Plymouth Hospitals NHS Trust

Transcription

1 Plymouth Hospitals NHS Trust LSA Audit

2 Local Supervising Authority Annual Audit Report Monitoring the Standards of Supervision and Midwifery Practice Plymouth Hospitals NHS Trust Date of audit 3 February 2014 Authors: Helen Pearce (Local Supervising Authority Midwifery Officer) Maria Patterson (Local Supervising Authority Midwife) Report completed 29 May 2

3 Contents Page Introduction to the Local Supervising Authority Annual Audit 4 The Standards for Supervision 5 LSA Audit Aims 6 Methodology 6 Formal LSA Audit Processes 6 Assessment of the LSA Standards for the Supervision of Midwifery Domain 1: Interface with Clinical Governance 7 Domain 2: Statutory Supervision 9 Domain 3: Leadership and teamwork 12 Domain 4: Interface with Service Users 13 Recommendations 15 Summary 15 Appendix 1 LSA audit visit agenda Appendix 2 Supervisor of Midwives action plan Appendix 3 Lay auditors full report Appendix 4 LSA audit tool Appendix 5 Supervisor of Midwives action plan Appendix 6 Peer supervisor report 3

4 Introduction to the Local Supervising Authority Annual Audit The LSA annual audit was undertaken by Helen Pearce LSA Midwifery Officer, Jane Fowler Supervisors of Midwives, and Sarah Bird, LSA Lay Auditor. The audit team was made to feel very welcome and appreciated the hospitality shown. The Supervisors of Midwives presented Meeting the challenges of supervision. The presentation provided examples of advocacy for women for example, care planning and supporting women s choices including place of birth. Supervisors had adapted a tool for responding to requests for complex care planning from midwives who had undertaken the Bournemouth University Preparation of Supervisors Course. The tool enabled the supervisors to review requests and then RAG rate them to decide whether a letter, visit or telephone call was required to discuss and support birth choices. The system was working well and was popular with women, midwives and supervisors. It was evident that the Supervisors had put a tremendous amount of work into addressing the recommendations from last year s LSA audit (Appendix 2). With one exception, the recommendations have been fully met or are a work in progress. This is an excellent result. The team have been challenged by increased midwife to supervisor caseloads and busy clinical workload. There have also been significant organisational changes that have fully involved the supervisors and therefore their time has been stretched over a number of priorities. There are 208 midwives notifying their intention to practise for the year , this compares to 197 ( ) and 202 ( ). There are 15 supervisors of midwives providing a ratio of on average 1: Two midwives have successfully completed the preparation of supervisors of midwives course to aid succession planning and contribute to caseload reduction. There were four supervisory investigations within the period These have resulted in one local action plan, one investigation remains outstanding as the midwife is on long term sick leave, two investigations resulted in no further action. The LSA database was reviewed as evidence to support that the supervisors are using the database effectively. By the end of March 2014 the supervisors had not met the standard of completing 90% of annual reviews. The LSA has written to the contact supervisors to ensure that this NMC requirement is met within one month. The supervisors had successfully uploaded all intention to practice forms by the 31 st March

5 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 an 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). 5

6 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. 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 two working weeks prior to the audit. 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. 6

7 Assessment of the LSA Standards for the Supervision of Midwifery The LSA Standards for the Supervision of Midwives are incorporated into four domains for auditing purposes; each domain is underpinned by the Standards and Guidance set by the NMC for registrants and for Statutory Supervision, including: The Midwives rules and standards NMC (2012) The code: Standards of conduct, performance and ethics for nurses and midwives, NMC (2008) Standards for Medicines Management, NMC (2007) Record keeping: Guidance for nurses and midwives, NMC (2009) Quality Governance in the NHS A guide for provider boards, DH (2011) Domain 1: The Interface of Statutory Supervision of Midwives with Clinical Governance Domain 1: Evidence was seen to demonstrate supervisor of midwives attendance at the Clinical Effectiveness Committee for 11 months of the year. Whilst this is good evidence to demonstrate supervisory representation at maternity governance forum the supervisor in attendance listed as supervisor of midwives/ manager. Within the August minutes there is no reference to any item or discussion from a supervisor of midwives. To aid greater transparency between the supervisory and manager/ substantive roles it would be of benefit for to agree a short supervisor s highlights report. This would be a summary of the key themes from audits, supervisory investigations, record keeping reviews which would be agreed at the end of the supervisor meeting. The highlight report would be taken by the attending supervisor to all relevant meetings so that a consistent and accurate report from supervision would be presented. Recommendation: To produce a short highlights report to share at relevant meetings. It is important for complete transparency about reporting activities so that information gathered within supervision is appropriately shared through trust systems. Recommendation: That a standing agenda item at the Clinical Effectiveness Committee is a highlights report from supervision The local Risk Management plan was noted to have a poor description of the role of the supervisor of midwives which the contact supervisor is in the process of addressing with the risk manager. Recommendation: To ensure the Risk Management Plan accurately describes the role of supervision in protecting the public and appropriately sharing knowledge through governance systems 7

