor. She values the input from the supervisors at round table meetings to discuss serious incidents and confirmed that information relating to serious incidents is shared by supervisors. She was concerned that at the time of the audit there was a low level of completed annual audits that had been uploaded onto the LSA database. Subsequent to the audit the supervisory team have been able to complete 92% of annual reviews which is an improvement but still does not meet the NMC expectation for 100% completion. Meeting with Head of Midwifery The LSA team met the Head of Midwifery who was disappointed by the low level of completed annual reviews on the LSA database (one supervisor had only recorded 29% completion). She was able to confirm that she receives a full copy of all supervisory investigation and that supervisors are appropriately involved in the review of serious incidents. The Head of Midwifery described how on her return from annual leave a Supervisor of Midwives provided her with a bound copy of the Kirkup report and a comprehensive briefing. The supervisors had also fully briefed the midwives. This is assuring and demonstrates proactive supervision. The Head of Midwifery felt that the supervisors of midwives were undertaking investigations in a sensitive manner and that appropriate support was being provided for midwives. Meeting with midwives Due to high activity on the day of the audit no midwives were available to speak to members of the audit team. However 24 completed questionnaires were received from midwives to express their views of supervision of midwives within North Devon. All midwives were clear with regard to the requirements to submit an intention to practice form and they clearly understood the process for doing so. All midwives responding would escalate concerns if they witnessed poor practice and this is very assuring. There was a variation identified in relation to when midwives had last had

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medicines management training and the LSA recommend that the supervisors review how midwives are ensuring that they comply with the NMC standards for medicines management. All midwives had a named supervisor of midwives and had had a recent annual review. Recommendation: Supervisors to review the findings from the midwives questionnaires and assess how midwives are ensuring that they comply with the NMC standards for medicines management 4.7 Rule 14- Met There have been no suspensions from practice this practice year.

Summary The supervisory team at North Devon are a strong team who have made significant progress in the previous practice year. The team work well together but are also confident and able to challenge each other. The team are proactive and have made significant progress against the LSA action plan; they are constantly striving to raise the profile of supervision and to push their service forward. The team are visible amongst their peer which is supported by the feedback from midwives. The team have established effective links with governance and are appropriately reviewing serious incidents and completing investigations within the time period. The team should be commended for their hard work to achieve the majority of the recommendations from their action plan.

A copy of this report will be sent to NHS England, the Regional Team, Clinical Commissioning Group and the Care Quality Commission.

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Appendices

Appendix 5.1 LSA Audit Visit - Agenda

Time Event

09.30-10.30

Presentation from Supervisors of Midwives (tea and coffee to be available please) Briefing for presentation: ‘Demonstrate how the Supervisory team have taken forward the LSA action plan 2014-15 highlighting the challenges and triumphs and identifying three key priorities for year ahead. Consider the findings and recommendations from the NMC Extra-ordinary Review of Guernsey’

LSA Team To attend: Head of Midwifery, Director of Nursing, General Service Manager, Risk Midwife. Open invitation: Obstetricians, Anaesthetists, Paediatricians, Lead Midwife for Education, Lay representatives, Midwives, Student Midwives, Members of the Trust Board and GP representative.

Time LSA Team 1 LSA Team 2

10.30-11.30

Meeting with service users (tea and coffee to be available please)

10.30-11.00

Meeting with Deputy Director of Nursing

11.00- 11.30

Meeting with student midwives

11.30-12.00

Tour of the unit LSA Team

12.00-12.30

Midwife open forum with LSA team (tea and coffee to be available please)

LSA Team

12.30-13.30

Meeting with Supervisors of Midwives (working lunch)

LSA Team

LSA Team 1 LSA Team 2

13.30-14.00

Meeting with Head of Midwifery 13.30-15.00

Review three care plans (with the maternal records) with lay user, peer supervisor Review of evidence from midwife questionnaires Review of written evidence available for women Review of evidence from tour of

14.00-14.30

Meeting with the Lead Midwife for Education

14.30-15.00

Meeting with Maternity Lead for Governance / Risk Manager

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unit

15.00-16.00

Review of findings LSA Team (in camera) - there will not be feedback on the day of the audit unless concerns about the safety of practice are identified.

Appendix 5.2 North Devon Action plan 2014-15

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Recommendation

To audit and evaluate midwives’ views and experience of statutory supervision

In progress

The supervisors provide a highlights paper for the Clinical Governance meetings to share learning from supervisory activities

Achieved

To document the system used to share information to and from supervision to risk management and governance systems

Achieved

To talent spot and support identified midwives to undertake the PoSoM course and be appointed as a supervisor of midwives.

Achieved

Audit of women’s views to demonstrate supervisors actively seeking user feedback to drive service developments

In progress

To review webpage and poster to develop clear messages and provide local information and a contact link.

Achieved

To locally determine a process to demonstrate how supervisors use the views of women to drive service delivery

Achieved

To complete 95% of annual reviews in the practice year 2014-15 Not met

Appendix 5.3 LSA Audit Tool

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LSA Audit 2014/15

Supervisors of Midwives Compliance with NMC LSA Standards Version 1

Please embed evidence in the ‘Evidence column’ suggestions for evidence are highlighted in yellow. If no evidence is available please identify an action to address with a completion date

Rule LSA standard LSA expectations Evidence Standard met/not

met and any areas for improvement

Notable SoM practice Areas of improvement

Rule 4: notifications by LSA

1.1 Intention to practise notifications are sent to the NMC by the annual submission date specified by the Council 1.2 Intention to practise notifications received after the annual submission date are sent to the NMC as soon as reasonably practicable.

Personalised ITP notification forms would have been sent to all midwives whose name appears on the effective register as of Dec 2014. Midwives to be eligible to submit an ITP notification must have effective registration on the midwives’ part of the NMC register and be intending to practise midwifery. Before the ITP is signed the named SoM must have carried out an assessment of the midwife’s compliance with the NMC’s requirements to maintain midwifery registration and must confirm that they are eligible to practise as a midwife. The named SoM must document the evidence they have reviewed for each midwife detailing how they meet the NMC PREP requirements of 35 hours learning activity (CPD) and 450 hours of registered practice in each 3 year Notification of Practice (NoP) cycle (this assessment can be done at the annual review). At the annual review the Midwife should provide the SoM with evidence that they have met the 35 hours in 3 years CPD requirement and the SoM needs to assess that the learning activity was relevant and was in a profile format

SoM team to provide evidence of local ITP notification arrangements

1. LSA published ITP guidance

was given locally to midwives detailing the name and address of the LSA/SoM (midwifery officer) to whom the ITP notification should be sent (poster/emails).