8 Good evidence was presented to indicate supervisory links with STEIS investigations. A supervisor of midwives participates in the review panel for all serious incidents, this is excellent practice. A Supervisor also participates in any subsequent expert panel. It is unclear as to how relevant findings and learning is disseminated to the supervisory team. In order to demonstrate the clear link, an item on the Supervisor Meeting should be to feedback from a supervisory review of a serious incident. Evidence was seen to demonstrate supervisor of midwives are actively promoting safe standards of midwifery practice via challenging poor practice. Appropriately, there have been four supervisory investigations with the practice year 1 st April st March These have resulted in one local action plan, one investigation remains outstanding as the midwife is off long term sick, two investigations resulted in no further action. The supervisors review the investigations spreadsheet on a regular basis to ensure that investigations are completed on time and that all supervisors gain experience in completing investigations. Supervisors regularly use the LSA decision making tool to aid decision making regarding whether to proceed to a supervisory investigation. There is good communication with the LSA when investigations are undertaken and information is appropriately recorded on the LSA database. There have been a number of complex investigations which have been managed with extreme sensitivity and care by the supervisors involved. Supervisors have been involved in running and supporting local programmes of remediation. All have been successful and testament to the amount of time and support that supervisors, clinical mentors, the practice development team, members of Plymouth University and the Head of Midwifery have invested in ensuring programmes run smoothly. There has been a great deal of shared learning and support that has resulted from some of the challenges that investigations and programmes of remediation have presented the team. The team has risen to the challenge, growing and developing their skills, confidence and competence. There has been a high level of confidentiality concerning individual investigations and programmes which is good practice. The supervisory team have identified that a trend from supervisory investigation within the past twelve months has been CTG interpretation. To address this trend the supervisors are seeking to commission training via Baby Lifeline for Plymouth NHS Trust and neighbouring Trusts on CTG interpretation. The supervisors have suggested that they could host the training. This is an excellent example of supervisors improving outcomes for women and improving trust systems. Recommendation: To implement additional CTG training for midwives Good Practice Evidence was seen to demonstrate supervisory concerns following a serious incident being shared with management and informing joint practice to improve services for 8

9 women. The supervisory team submitted evidence following an incident involving a homebirth being transferred to Central Delivery Suite when the community midwife could not get make contact with the labour ward by telephone. Following this incident, there was the joint working between managers and supervisors. The result has been a red phone installed on the labour ward for urgent calls. The LSA were informed that this initiative is working well. Domain 2: The profile and effectiveness of Statutory Supervision of Midwives. It was evident that the Supervisors had put a tremendous amount of work into addressing the recommendations from last year s LSA audit (Appendix 2). With one exception, the recommendations have been fully met or are a work in progress. This is an excellent result. The area that was not met was to achieve 90% of annual reviews for midwives; the team achieved 81% completion (excluding long term sickness absence and maternity leave). The LSA has written to the contact supervisors to ensure that this NMC requirement is met within one month. The annual review is the supervisory tool for ensuring that all midwives have met their PREP and re-registration requirements. For the forthcoming practice year ( ) the standard has risen, therefore supervisors need to review their current systems to ensure that the standard will be attained. The annual review is an important cornerstone of supervision and assures the organisation, the public, the regulator and the individual practitioner that they are fit to practise. The team need to consider how they can use group supervision, Skype and telephone contact to access midwives. Recommendation: Supervisor to complete 95% of annual reviews by the end of March 2015 (excluding maternity leave and long term sick) To demonstrate the effectiveness of the Plymouth supervisory team the supervisors provided an example of how they participate in daily case review sessions on the delivery suite. This is an excellent example of supervisors responding in real time to clinical incidents, sharing examples of good practice and facilitating learning adverse events. The profile of supervisors within the Trust is positive and they have increased their visibility via the development of website and generic e mail. The website details information for women or staff regarding the role of the Supervisor of Midwives, the Supervisor of Midwives team in Plymouth and how to contact a Supervisor of Midwives. The generic e mail is a new initiative which aims to make the supervisor more accessible to women. These are examples of supervisors taking proactive steps to engage with midwives and women. Midwifery staff interviewed by the LSA team gave many positive responses about supervision. There is work to do around consistency and focus of the annual review but this is a national challenge and is being taken addressed on a UK wide basis by the LSAMO UK Forum. 9

10 The contact supervisor attends regular quarterly briefings with the Director of Nursing and the Head of Midwifery. These meetings have been positively evaluated by the Director of Nursing and the Head of Midwifery. Supervisory minutes were seen following the Director of Nurse briefing, which detailed the Director of Nursing s support for the completion of the LSA action plan by supervisors and interest in how supervisors managed complex care planning. The Director of Nursing felt confident about the effectiveness of the supervisory team. This is a positive example of how supervisors are engaging at Trust board level, ensuring that there is appropriate sharing of information and the mitigation of risks. During the LSA audit it was noted that the Director of Nursing briefing did not follow the LSA template this is a recommendation. Recommendation: LSA template to be used for Director of Nurse briefings. Evidence was sought from supervisors to indicate how they review midwifery record keeping standards. The supervisors were able to describe how they have participated in regular record keeping audits when contributing to the assessment for CNST 3 which the maternity service has successfully achieved. The supervisors also described how they undertook a record keeping audit at each supervisory review. The supervisors also aspire to conduct a monthly on the spot records keeping audit however this is often been challenging to achieve due to activity levels. There is no supervisory controlled drugs audit as this is undertaken by the pharmacist team who provides a monthly report Good Practice The supervisors have developed a supervisory patient satisfaction survey tool which is excellent. The survey is carried out on a monthly basis by an allocated supervisor of midwives who is seeking women s views of their experience of the maternity service. The survey is undertaken either in paper format or via an electronic I-pad using the Meridian system. Informal feedback is given at each supervisor of midwives meeting by the supervisor of midwives who has collected data for that month. The results from this excellent initiative now need to be collated and reviewed with the outcomes shared through governance systems, training programmes, guideline reviews as appropriate. Recommendation: To collate the results of the supervisory patient survey and use feedback to inform practice and service developments. The LSA database and demonstrated that the supervisors successfully uploaded all intention to practice forms by the 31st March and that all new starters had been allocated a supervisor of midwives. All supervisory investigations have been entered onto the LSA database and the supervisors had corresponded appropriately with the LSA. One investigation remains outstanding and this is due to the midwife being on long term sick. 10

11 There is access to a supervisor of midwives on a 24 hour basis with a rota being available for staff. Good evidence was provided to indicate that supervisors are involved in networking activities locally and regionally. Supervisors attended the supervisory conference at Bournemouth and have networked with supervisors at Yeovil to share good practice. The contact supervisor regularly attends the quarterly contact supervisors meeting. The Plymouth supervisory team have been proactive in attempting to reinstate the quarterly cluster meeting between the Devon and Cornwall supervisors but the invitation was not taken up by other local supervisory teams. With regard to supervisory resources there is administrative support to help coordinate major events but there is no other administrative support. There is a room where resources are kept for the supervisors, however this room is shared and utilised by any number of staff and is not available for confidential conversations. All supervisors aim to use their allocated supervisor time to attend the monthly meeting. Any other time is documented in their diaries or on their calendar. Time for supervision is dependent upon clinical commitment. Additional time is available for investigations and the Head of Midwifery ensures that supervisors are supported with sufficient time. There have been a number of discussions relating to the on-call role for supervisors of midwives who were concerned about being called when the unit was clinically busy as a pair of hands. This situation has been closely monitored by the Contact Supervisor via a database. Results are reviewed with the Head of Midwifery at their monthly meeting. Results indicate that supervisors have been called to assist in the Unit four times in a six month period. There has been a major and successful recruitment drive (17 WTE additional staff). Consequently there is an expectation that calls to supervisors to cover staff shortages will continue to decline. There is an excellent process in place to ensure that all new starters to the trust are allocated a supervisor of midwives. The contact supervisor meets with the new starter during the induction period and signs and uploads the intention to practice form. Evidence was seen in reference to three new starters who had their intention to practice forms uploaded within two days of starting the trust and prior to commencing clinical practice, this is assuring. The Midwives handbook refers to access to a supervisor of midwives on call twenty four hours per day and details each supervisor of midwives contact number. There is however no description of the role of the supervisor which would be helpful for new starters. There is a recognised process for midwives to change their supervisor of midwives however this process is not documented. Evidence demonstrated supervisors are following LSA guidance in relation to the nomination, selection, and appointment of future supervisors. 11