2. Every SoM has completed an assessment for each midwife to demonstrate registration compliance and this was documented (ITP forms checked/LSAdb/Annual reviews).

3. The staff list was checked against ITP list and that all ITPs have been entered.

4. LSA/SoMs have run enquiries on the LSAdb

Standard to be met if All SoMs have uploaded ITPs before the midwives practice. There is adherence to rigorous and robust processes that provide assurance that SoMs have carried out an assessment of the midwife’s compliance to maintain midwifery registration and to confirm that they are eligible to practise. All midwives who have notified their intention to practise and have a named SoM. All Midwives have a named SoM.

Each midwife also has a personnel email from the supervisory team as a personnel reminder. Annual reviews will be completed by the March 31

st for

this year. Helen Fardon will have completed all annual reviews by 26

th March

SOM allocation List All annual reviews will be completed using new LSA paperwork. All annual reviews will be uploaded directly onto the database. Each midwife has already been sent the new paperwork prior to their annual review. The annual


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Rule LSA standard LSA expectations Evidence Standard met/not met and any areas for improvement


documenting how the learning activity has informed and influenced their practice. The written work must reference the professional standards such as the NMC Code. SoMs should use the NMC PREP standards for guidance When the SoM signing that on that day it has been checked that the midwife had met the requirements. NB – the SoM may sign the ITP and the midwife’s annual retention fee is due in the next month and she fails to pay. The SoM would have signed the ITP in good faith that the midwife would maintain current registration to be able to practise. SoMs must use LSAMO Forum UK policies for their practice

Confirming midwife’s eligibility to practise

Annual review of practice by a Supervisor of Midwives

To stay on the register a midwife must renew their registration requirements every 3 years (periodic renewal) and pay an annual retention fee (1

st and 2

nd

years).

Midwives in practice - All midwives who are about to practise in 2015/16 practice year have had their ItPs entered onto the LSA database by their named SoM before they start practising on 1

st April 2015.

Midwives practising after 1

st April

- Before practising all midwives have submitted their ITP.

LSA to run Report 13 (SoM caseloads) Report 17 (dates of annual reviews by Trust) Report 18 (percentage of annual reviews by SoM) Report 43 (MPW ITP entries by Trust) Report 44 (MPW ITP entries by SoM by caseload) Report 47 (no ITP on effective date but has for previous practice year)

5. Midwives are informed before they commence employment and before practising how to notify ITP (pre employment letter).

6. On commencing employment a midwife has a named SoM (pre employment letter).

7. A current list of SoMs and supervisees is kept and updated regularly (caseload lists).

Peer SoM/LSAMO at audit visit

1. Meet with midwives and ask

them how their named SoM checked PREP standards before signing ITP. Did the SoMs record evidence for each midwife? (questionnaires to be handed out and collected)

2. Check that all SoMs understand the NMC PREP requirements

review paperwork is also available on the supervisor of midwives website. New midwife starters are now sent a letter from the supervisory team as part of the trust recruitment pack. Once they have started they receive a letter from the contact supervisor of midwives supervisor about their named SOMThere is also a checklist for the SOM to complete SOM prep has completed. Self assessment forms will be completed by 31

st March and

downloaded onto the database.

Report-13caseloads above 1;16 for 2 soms. 2 posoms in training. Annual reviews- 17 outstanding. 80% compliance-? Some midwives have in paper copy but not uploaded. To do by the end of March.


23



and what actions should be taken if a midwife does not meet them.

3. Check all SoMs knowledge and

awareness of policies (Confirming eligibility to practise policy and Annual review of practice policy).

4. Check SoM ITP (copy) storage arrangements (paperless LSA).

5. Check local system for notifying ITPs for agency midwives.

6. Check local system for new starters to have submitted ITP before practising.

7. Review number of LSAdb error reports for the year and reasons for errors.

Using new tool. As part of recruitment pack a letter goes to mws from som. See above. 2 X new midwives had next years itp entered for this practice year. They were registered with the South West. Caseloads regularly reviewed at meetings

Rule 6: Records

1. LSA must publish local guidelines for transfer of midwifery records from self- employed midwives. Midwife standards: 1. all records relating to the care of the woman or baby must be kept securely for 25 years. This includes work diaries if they contain clinical information. NMC The Code 47 You must ensure all records are kept securely.

When a self-employed midwife/ independent midwife (IM) ceases to be registered with the NMC, she must transfer her records to the LSA. All SoMs that are named SoMs for IMs must advise anyone working in self employed practice of the LSAMO Forum UK policy Transfer of midwifery records for self-employed midwives. Midwives have a responsibility to keep secure any records that contain person identifiable information and clinical information (this includes work diaries) SoMs must audit safe storage of records (this can be done with governance).

SoM team to provide evidence that midwife clinical records are kept securely

All SoMs who have self-employed midwives on their caseloads discuss their record storage arrangements for women and babies at the annual review. All SoMs have evidence that they have discussed the LSAMO Forum UK transfer of records policy with self employed midwives. The SoM team have reviewed the safe storage of records policy that the Trust has written to ensure that it meet NMC Midwives Rules and the Code (copy of Trust policy).

Standards are met when Clinical midwifery records are securely stored and this is audited. Self-employed midwives are aware of and adhere to the transfer policy.

Annual reviews are stored in locked filing cabinet cabinet within a locked room. Annual reviews are now being completed electronically and uploaded onto the LSAdb. ITP’s are photocopied and the originals are returned to the midwives. . No independent midwife. 1 bank midwife.


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The SoMs have audited the safe storage of records (record keeping audits that include monitoring safe storage). . Peer SoM/LSAMO at audit visit Review evidence of Annual review documentation of discussion of storage of records for self employed midwives. Meet with the midwives and discuss their understanding of safe storage of records.

Review in practice the local arrangements for safe storage of records (community midwife work diaries with clinical information in them etc.). Trust recordkeeping policy to be reviewed.

Soms have reviewed trust recod keeping policy. Met NMC requirement. Reviwed community midwifery diaries storage. Now brought into unit and securely stored. Needs to be written as a procedure. Contact SOM will ensure that there is reference to community diaries etc within trust policy

Rule 7 LSA MO

2. The LSA must… 2.1 using an appropriate framework, complete an annual audit of the supervision of midwives within its area 2.2 monitor the practice of SoMs as part of maintaining and improving the quality of the provision of statutory supervision of midwives 2.3 involve women who use the services of midwives in assuring the effectiveness of the supervision of midwives.

An annual LSA audit must be completed and this document is the framework for the audit. A LSA audit report will be produced within 8-10 weeks of the audit visit. The SoM team will facilitate the LSAMO to complete an annual audit of supervision of midwives within its area. The LSAMO must monitor the practice of SoMs as part of maintaining and improving the quality of the provision of statutory supervision of midwives. SoMs must involve women who use the services of midwives in assuring the effectiveness of the supervision of midwives.

SoM team to provide evidence that LSA audit report has been shared locally with midwives (local dissemination email evidence). The SoM team presented the LSA audit report to the Board (or equivalent meeting) (Board meeting notes). The SoM team developed an action plan in response to the audit and achievement of this action plan was monitored at SoM meetings (action plan and meeting notes). Lay auditor has reviewed effectiveness of supervision as part LSA audit (within LSA audit report). Each SoM has completed the competence self-assessment document and for this to

Standards are met when Women and babies and midwives have been provided with high quality supervision which is closely linked to clinical governance.

Audit report-presented at quality assurance committee. Audit report on SOM webpage so midwives or women can access. SOM have been involved in articles for local newspaper re: maternity services and supervision


25



SoMs must be available to offer guidance and support to women accessing maternity services and that these services respond to the needs of vulnerable woman who may find accessing care more challenging.

be reviewed and a development plan for each SoM has been made (self assessment documents uploaded to the SoM PREP activity page). LSA audit visit lay reviewer/SoM/LSAMO Lay auditor Lay auditor to meet with a range of service users and carry out audit activities/tasks that assure the local effectiveness of supervision (see separate tool). Peer SoM SoM to check that women have the name and contact details of the LSAMO locally (website, patient information and posters). Discuss the LSA action plan and the achievement of the objectives within it with the team. Ask SoMs about communication and accessibility of LSAMO.

Rule 8 SoMs

1. The LSA must:

1.1 publish a policy setting out its criteria & procedures for the appointment of any new SoMs in its area 1.2 Maintain a current list of SoMs in its area 1.3 ensure provision of a minimum of six hours CPD per practice year. 2. To be appointed for the first time as a SoM, a midwife must: 2.1 Have a minimum of three years’

SoMs must use the LSAMO Forum UK policy for the Nomination, selection and appointment of SoMs. Any midwives on the Preparation of Supervisors of Midwives (PoSoM) must have been through LSA selection processes. A current list of SoMs is available on the LSAdb and will be reported in the LSA audit report. Each SoM must record on the LSAdb that she has achieved her SoM PREP activity by the 31 March in that practice year.

SoM team to provide evidence that The LSA policy was used for recruitment and appointment of SoMs (recruitment posters). The SoM team will have prepared a 3-5 year plan for maintaining 1:15 ratio (local team recruitment and retention strategy for SoMs/ minutes of meeting where plan is discussed). Evidence 6 hour SoM CPD PREP for every SoM (uploaded to LSAdb).

When LSAMO Forum UK policies are utilised for the recruitment of SoMs. Team has a recruitment and retention strategy plan. CPD SoM PREP requirements are met.

POSOM students This year we had funding to two POSOM students this year. The supervisory team sent each and every midwife an email inviting them to apply to become a supervisor of midwives. We had a very positive response


26



experience as a practising midwife. At least one of which must have been in the two-year period immediately preceding the first date of appointment. 3 She must also have either 3.1 Successfully completed an approved programme of education for the preparation of SoMs within the three-year period immediately preceding the first date of appointment; or 3.2 Where it is more than three years but less than five years that have been passed since she successfully completed an approved programme of education for the preparation of SoMs complied with the CPD requirements. 4 For any subsequent appointment as a SoM, she must be a practising midwife and; 4.1 Have practised as a SoM or a LSAMO within the three year period immediately preceding the subsequent date of appointment; or 4.2 Where she has only practised as SoM or a LSAMO within a period which is more than 3 years but less than 5 years immediately preceeding the subsequent date of appointment, have also complied with the continuing professional development requirements for a SoM referred to in paragraph 1.3. 5. A SoM must be capable of meeting the competencies set out in the NMC standards

Each SoM must demonstrate ability to achieve the competencies set out in the NMC (2012) Standards for the preparation of supervisors of midwives. It is the responsibility of the team to raise concerns about the competence of a SoM directly with the LSAMO. Any concerns will be dealt with using the following policies Complaints against a SoM http://www.lsamoforumuk.scot.nhs.uk/media/16947/complaints_against_a_som_or_lsamo_policy_.pdf Reviewing the ability of a SoM to undertake the role http://www.lsamoforumuk.scot.nhs.uk/media/16965/reviewing_the_ability_of_a_supervisor_of_midwives_to_undertake_the_role_policy.pdf All SoMs are working to the LSAMO Forum UK policies.

Evidence – 100% SoMs to have completed self assessment. LSA audit visit SoM/LSAMO Review list of SoMs from LSAdb and review caseloads, ratio, appointments and resignations.

Date of interviews for 2014

Number of candidates who attended interview

Number of students on programme

Names of mentors for each student Review all SoM competency self-assessments and develop a training plan for any individuals/ team. Detail any complaints raised about SoMs in the team and how they were managed.

Competency tools completed.

with four midwives being interested. The NMC process was followed. Three candidates were interviewed. Two candidates were selected as per LSA and NMC standards. The contact SOM was a panel member for the POSOM interviews Both POSOM students have been allocated a mentor who is eligible to be a sign off mentor and is on the mentor register. We have two more interested midwives for this years course should funding be available. Midwives have completed LSA audits forms for midwives. Forms have been given to LSAMO

Rule 9 LSA responsibilities for supervision of midwives

1. the LSA must: 1.1 ensure that a local framework exists to provide: 1.1.1 equitable, effective supervision for all midwives working within the LSA

LSAMO Forum UK policies are adhered to by all SoMs. All student midwives must have access to a SoM and there should be local systems for this.

SoM team to provide evidence that Student midwives had access to supervision (evidence and written explanation as to how this is achieved).

All student midwives have access to supervision.