12 Good Practice An excellent initiative is the questionnaire for midwives regarding their views of supervision. This is being led by one of the midwives undertaking the Preparation of Supervisors of Midwives course at the University of West of England. Results are scheduled to be shared in June with the team. Domain 3: Team working, Leadership and development. Attendance record is kept of each supervisory meeting but there is no annual compilation of the number of times each midwife has attended. Recommendation: To maintain a record of attendance at the supervisory meeting. Due to retirement, career change, a resignation and leave of absence from Supervision the current supervisory caseloads are above the recommended 1:15. There are currently two midwives undertaking the preparation for supervisors of midwives course at the University of the West of England who are due to complete this year. The team have identified that they will need to train two more supervisors for the There is already one excellent candidate identified (from last year s recruitment campaign) and the team are actively encouraging other midwives to undertake the preparation programme. The recent turnover of supervisors means that caseload numbers will be above average for some months this year until the new supervisors are able to take up a place. The LSA will offer additional support during this period and whilst an appointment of an external supervisor was considered this was not possible due to distance. Other solutions are being considered to mitigate the risks. The supervisors ensure equity in the allocation of the investigation workload via maintaining a spreadsheet. This is a good example of the supervisory team working effectively. The LSA team are confident that the supervisors demonstrate their leadership skills in a number of ways. The supervisors triage women requesting homebirths and support community midwives via assisting with complex care planning. The supervisors participate in expert panels following serious incidents and in guideline development. The contact supervisor regularly attends the quarterly contact supervisor meetings and disseminates information and presentations to the wider team. The supervisors demonstrate leadership across the trust via the participation in the Trust open day. The LSA report and action plan for was presented at the Trust Clinical Excellence Committee meeting by the Head of Midwifery, who is also a supervisor of midwives. The supervisors provide support and mentorship for students and act as sign off mentors. There is a named supervisor allocated to third year students whilst they are case loading, which aims to reinforce the role of the supervisor. A named supervisor meets with the student cohort at the start of each term and seeks out the student 12

13 within the workplace to offer guidance and support. The supervisors have good links with Plymouth University and there is a named supervisor on the curriculum planning committee who also participates in the review of education programmes. The supervisors also act as mentors for student supervisor of midwives. Good Practice The supervisory team elected to support an external supervisee through a period of supervised practice. In order to facilitate the programme the supervisors were required to liaise closely with Plymouth University and the LSA. The supervisors identified named clinical mentors who were both experienced midwives. The outcome of the programme was successful and this is a credit to the team involved. This was an exceptional piece of work, the supervisors, clinical mentors, Plymouth university lecturer and the Head of Midwifery worked collaboratively to ensure that the programme of supervised practice was delivered to the highest possible standard. Domain 4: Supervision of Midwives and interface with service users. The Lay auditor Sarah Bird spoke to the Contact supervisor and maternity service users and below is a summary of her report. The report can be found in the appendices. It appeared from the case studies discussed and the women that the LSA team met, that most women that come into contact with a supervisor do so after being referred by their midwife. The supervisory team need to continue to develop proactive engagement with women so that they are not just seen as a resource for midwives. Homebirth guidelines were submitted as evidence however the links to supervision were not clearly visible. The supervisors explained that the guidelines were shared as a supervisor is on the guideline development committee. The development of the Jubilee Team came about as a result of needs of service users. Feedback has been excellent and the LSA team met a number of women and their partners who had been cared for by members of the Jubilee Team. It was clear that care was sensitive and individualised with midwives providing care that went beyond what could be reasonably expected. It is important that supervisors have a strategy and action plan around supporting normal birth, show leadership in the area, and are looking at ways to measure their impact. Currently it appears that this is focused on the activities and outcomes from the Jubilee Team. Recommendation: For supervisors to develop a strategy and action plan to support normal birth The supervisory team describe that they actively recruit for their MSLC and that a supervisor attends each MSLC meeting. 13