Student midwives have an allocated SOM. PDM also a SOM and provides teaching for the students midwives

http://www.lsamoforumuk.scot.nhs.uk/media/16947/complaints_against_a_som_or_lsamo_policy_.pdf



http://www.lsamoforumuk.scot.nhs.uk/media/16965/reviewing_the_ability_of_a_supervisor_of_midwives_to_undertake_the_role_policy.pdf





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1.1.2 support for student midwives to enable them to have access to a SoM 1.2 ensure the ratio of SoMs to midwives reflects local need and circumstances and does not compromise the safety of women. This ratio will not normally exceed 1:15 1.3 put in place a strategy to enable effective communication between all SoMs. This should include communication with SoMs in other LSAs. 1.4 monitor and ensure that adequate resources are provided to enable SoMs to fulfil their role 1.5 Publish guidelines to ensure consistency in the approach taken by SoMs in their area to the annual review of a midwife’s practice. These must include that the supervisor undertakes an assessment of the midwife’s compliance with the requirements to maintain midwifery registration 1.6 ensure the availability of local systems to enable SoMs to maintain & securely store records of all their supervisory activities

Ratio 1:15 (adjusted if there is a full time SoM or additional time is given). The LSAMO will cascade information to all SoMs via CSoM. The CSoM will communicate any team issues to the LSAMO directly. Resources for supervision should be reviewed at every SoM meeting and any concerns raised via CSoM to LSAMO. LSAMO Forum UK policy adhered to – Annual review of practice by a SoM http://www.lsamoforumuk.scot.nhs.uk/media/16944/annual_review_of_practice_by_a_supervisor_of_midwives_policy.docx.pdf Local systems have been developed to ensure that SoMs have safe storage systems of any supervisory records.

Ratio 1:15 to be maintained and an action plan drawn up by the team with the LSAMO where the ratio is not met to show that midwives still receiving supervision (report showing ratios). They have a CSoM and this person has attended 100% of LSA meetings. Protected time is discussed at local meetings and when the SoM is not able to take then this is escalated to the LSAMO (SoM meeting notes) LSA audit visit SoM/LSAMO Discuss resources for supervision with team. Discuss annual reviews with midwives to ensure that there is consistency with the approach. Discuss annual reviews with SoMs and how the information gained feeds into the training needs analysis plan for midwives. Check SoM record storage arrangements.

Individual arrangements

Shared drive systems

Paper records

LSAdb

Action plan CSoM attended all CSoMs forums. Exception reporting to LSAMO.

in relation to supervision. Also SOM team have developed teaching resource package for midwives etc SOM list attached above. All SOM are using the LSA annual review paperwork. SOM are now uploading annual reviews onto the database. Plan for forthcoming year would be for SOM to have tablets to enable them to do SOM reviews in the workplace. LSA agenda has been adopted by SOM team All som Annual reviews will be completed by March 2015. Contact SOM will ensure that all som reviews throughout the year are completed in a timely manner. See above for storage details

Rule 10: supervisory investigations

1. LSAs must publish guidelines for investigating incidents, complaints or concerns relating to midwifery practice or allegations of impaired fitness to practise against a midwife. These guidelines must: 1.1 provide for an open, transparent,

SoMs must follow LSA investigation policy when reviewing practice and investigating midwives. Policy – Review and investigation process http://www.lsamoforumuk.scot.nhs.uk/media/19380/lsa_review_and_investigation_

SoM team to provide evidence that SoMs adhere to the LSA policy for investigations. Total number of investigations=

Investigations are completed in an open, fair and timely manner.

All DMT’s are completed in a fair and equitable allocation. The contact SOM has taken responsibility for allocation of

http://www.lsamoforumuk.scot.nhs.uk/media/16944/annual_review_of_practice_by_a_supervisor_of_midwives_policy.docx.pdf




http://www.lsamoforumuk.scot.nhs.uk/media/19380/lsa_review_and_investigation_process__rule_10__doc_nov_13.pdf



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fair & timely approach, which demonstrates robust decision making processes that stand up to external scrutiny 1.2 provide opportunity for the midwife to participate in the investigation 1.3 set out the requires actions and possible outcomes following an investigations 1.4 provide for an appeals process.

process__rule_10__doc_nov_13.pdf There should be an effective, shared and transparent interface between supervision and clinical governance. Information governance policies should be adhered to at all times. Complaints about investigations should be raised with the LSAMO and all midwives should be informed of the complaints/appeals processes.

Outcomes for the investigations No further action= Local action plans= LSA practice programmes= Total number of complaints/appeals related to investigations= All investigations have been logged onto the LSAdb. All documentation related to that investigation has been logged onto the system. All investigations are completed within the 45 working day time frame. Number of investigations completed within 45 day= Number of investigation not completed with 45 day= Reasons > 45 days = Evidence that SoMs are involved in

1. clinical governance 2. clinical risk 3. serious incident reviews

LSA audit visit SoM/LSAMO Evidence – assess SoM knowledge of policy and identify any training needs. LSAMO to Meet with clinical governance team members Meet with HoM Meet with line managers Meet with risk manager

DMT’s ,also for allocation of SOM investigations. DMT’s are being completed on all STEIS reports, incidents from the risk meeting and SEA’s After completion of several DMT’s the SOM team noticed a trend with regards to reduced FM. Consequently action was taken. All SIRI’s are now reported to the contact SOM and a SOM now attends to provide clinical advice and support for the midwives. All DMT’s are discussed at the SOM meeting , it is an agenda item. We have undertaken 9 investigations. 2 have resulted in supervised practice, 4 have resulted in local action plans, 1 was resolved locally and 1 is ongoing. All investigations are logged on the



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Meet with DoN 100% of decision tool kits to be reviewed at LSA audit visit. The HoM is kept informed of investigations and outcomes. There is an active interface between supervision and governance. There is a local system to monitor number and trends within investigations. Review number of investigations completed within 45 working days and reasons when they were not. SoMs are involved in Serious Incident reviews when they involve midwifery practice.

LSAdb. We have 2 investigations not completed within 45 days. 1 because of A/L and 1 because of workload. SOM attends risk meeting. SOM now a proforma for the risk meeting on the G drive which can be accessed by all SOM which gives information the risk meeting update SOM attends guideline group Contact SOM met with DON twice but then sadly the DON left the trust. Interim DON in place . For contact SOM to resume quarterly meetings. Contact SOM meets regularly with the HOM. HOM invited to have a HOM slot at the supervisory meetings . See aboveContact SOM has also presented the LSA audit report to the QAC. This had a positive response and the team have been invited to return this


30



year. Also a SOM attends the MSLC

Rule 14: suspension from practice by a LSA

1. LSAs must publish guidelines relating to the suspension of a midwife from practice. These guidelines must include the process: 1.1 for the investigation of any allege impairment of a midwife’s fitness to practise in accordance with the standards set out under Rule 10 1.2 by which it will determine whether or not to suspend a midwife from practise 1.3 by which midwives will be given notice of suspension from practice.

LSAMO to complete all LSA suspensions from practice to NMC required standards and follow LSAMO Forum UK Policy.

SoMs to clearly highlight within in their investigation reports when the practice of the midwife is so concerning that if the midwife were to continue to practise that she would be a risk to the public. Number of NMC referrals = Number of LSA suspensions= Letters to HoM to inform them of LSA decision to suspend.

Suspensions are carried out to the LSAMO Forum policy.

NONE

Appendix 5.4 Lay User Report

31

LSA Standards 2.2 monitor the practice of SoMs as part of maintaining and improving the quality of the provision of statutory supervision of midwives 2.3 involve women who use the services of midwives in assuring the effectiveness of the supervision of midwives. On the day of the LSA audit the lay reviewer will complete these activities and then complete this table as a report to the LSAMO confirming what they found

Lay Reviewer Activities Findings Recommendations

ACTIVITY - website Review Trust website information displayed to women and midwives about supervision in this Trust. Website

Does clearly present the purpose of

Commendations Areas for improvement Yes, although information is split over four

Seek user views on whether the webpages

Statutory Supervision of Midwives Local Supervising Authority Standards for England

Local Supervising Authority Audit Tool for Lay Reviewers North Devon- Sarah Bird

Torbay 10/02/14 - SB


32


supervision to women?

Does it clearly identify to women when and why a mother might want to contact a SoM?

Does it clearly show how a SoM can be contacted 24/7?

Does it identify who the LSAMO is and how she can be contacted?

Could you find the SoM page by using the Trust search engine?

What impact does the SoM information have?

Women

Did any of the women you met on the LSA audit visit day know that there was information about supervision on the Trust website?

Midwives

pages which are particularly difficult to navigate when using a smart phone. Not on the first page (which is very midwife focused), but the information is on the page entitled “Safety of Women and Babies”. Yes and offers a very quick response time by phone (call back usually within an hour). No. The role of the LSA and LSAMO is explained but contact details are not listed. Also states that SoMs are “supported by” rather than “accountable to” the LSA. Yes for the main site but not on the mobile site Being on four different pages splits things up quite a lot and it feels a bit disjointed. When using a smart phone or tablet it is tricky to switch between pages and get all of the information. No. One woman had had two babies at North Devon in less than two years but she was not aware of Supervisors of Midwives or their role. Another woman I spoke to had not heard of SoMs but had used the maternity webpages and found them easy to use and informative.

meet their needs and how the information might be improved. Ensure that users are involved in regular reviews and updates to ensure that the information available continues to meet the needs of women. Seek user views on whether the information and format of the webpages could benefit from being revised. Ensure that this response time is being met or review the wording on the website. Identify who the LSAMO is and how she can be contacted. Discuss with those responsible for IT at the Trust whether it is possible to make the SoM webpages easier to use on a smartphone or tablet. Seek user views on whether the content and presentation of the information meets their needs. Seek user views on how the webpages could help to raise the profile of Supervision and encourage women to engage with it. Ensure that midwives are aware of the information about SoMs on the Trust website and are able to signpost women there that might want or need to engage with the SoM Team.


33


Ask midwives to see if they know about the information about supervision on the Trust website?

Supervisors of Midwives

How many contacts from women come from the Trust website information?

Can the SoM team provide you with 3 specific examples of when they have been contacted and what actions were taken?

How were users involved in the development of the information contained on the website?

I did not ask this question on the day of the audit. This information was not available on the day of the audit. The team believe that they are receiving something via the SoM email address each week. This was not available on the day of the audit. No.

Ensure that the number and nature of web-generated activity is captured so that emerging trends can be identified and acted upon. Seek user views on how SoMs follow up enquires originating from the SoM webpages and review regularly. Ensure that users are involved in the regular review of the content of the SoM webpages.

ACTIVITY – written information Review any written information given to women about supervision

Does the written information clearly present the purpose of supervision to women?

When do women receive information?

Does it identify when and why a mother might want to contact a SoM?

Does it clearly show how a SoM can be contact 24/7?

Yes. At booking. (8-10 weeks) No. “Concerns with maternity care” does not cover all the things that a SoM can do to support a woman. Yes, although contact details are not included in the same piece of text.

Seek user views on whether the information given at booking meets the needs of women. Seek user views on whether this is the best/only time that women receive written information about Supervision. Seek user views on how this could be better conveyed. Seek user views on how it can be shown that SoMs can be contacted 24/7.


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What impact does the SoM information have?

Women

Did any of the women you met on the LSA audit visit day know that there was information about supervision within the information they were given at booking?

Midwives

Ask midwives about the information they give to women about supervision?

When would a midwife refer a mother to a SoM?

Supervisors of Midwives

When was the written information last reviewed and last updated?

How were users involved in the development of the information?

Has the information ever been evaluated that it meets the needs of women?

Minimal. The information although accurate is not engaging and does not invite contact from women. No. One felt that the information in the Booking Pack was rather repetitive the information was good and comprehensive; it answered her questions and explained medical terms clearly. However, another woman remembered receiving the pack but didn’t read it as there was too much information and if she had a question she went online or asked her midwife. I did not ask this question on the day of the audit. I did not ask this question on the day of the audit. I did not ask this question on the day of the audit. I did not ask this question on the day of the audit. I did not ask this question on the day of the audit.

Seek user views on what information women require and how best to meet their needs. Consider developing a letter or flyer to include with other leaflets at booking which signposts women to the SoM webpages. Seek the user views on how information about Supervision could best be presented to women at booking. Ensure that midwives are aware of the information available to women about SoMs on the website and in the Booking Pack. Ensure that midwives understand how and when to refer a woman to a SoM. Ensure that users are involved in regular reviews of the written information provided to women to ensure that it meets their needs.

ACTIVITY – personalised care plans with peer SoM/LSAMO Review anonymised SoM care plans written for complex women to make sure that they meet the requirements of NMC Code and are women centred.

Very few care plans for women with complex needs have been written by the SoM Team in North Devon.

Explore the reasons for such low numbers of care plans being written by SoMs referencing at the women, local policies/implementation of policies, medical colleagues and midwives.