14 The LSA lay user suggested that supervisors might be able to reach women in the more deprived parts of the local community by working in partnership with other organisations (e.g. social housing provider s tenants groups, Children s Centres, Mums and Toddler groups) which may help to access the views of different women. Whilst time is a scarce resource it is important to consider how supervisors could wisely use external networks to connect with women. Service users views are sought out to drive service development via a survey carried out by supervisors once or twice a month, it is not clear as to how this data is reviewed. Recommendation: To collect information about service user views and formulate an action plan on the basis of this There is a poster in reception giving good information about the role of a supervisor and naming the supervisor of the day. There is a clear process for updating the information daily. No additional information about supervisors of midwives was visible elsewhere on the wards, a duplicate poster/display on the ante/post natal ward might be useful to families as well as elsewhere. It is unclear if any information is available in other languages to women on request. The supervisory website was under review at the time of audit. Currently there is only a small amount of information relating to the supervisor of midwives role. The web link given does not work and it does not have a warm tone. It is not as encouraging of people to contact as it could be. It would be useful to see a few case studies or examples of how a supervisor might help a woman or family to illustrate the value of the role to the user. The Head of Midwifery has forwarded a link to an updated webpage which at the time of the audit had not gone live. This new supervisor of midwives page is better than the previous one it is lighter, brighter, easier to read and much friendlier. However, it does not mention safety or protection of the public and LSA lay user found that it was still rather distant in tone and felt that some examples of how the supervisory team has worked with families or some feedback from users would be helpful. Recommendation: To further develop the Trust Supervision web page to ensure a range of welcoming information available to women The supervisors of midwives demonstrated advocacy for women for example, care planning and supporting women s choices including place of birth. The supervisors are proactive in supporting normal birth however the Central Delivery Suite did not appear to have any birthing aids (e.g. balls, beanbags, stools) available and even the room with the birthing pool has medical equipment visible in the room. The rooms appeared clean and of a good size but they were hard-edged and not at all homely. The atmosphere in the ante/post natal wards and on the delivery suite was calm and friendly but without a feeling of being woman centred. 14

15 The supervisory team arranged for a number of women to share their experiences of the maternity services available in Plymouth. Each of the women attending had either had her baby at home or had hoped to. All had been under the care of the Jubilee Team for their most recent pregnancy and birth so were a small selected sample. It would have been beneficial to have met women that had birthed in the Consultant unit, however, the LSA team were constrained by time and unable to interview other service users. Feedback from women regarding the quality of their midwifery care was very positive. The women s comments can be read in full in appendix 3. Recommendations 1. To produce a short highlights report to share at relevant meetings. 2. That a standing agenda item at the Clinical Effectiveness Committee is a highlights report from supervision 3. To ensure the Risk Management Plan accurately describes the role of supervision in protecting the public and appropriately sharing knowledge through governance systems 4. To implement additional CTG training for midwives 5. LSA template to be used for Director of Nurse briefings. 6. To collate the results of the supervisory patient survey and use feedback to inform practice and service developments. 7. To maintain a record of attendance at the supervisory meeting. 8. For supervisors to develop a strategy and action plan to support normal birth 9. To collect information about service user views and formulate an action plan on the basis of this 10. To further develop the Trust Supervision web page to ensure a range of welcoming information available to women A recommendation for all supervisory teams in : 11. Supervisor to complete 95% of annual reviews by the end of March 2015 (excluding maternity leave and long term sick) Summary The supervisors of midwives are a highly committed and enthusiastic group who work well together. They recognise the strengths of individual team members and whilst providing support for each other, they are equally able to challenge and debate issues. The team have achieved a number of excellent outcomes over the previous practice year and they should continue to build on this good work. They should be extremely proud of their achievements this year. There is a renewed energy and focus and this is reflected in attracting excellent candidates who came forward to train as supervisors of midwives. The team have raised their profile at a strategic level and undertaken complex supervisory investigations to a high standard and with great sensitivity. 15

16 The LSA would encourage the supervisory team to further involve women in service development and in particular to seek out the views of women from harder to reach groups. A copy of this report will be sent to NHS England, the Area team and Clinical Commissioning Group. Following agreement of the audit outcome report the supervisory team should review the strategy for supervision and develop the attached action plan (Appendix 5) returning to Gayle Masterson within 4 weeks of receipt of this report. The action plan will be monitored by the LSA, thus completing the cycle. 16

17 Appendix 1 LSA Audit Visit - Agenda Time Meeting Venue Meeting with Contact Supervisor of Midwives LSA team Contact Supervisor of Midwives Refreshments Presentation from the LSA LSA Midwifery Officer - open invitation Meeting the challenges for supervision Presentation from Supervisors of Midwives 'Demonstrating the effectiveness of supervision' 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 Meeting with Head of Midwifery Meeting with Director of Nursing LSA team LSA team Meeting with Lead LSA team

18 Appendix 1 Midwife for Education Lunch Review evidence LSA team Tour of unit LSA team Meet with women - patient experience feedback Meet with midwives Meet with student midwives LSA team Wards / clinics Closing remarks All