35


Ask for at least 3 SoM care plans written in the last 6 months and benchmark them against the Code Check that

1. Women are treated as individuals and have a copy of the plan

2. Women have not been discriminated against

3. Midwives/SoMs have acted as

advocates helping women to access information and support.

4. Plans are referenced for women to show the evidence /best practice (LSAMO can assist).

5. Plans are kept confidential and are shared with team members as considered appropriate.

6. Women have been listened to and

their concerns and preferences have been responded to.

7. Women have contributed to the plan.

Only one care plan was available to review on the day of the audit. Yes, a copy of the letter was given to the woman, reassurance was given but there was no mention of the woman’s partner. No. No sign posting to evidence, guidelines, research or policy. As above. No details of risks for hospital births given so the woman cannot make a comparison. Raised BMI is listed as an obstetric risk factor but it is not mentioned in the letter. Care plan in woman’s notes and shared with the SoM Team. Yes, although there is little in the care plan that details what will happen if the woman decides to remain at home. There is no evidence that the woman has contributed to the development of the plan for her care.

Consider asking other SoM Teams to share the care plans that they produce and as a Team explore what advice and support would have been made available to the woman in North Devon. Consider the developing a standard letter (which can be amended and made personal to each woman) and a proforma/format/framework for the care plan to be based upon. . Review how the SoM Teams support women by providing information and acting as advocates. Seek user views on how this might be improved. As above. Review how care plans are shared and stored and make any changes as required. Ensure that any framework or proforma developed includes the woman’s choices and concerns and any supporting information she requires to make decisions about her care. As above.


36


8. Plans have been written in language that women can understand.

9. Any care that has been declined has

been clearly stated within the plan with the recommended course of action clearly documented so women know what they are refusing and the risks when they choose to do this.

Supervisor of midwives Discuss with SoMs how care plans are communicated to midwives and wider team with SoMs and review whether this seems to be appropriate? Discuss storage of SoM care plans? Discuss how the wider team are involved in care planning?

There is some medical terminology and jargon used in the care plan. Yes, although no supporting evidence and information is given. Therese is the first point of contact. Plans are discussed at the SoM Team meeting. Women are sent a copy of the plan, a copy is put into the hospital notes and a copy is held on the secure G-drive in the SoM file. Care plans are discussed at SoM Team meetings. I was confused about the role of risk management

Ensure that care plans are written in language that the woman can understand. There is no mention that birth is can be unpredictable and that any plan might have to change. Seek views of women, midwives, medical colleagues and others concerning how care plans are communicated. I am concerned that local policies and/or practices are removing choice from women and all but women with the lowest levels of risk are encouraged to have consultant led care. Review to ensure that the current arrangements are appropriate. Set dates for further reviews. Seek views of women, midwives, medical colleagues and others how the wider team are involved in care planning.

.

ACTIVITY – User involvement Meet with recent service users

Lay reviewer to meet with service users and ask them what they know about supervision and how to contact a SoM?

Ask women who have had any interactions with SoMs how they were provided with additional advice and

Users not aware of Supervision. I did not ask this question on the day of the audit.

SoM Team to engage with service users who have been supported by SoMs and work with them to increase the awareness and effectiveness of supervision locally. As above.


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support and did it meet their needs?

Check to see if any service users been asked to provide feedback about any individual midwives who have provided care for them? (positive experience/ poor experiences)

Meet with service user representatives

Meet with user forum leads (MSLC) and ask how supervision engages with them?

Review with user leads how women’s concerns were raised with SoMs and how SoMs actioned their concerns?

Review with user leads how positive feedback is given back to individual midwives/ to the service?

Supervisors of midwives

Discuss with SoM team how they work in partnership with women and create opportunities for women to actively engage with and influence maternity service provision?

Review how the SoM team can demonstrate that they have actively listened and provided support to women who raise concerns about the care they have received? (NMC SOM Competence)

Review how SoMs provide additional support to women who are experiencing difficulty in their care choices? (NMC SOM Competence)

The only feedback women have been asked for was via the Friends and Family questionnaire (postnatally). No one from the MSLC was able to attend the day of the audit. I did not ask this question on the day of the audit. I did not ask this question on the day of the audit. MSLC – SoM attends meetings, user numbers are dwindling so they are looking at making changes (time, venue etc.) to recruit new members. Also working with Breastfeeding Peer Supporters and Childrens Centres. Also featuring in local press. De-brief for a woman who was not happy with the care plan developed by the doctors caring for her. Midwife/SoM “virtual clinic” to support midwives in the care they are giving to women and in turn shaping services by spotting emerging trends. SoM Team has developed guidelines for reduced foetal movements following incidents looked at by the SoM team.

Review with service users how feedback can be given to individual midwives and how this can be used to improve the care given to women and their families. Work with user forum leads and other to ensure that the SoM team is fully engaged and effective in these areas. Discuss with other units ways that they have effectively engaged with service users and recruited them to various teams and/or fora. Consider the use of social media. Build on the “Virtual Clinic” to ensure that women’s voices are heard and support given. Proactively seek women who have concerns about the care they have received. Work with service users, medical colleagues and others to ensure that women have a range of choices about the care they are given


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and develop the support that the SoM team can give.

Other activities undertaken: Environmental

Quality / availability of signage for women and families

Overall feel of unit

Does environment support normal birth?

Facilities available for fathers / family?

“Ladywell” signs rather than “maternity” or “women’s services” – one family found this confusing, one found it ok. No reduced rate parking available mentioned by one family. “I like it”, “it’s small and there are familiar faces”, “it’s homely”, “everyone is really nice and polite”, “the midwives are friendly, not busy or stressed”, “The staff are brilliant”, “it’s nice”, “brilliant staff, friendly and approachable”. The unit is clean and spacious with good information on boards, although paper posters stuck on the walls look tatty. The larger birthing rooms have birthing balls, and cupboards hiding medical gases etc. The pool room that I saw had adjustable lighting and lots of space. “Sometimes the response to the bell was delayed”, “Bassett Ward was very warm”. Woman admitted at night: “The midwife knew who we were (when phoned the unit) and they were expecting us.” “Very much so – but without pressurising you”, “they let my partner support me and took a step back”, “they dealt well with my panic attack during my last labour”, “yes”. “Fine, I was brought toast and coffee”, “it was all fine, I had food and drink and I could use the loo if I needed it, it was all good”. One of the fathers was brought a cup of coffee by a

Seek user views on the environment in the unit, how it is used and how it might be enhanced.