19 Supervisors of Midwives action plan Appendix 2 Recommendation Action required Lead Timescale Measure of success LSA comment Action to be completed within the next month Agree a strategy and annual work plan for supervision. RM SS May 2013 Met For the annual work plan to be a standing item at each supervisor meeting and progress against objectives documented. Review the current management of midwives who leave the Trust to ensure that they are not orphaned on the Local Supervising Authority database. Yearly strategy to be decided at next SOM meeting ((8/5/2013) and the ongoing process to develop subsequent annual work plans Development of agenda reflective of the work plan with timely review of actions and progress made Agenda item at SOM meeting Action to be commenced within the next two months Agree a process for the involvement of supervisors Process in Maternity RM Framework when poor midwifery practice is identified. TOR for SOM meetings In association with the Trust Guidelines and policies maternity and management attached teams to review the escalation Maternity RM Framework policy and the maternity attached above. service risk management strategy. Improve the visual information concerning the availability and Website improvement in progress specific page RM SS RM SS SF/NP SF/NP May 2013 Achieved Written strategy and work plan for the Supervisory team A rolling user-friendly agenda reflective of the needs of Supervisors Midwives orphaned by GM otherwise transferred NM Complete Supervisors page on website Met Met Met Further revision required Further revision

20 Supervisors of Midwives action plan Appendix 2 purpose of supervision in the clinical and public areas of the maternity unit To review the current variation of caseload for individual supervisors of midwives, ensuring that ratios do not generally exceed 1:15 dedicated to Supervision to be designed Posters to be developed for display in public areas and on entrance to ward areas (poster competition for staff) NMC booklet Supervisors, how can they help you to be provided in all areas Local Supervision leaflet to be developed and provided to all patients Notice board to be positioned visible to the public in Maternity Reception with Supervision information and SOM on call details Explore examples of good practice from other areasexternal visit Update spreadsheet allocating supervisors to supervisees as per choices pro forma completed by supervisees Allocate new midwives to the Trust to Supervisors with spare capacity and remove supervisees who JW NM NM JT NM, JW, JT RM SS April 2013 April 2013 April 2013 May 2013 Completed March/April 2013 Ongoing via RM July 2013/ Ongoing Posters visible on display in all areas NMC booklet visible and accessible in all areas and Leaflet availableapproved and in circulation in all booking packs and ward areas Notice board in place Visit completed-good practice shared and evidenced in SOM meeting minutes Ratio of supervisor of Midwives to supervisees meets Recommended ratio of 1:15 required Good poster in reception area NMC pack in booking information Increased ratios due to changes in SoM numbers. Succession planning in place Other plans discussed to

21 Supervisors of Midwives action plan Appendix 2 To develop systems to demonstrate how supervisory activities are informed by the views and experiences of users leave area Revisit supervisory allocation and ratio once number of supervisors practising stabilises or new supervisors are trained Local Supervision leaflet to be developed and provided to all patients to include invitation to be involved in user forms Weekly Supervisors face to face ward round to engage and survey users re: user experience via Meridian system to be implemented themes and findings to be disseminated via Maternity newsletter and monthly SOM meeting Regular attendance of SOM at local MSLC s findings to be fed back through monthly SOM meeting Explore examples of good practice from other areasexternal visit NM NM, JT JW JW NM,JW JT April 2013 May 2013 Ongoing May 2013 Leaflet availableapproved and in circulation in all booking packs and ward areas Meridian Reports of user experience available and disseminated Regular SOM attendance evidenced in minutes Minutes of SOM meeting reflect user engagement and views Visit completed-good practice shared and evidenced in SOM meeting minutes mitigate risk Met Evidence seen Evidence seen

22 Supervisors of Midwives action plan Appendix 2 Review the current management of midwives who leave the Trust to ensure that they are not orphaned on the Local Supervising Authority database. To publish and share the minutes of supervisor of midwives meetings (removing confidential information) Achieve 90% completion of annual reviews for the period April 2012-March 2013 (excluding midwives on long term sickness absence or maternity leave Review the birth environment with a user representative (e.g. from MSLC) Consider using the NCT birth environment audit tool All midwives/supervisors to be made aware of the process they need to take when leaving the Trust as area of work and how to change Supervisor SOM to transfer midwife to future SOM when requested as per guidance on LSAdb Review of whole of Trust website ongoing Ongoing completion of annual reviews by targets identified on LSAdb Undertake review of birth environment using NCT audit tool with user representative. Formulate action plan in response to results of review Action to be commenced within the next three months To agree, within the next three months, a method for annual record keeping audits by Ask other areas what tool they use for record keeping audit RM SS RM SS ALL SOMs May 2013 Dec 2013 Ongoing JW, JT May 2013 RR LR RM June 2013 Entry in Maternity Newsletter Item for annual reviews/meeting with supervisees Agenda item monthly som meeting departures/arrivals Edited minutes available to all via Trust website Minimum of 90% of annual reviews being completed within time frame Review completed and action plan formulated Continuous, evidenced auditing of record keeping of LSA database updated appropriately Website is a work in progress Not met Review undertaken environment remains very clinical Audit undertaken