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midwife while I was speaking to him.

Appendix 5.5 Peer SoM report

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External Peer Supervisor of Midwives Report

Name of Trust:

Date of audit:

Completed by Supervisor of Midwives:

External Peer Supervisor of Midwives as part of the LSA team

There is an external peer Supervisor of Midwives on each LSA audit team. On the audit day please present to the Trust, maternity reception at 09.00. There will be opportunities for the external peer Supervisor of Midwives to engage with the supervisory team to assist the LSA team with the review of the supervisory teams performance against the NMC Midwives rules and their standards. There will also be opportunities to meet with representative groups which will include midwives, student midwives and service users to seek assurance that supervision is meeting the requirements of the rules and is visible and accessible. This template should be completed during the visit and sent to the LSAMO 5 working days of the audit. It is recommended that a Supervisor of Midwives undertakes an LSA audit in an alternative Trust / organisation every two years as part of their continuing professional development as a Supervisor of Midwives. This can be summarised in a reflection on the key learning arising from the experience, and be included as part of the SOM PREP. Other benefits of involvement as an external peer Supervisor of Midwives include networking and sharing of good practice examples between organisations to strengthen statutory supervision of midwives.

5.6 Supervisory Action plan 2015-16

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Recommendation

Recommendation: To review information at switchboard concerning contacting the on-call supervisor of midwives.

The supervisory team to review their processes with regard to uploading the ITP’s of new starters at the end of the practice year

Supervisors to ensure that 100% of annual reviews are completed to ensure compliance with the NMC midwives rules.

Trust record storage policies to detail the procedure for the safe storage of community diaries

Lockable notes trolleys should be utilised to ensure the safety and security of patient records

Supervisors to audit the safe storage of records on a regular basis

100% of supervisors to complete the supervisor’s competency document.

The Head of Midwifery to re-join the supervisory team

Supervisors to review the findings from the midwives questionnaires and assess how midwives are ensuring that they comply with the NMC standards for medicines management

For the supervisors to agree with the Maternity Governance Manager, a short briefing template highlighting key supervisory activities / outcomes to be shared through Trust governance systems

For the LME and LSA to support the supervisory team by providing relevant and timely national information and attendance at a SoM meeting

5.7 LSA Audit Questionnaires for midwives

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LSA Audit Questions for Midwives 2014/15 –

North Devon, based on 24 questionnaires

returned

Please return this questionnaire to Helen Pearce LSAMO or one of her team. If you would like to

speak to the LSAMO directly please contact her on [email protected] or phone 0113825088.

1. Rule 3 – a) How were you informed about the process of notifying your intention to

practise as a midwife to the LSA before you commenced practicing?

University x 4

By Post x 5

Letter from NMC

Was informed by email

By senior midwife at Trust Induction

Received in post

I qualified in 1989

b) Was this process followed?

Yes x 24

2. Did you have clear guidance from the supervisor of midwives and LSA about who to

submit your ITP to for the 2015/16 year?

Yes x 24

3. Rule 5 – Are you confident that you are capable of meeting the competencies and essential

skill clusters as set out in the standard 17 of the standards for pre-registration midwifery

education (NMC 2009) that are within your sphere of practice?

Yes x 24

4. If the above answer was ‘no or don’t know’ then you have identified some personal

training needs, have you been able to discuss this with your named SoM?

N/A

5. Are you able to make sure that the needs of the women and her baby are the primary

focus of your practice?

Yes x 23

No x 1

Did not answer x 2

6. What would you do if you saw poor standards of practice?

Report incident to line manager/SoM x 24

mailto:[email protected]


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7. Have you ever experienced problems that prevented you from working within your scope

of practice as a midwife (Standards within NMC code and rules)?

No x 15

8. When did you last have training to supply and administer medicines in the

following areas?

Medicine Training (Approximate) date

Midwife exemptions

2012 2010 x 2 1989 2014 x 2 Jan 2015 2004 1986 2009

PGDs

2010 x 2 2001 Jan 2015 2003 2014 1986 2009

Controlled drugs

2011 2010 x 2 1999 Jan 2015 2006 2014

Complementary and alternative therapies

2012 1999 Jan 2015 2010 x 2 2014 1998

Intravenous medication

March 2013 2006 1997 x 2

General sales list

9. When did you last read the NMC Standards for Medicine Management?

Jan 2015 x 3

2014 x 6

Nov 2013

June 2014

2014

07/03/2015

Oct 2014

July 2014

March 2014


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10. Do you have a named Supervisor of Midwives?

Yes x 24

11. Have you had the opportunity to meet your named SoM at least annually to review your

practice and to identify your training needs?

Yes x 24

12. Were you given a copy of your annual review?

Yes x 22

No x 2

13. Did your SoM check that you had met your PREP requirements at your annual review?

Yes x 24

14. Can you rate your last annual review with your named SoM on a scale of 1 – 5

(1 poor experience – 5 excellent experience)

3, 3, 3, 4, 4, 4, 4, 4, 4, 4, 4, 5, 5, 5, 5, 5, 5, 5, 5, 5, 5, 5, 5, 5,

15. Do you think it is important as a midwife to have annual review every year?

Yes x 24

16. What was the date of your annual review?

Oct 2014

Feb 2015

March 2014 x 3

July 2014

24/11/2014

31/03/2014

31/07/2014

07/08/2014

Dec 2013

7/07/2014

May 2014 x 2

Summer 2014

Feb 2014

16/06/2014

18/02/2014

May 2015

03/03/2015

June 2014

17. Did your annual review include you obtaining feedback from women (feedback forms)?

No x 23

Yes x 1


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18. Do you think that your named SoM should obtain feedback about your competence &

conduct?

Yes x 19

No x 2

I don’t know x 3

19. Did your annual review include a review of your record keeping standards?

Yes x 24

20. Can you tell how your recordkeeping standards were reviewed?

By looking at the notes & Audit tool x 24

21. Is your annual review by a SoM different from your review/appraisal by your line

manager?

Yes x 17

No x 6

Didn’t fill in the question x 1

22. Do you have 24 hours access to a SoM?

Yes x 24

23. How do you see SoMs leading and innovating within the organisation?

I see SoMs as holding an important role within midwifery both as supporting women and

midwives.

They work hard – and an individual are good leaders involved in all aspects of the maternity

services.

Within the unit I feel that SoMs have more of a supportive role, rather than more leading or

innovative may be due to restrictions within the organisation.

Ensuring safe staffing levels & safe standards of care. Addressing issues before they become

a major risk.

I would see our SoMs as being advocates and supports of both midwives and the women in

our care.

Supporting midwives to assess care policies and update as need identified.

24 hour access to advice from SoM always have a SoM avalaible.

Supporting Midwifes at work, especially during difficult situations/births.

I want the supervisory system to continue.

They have a supportive role rather than innovative. However, it is hard to answer this as I

have not been with the trust.

I don’t see them as leaders or innovators but they can be very supportive.

I don’t see them doing anything – but they can be supportive.

Great Support.

I see them as a support network.

Good strong support, I know I can turn to a SoM/my SoM with any concerns.

They are ‘visible’ & easy to access.


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I am a POSOM so I see a lot of what they do.

Used positively in trust.

Newsletter advising of changes to core/practice issues.

Support training needs as I require them.

I can’t comment as I am a new starter.

We have a fantastic team who are consistently providing excellent support & resource for

our women and profession.

24. Is there anything else you would like to tell me about?

Positive experiences of supervision

Support.

I have has a good support in the past in attending round table reviews.

Reassurance

Newly qualified not had enough experience of using my SoM to comment.

Listening ear

Buffer between midwives & managers

I have always had a good relationship with my named supervisor and value this relationship.

I have found it essential in my role.

Supportive with practice and development.

The fact that it may be removed from our unit, when it has been actively beneficial for most

of my time here as a midwife.

Record keeping audit was a very positive experience.

Good route for raising concerns regarding a colleague that can be dealt with informally

rather than formal line management.

Approchable.

I found my supervisor very supportive and helpful during my preceptorship period.

Good relationship with SoM, feel comfortable debriefing with her & value her input.

I have always found it great to have someone I know I could turn to for advice & support if I

were to need it. She gave me feedback and encouragement.

All supervisors supportive in practice for individual needs and for midwives in the unit as a

whole.

Also support for women requiring more complex care to make choices.

Previously I have found my SoM very approachable regarding issues I did not feel

comfortable speaking with my line manager about.

Supportive in practice.

My experiences have always been positive and have assisted me greatly over the years to

assist me in practically the very best care for my women.


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24 midwives gave feedback on their named SoM and these replies have been disseminated to the SoMs concerned. Below is a summary of responses. Negative responses tended to be associated with lack of experience with that element of SoM practice.

Does your named SoM demonstrate the ability to support you to maintain your fitness to practise and provide safe and evidence-based care?

She doesn’t do this at all

Perhaps she does

Yes, she does this

She does this very well

Excellent ability √

What evidence do you have to support your perception?

Very experienced midwife, high level of knowledge and understanding. We meet as and when I need and yearly for my annual supervision Kirsten has always been fair minded, compassionate and a constant support. She is a mine of information and experience. Professional development portfolio. Supervisory review. Professional Plan. New starter: Not yet met formally with my SoM. Annual supervisory. Reviews CPD/PREP High Standards for herself & others Recommends current/recent guidelines, policy’s & articles as well as additional training or study days that will benefit me. Discussed ways of increasing knowledge and study as I enjoy this lot. Yes, I am able to contact her at any time I have a worry concern in either personal or professional area. I have felt supported by my supervisor. Kirsten has supported me very well during my practice. Verbal feedback. Yearly review to discuss my practice and areas which need development. Implements ways to improve/change practice. My supervisor has supported me through difficult times that I was involved in.

Does your named SoM support and work collaboratively with you in handling complex ethical, legal and professional issues?


Perhaps she does

Yes, she does this

She gives very good support

Gives excellent support √


We work together, using resources to update knowledge e.g. guidelines Supportive in serious untoward event meeting. Would be available if needed. Support I needed when I was a clinical mentor for a midwife undergoing supervised practice. Have had no need to but I feel she would be. Not had to deal with these issues. Always available to discuss any concerns or problems. Available to discuss concerns or problems. Discussions. When under investigation regarding drug error I well supported and helped to work through these issues.

Does your named SoM recognise when you are anxious or in distress and respond appropriately so as to promote your wellbeing, personal safety and resolve conflict?


Perhaps she does this

Yes, she does this


She does this extremely well √


Has enabled me to rest when I am obviously over tired and stressed. Completely


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supported me during a period of conflict with a staff manager. My SoM has recently supported me through a period in my career where I have felt particularly stressed. Just having someone to explore these issues with has been invaluable. Yes I am able to approach my supervisor freely. I believe she seems aware when I have seen her in passing. But I haven’t seen her for a while. She has supported me with a wellbeing issue. No experience to date. My SoM has been extremely supportive during difficult times and this has enabled me to work effectively and feel in control of situations – it’s very much appreciated. She has not been working when I have been anxious or upset. During our review I was given the opportunity to air my views and concerns elevating stress. Always supported me and accompanied me to a SUI. My SoM has contacted me following difficult shifts to ensure that I was on and to see if I needed to debrief. I was regularly in touch with my SoM, other than yearly reviews and felt that it was well recognised when I was dealing with personal issues. SoM has been very supportive.

Does your named SoM use appropriate strategies to support you in a way that maximises your potential in practice?



Yes, she does this


She does this extremely well


Encourages me to use my skills affectively. She has supported me to do further training to enhance my practice. Is supervisor is very open. In documentation and verbally when practice like. My SoM attempted to put in place my learning needs, but the unit was unable to carry this further. Always willing to work alongside me if required. Identifies learning needs and areas of development within my practice, to enhance my practice. I have been encouraged to attend workshops and develop skills.

Does your named SoM operate in a way that takes account of all equality and diversity issues, ensuring a fair, honest and transparent approach to supervision?



Yes, she does this




Supports knowledge in differently situations. Yes she does. I feel that my SoM has a fair and honest approach, treating everyone equally.

Does your named SoM act as a role model, applying best practice, motivating and providing visible leadership in the workplace?



Yes, she does this




Positive model of care. Due to her role which means she is not front line staff. I rarely get the opportunity to see her/work with her, so I cannot comment. Works as practice development midwife so a visible leader. Very visible, very active and motivated. Odd questions! As my understanding of a SoM is to provide support for midwives and


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mothers not to be leaders. We do not work in the same area. Needs more allocated SoM time. I feel my SoM does act as a role model, encourages me to develop my practice and is an evident leader. Her own practice and approach to difficult situations has been inspirational – the leadership skills demonstrate motivation and best practice.

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