23 Supervisors of Midwives action plan Appendix 2 supervisors of midwives which will disseminate findings through supervisory and trust governance processes and ensure appropriate individual feedback To audit midwives views and experience of statutory supervision within the next three months. Within the next three months, commence regular meetings, with the Head of Midwifery and the Director of Nursing to report supervisory activities. Investigate use of Meridian system for collecting data Review options and bring to SOM meeting Adopt and enforce Bring findings to governance meetings Decide what you want to establish from the audit Develop a tool/questionnaire to audit supervisees supervisory experiences Circulate to all supervisees Analyse results and feedback to supervisory team and LSAMO To arrange appointment dates for meetings with HOM/Director of Nursing HOM monthly meetings with Contact SOM Quarterly meetings with Director of Nursing and HOM to commence LR RR RM RM July 2013 August 13 January 14 May 2014 June 2013 August 2013 In progress Arranged supervisees which can be used to support supervision A benchmark from which to work to improve the profile of supervision and develop further actions Arranged 24 th May at :00 15 th August :00 27 th November 11:00-12:00 Work in progress being undertaken by PoSoM course student supervisor Met Action to commence within the next six months

24 Supervisors of Midwives action plan Appendix 2 To audit and evaluate the views of women, midwives and medical staff of complex care planning. Discussing and disseminating the results of the audit Monthly Safe Birth Clinic Supervisor of Midwives to be involved in MDT meetings Information leaflet regarding MDT meetings to be provided to all patients whose complex needs will be discussed to ensure patients involved of MDT process. Weekly Supervisors face to face ward round to engage and survey users re: user experience via Meridian system to be implemented (to include experience when complex care needs identified) themes and findings to be disseminated via Maternity newsletter and monthly SOM meeting Next Patient Survey (due June 2013) to have question related to complex care need patients how involved in care planning did they feel. Staff survey to be designed and undertaken JT/BM NM/RR NM,JW JT NM JT/JW Completed May 2013 May 2013 June 2013 July 2013 Safe Birth clinic running with referral mechanisms in place. Leaflets designed, approved and in use Meridian Reports of user experience available and disseminated. Survey undertaken and results disseminated Met

25 Supervisors of Midwives action plan Appendix 2 to include Midwives and Doctors re: experience and suggestions when patients have complex care needs dissemination of results Recommendations for the Trust To provide appropriate administrative support to the contact supervisor and supervisors of midwives when undertaking investigations. Negotiate with HOM and Trust for administrative support RM/HP June 2013 Administrative support in place Partially met

26 Lay auditors report Appendix 3 The LSA audit tool is divided into four domains. This tool concerns domain 4. In line with NMC good governance practices, each domain is benchmarked against the Local Supervising Authority Standards for Statutory Supervision of Midwives in England (LSA, 2005), which informs the framework for the London audit process. For more information on the LSA standards on the Statutory Supervision of Midwives, visit

27 Lay auditors report Appendix 3 LSA AUDIT: GUIDANCE CRITERIA FOR THE ASSESSMENT OF RATING OF SUPERVISORY TEAMS INTRODUCTION The following criteria, based on the Nursing and Midwifery Council s Midwives Rules and Standards (2012) are designed to help teams understand what contributes to the final rating of their team against the LSA domains when they are assessed at their annual audit. It supports understanding of what good may look like, and gives clear guidance on how excellent statutory supervision in action will enhance midwifery practice, women s experiences of care and delivery of a safe high quality service. Each domain will be rated Green, Amber or Red according to the strength of the evidence seen. In allocating a rating the author of the report will be acting in collaboration with all of those who attended the audit and reviewed any evidence. It is anticipated that teams may present a mixture of evidence across the spectrum from strong to weak, and therefore the rating will be based on where the majority of evidence lies. If, however, there is difficulty meeting a statutory requirement, for example supervisory ratios, then this will determine the RAG rating for that domain. There are some key principles across all the domains about what good evidence might look like and these are presented below. This is followed by domain specific guidance. Please note the criteria for evidence is not an exhaustive list and supervisors are free to submit evidence that they feel is relevant and supportive of the team activity for the year. These criteria will be used to create a summary dashboard for each organisation that will include the RAG rating for each domain, the SoM ratio, the Midwife to Birth ratio and vacancy rate.

28 Lay auditors report Appendix 3 PRESENTATION OF EVIDENCE FOR THE LSA CORE PRINCIPLES STRONG MODERATE WEAK Evidence is sent to the LSA in good time There is a variety of evidence across the domains with little repetition or a small amount of appropriate crossreferencing The evidence is laid out clearly in the domains with good explanation It is clear when supervisors have acted as supervisors and the impact that they have had The evidence has been co-ordinated and reviewed before presentation to the LSA It is apparent the whole team are involved in the work of the team Evidence is presented just in time or slightly late There is reasonable variety although some evidence may be relied on a number of times Some evidence is hard to assess or is not explained but the majority is understandable Supervisors work is mostly apparent although sometimes there is overlap with their substantive post Some members of the team are involved in the evidence to a greater degree than others Team are aware of challenges are have an action plan to address them Evidence is presented late There is over reliance on certain pieces of evidence or there are large amounts of repetitive evidence There is no explanation of the evidence within the domain documents and much of it is hard to assess It is unclear what supervisory input has been or why the evidence is present There is a lack of co-ordination of evidence The evidence relies on a few motivated individuals There is no evidence of an action plan to address challenges

29 Lay auditors report Appendix 3 Domain 4: Supervision of Midwives and Interface with Users Supervisors of Midwives are available to offer guidance and support to women accessing a midwifery service that is evidence based in the provision of women centred care Criteria to be audited LSA verification and comments Measurement Met Partially Met Not Met SOMs are ambassadors for treating women with kindness and respect and lead on improvements in partnerships with service users and management I feel that this criterion has been partially met. I found it hard to gain a sense of The SoM Team during the audit this might have been because the team is a large one and so not everyone can play a role or it might be that not everyone in the team is as visible and as active as their colleagues. I also felt that there was an emphasis on the day and within the evidence of the involvement of SoMs with the Jubilee Team and the women they care for and not right across the piece. It appeared from the case studies discussed and the women that we met that most women that come into contact with SoMs do so after being referred by their midwife or are initiated by a SoM. My concern is that the SoM team are seen first and foremost as a resource for midwives rather than women and that the role of ambassador for treating women with The SoM team are ambassadors for treating women with kindness and respect and advocating for women s voices to drive service delivery at every opportunity and are leading work on developing this across the service Contacts between SoMs, Midwives and Women are not all led by Supervisors but show midwives The SoM team will work well with women when opportunities present themselves and try to advocate for women s views on some projects Contacts between SoMs and women and midwives tend to be initiated by SoMs The SoM team work with women effectively when asked to, tend not to advocate for women s views in project work/service development Team have limited evidence of contacts with women and midwives

30 Lay auditors report Appendix 3 Criteria to be audited LSA verification and comments Measurement Met Partially Met Not Met kindness and respect falls to others. I would imagine that the development of the Jubilee Team came about as a result of the views of women being captured but I did not see any evidence of user involvement in other projects currently underway e.g. the staff rotation project. and women find the team accessible and approachable SoM involvement with the MSLC I did not see the evidence relating to this criterion. LSA comment verbal evidence provided The SoM team have a minimum 90% attendance at the MSLC meetings and are active contributors e.g. sharing their LSA audit and annual report and seeking MSLC contributions SoM team attend the MSLC on 75 90% of occasions. Contribution is limited SoM team attend less than 50 % of MSLC meetings The SOM team proactively seek the views of women / actively recruit for the MSLC I did not see the evidence relating to this criterion. There is undoubtedly a challenge in reaching some women in the more deprived parts of The SoM team are actively involved in recruiting for MSLC SoM team are actively engaging with users /support recruitment to the SoM team do not actively participate in the MSLC / there is limited contact

31 Lay auditors report Appendix 3 Criteria to be audited LSA verification and comments Measurement Met Partially Met Not Met the local community however I feel that working in partnership with other organisations (e.g. social housing providers tenants groups, Childrens Centres, Mums and Toddler groups etc.) would give access to the views of these women. Also the growing immigrant communities could/should be accessed. MSLC with service users SoM are accessible to women, e.g. web link, user strategy, user information I feel this criterion has been partially met. There is a poster in reception giving good information about the role of a SoM and naming a SoM of the day. There is a clear process to up-date this information each day. I did not see any further information about SoMs elsewhere on the wards, a duplicate poster/display on the ante/post natal ward might be useful to families as well as elsewhere. I don t know if this information is available in other languages to women on request. The website is under review at the time of audit. Currently there is only a small amount of information relating to SoM and it is somewhat buried between Birth afterthoughts and Domestic abuse in SoM team uses a variety of ways to publicise the team and their contact methods, to women and their families, NMC leaflet is widely distributed Supervisors are easy to find on the Trust web pages and have a range of welcoming information available to women including SoM team have posters up and information on the website. NMC leaflet is available in ad hoc way Web information is present, not necessarily easy to find and limited in content. Contact details are clear and when to call The team are not well publicised in the unit and women have an mixed experience of getting hold of a supervisor, NMC leaflet is not available Information about services on the web is poor quality, limited and hard to find