Nursing & Midwifery Council (NMC) report on the review of West Midlands local supervising authority

Date of review: 7 July – 9 July 2009 Date of report: August 2009

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NMC document information Document purpose

Information

Title NMC report on the review of West Midlands local supervising authority

Authors With comment from

Helen Meehan – Midwife reviewer Claire Bonnet – Lay reviewer Mary Vance – LSAMO reviewer Susan Way – Midwifery adviser

NMC department

Midwifery

Publication date

September 2009

Circulation list: West Midlands LSA NMC Review team NMC website: www.nmc-uk.org Department of Health (England) Contact Details Midwifery Department Nursing & Midwifery Council 23 Portland Place London W1B 1PZ 0207 333 6692 / 0207 333 6549

Web: www.nmc-uk.orgEmail: advice@nmc-uk.org Final version

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Contents Page

1 Executive summary 1.1 Overview and key recommendations

4

2 Introduction 2.1 The West Midlands LSA

2.2 Profile of the West Midlands LSA

2.3 Maternity Services in the West Midlands LSA

6

3 The NMC review of West Midlands LSA 3.1 Decision for review

10

4 Review findings 10

5 Conclusion 11

6 Evidence of standards being met / unmet 12

Appendices

Page

1 The Local Supervising Authority 26

2 The NMC framework for reviewing LSAs 27

3 The review team 28

4 Key people met during the review 29

5 Programme for the review 30

6 Documentary evidence viewed 32

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1 Executive Summary The Nursing and Midwifery Council (NMC) exists to safeguard the health and wellbeing of the public.

• We register all nurses and midwives and ensure that they are properly qualified and

competent to work in the UK

• we set the standards of education, training and conduct that nurses and midwives need

to deliver high quality healthcare consistently throughout their careers

• we ensure that nurses and midwives keep their skills and knowledge up to date and

uphold the standards of their professional Code

• we ensure that midwives are safe to practise by setting rules for their practice and

supervision

• we have fair processes to investigate allegations made against nurses and midwives

who may not have followed the Code.

The purpose of this review has been to examine the function of the West Midlands Local Supervisory Authority (LSA). The review aims to be both formative (an aid to development) and summative (a check that a required standards are being met). The West Midlands LSA was identified for review after their annual report was risk assessed and concerns identified (section 3). The risk-based approach to reviewing LSAs has been approved by the NMC Midwifery Committee and is in line with the NMC risk framework and the Regulators Compliance Code1. 1.1 Overview and key recommendations The NMC has reviewed the performance of the West Midlands LSA against key standards set within the Midwives Rules and Standards (2004). The NMC review of the LSA has focused on the supervision of midwives and the safeguarding of the health and wellbeing of women, babies and their families. The main finding of the review is that West Midlands LSA has met all of the 53 standards set by the NMC. Recommendations of areas that would support continued development in accordance with the aims of the review are given below. Supervision is well supported and understood within its host organisation, the West Midlands Strategic Health Authority. It is evident the LSA has strong leadership, and the strategic position of the LSAMO within the organisation enables supervision to be dynamic and meet challenges head on. This report will be published on the NMC website www.nmc-uk.org. Actions concerning the recommendations related to supporting continued development should be detailed in the LSA annual report to the NMC. There are no recommendations in relation to meeting the NMC standards.

1http://www.cabinetoffice.gov.uk/REGULATION/reform/enforcement_concordat/compliance_code.asp

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Recommendations to the LSA to support continued development The LSA is recommended to: Training

• Promote the training of supervisors of midwives (SoMs) so that succession planning can support the NMC ratio of 1:15 SoMs to midwives.

• Provide training in report writing skills to assist SoMs in compiling their annual supervisory report to the LSA.

Supervisory records

• Monitor the use of the LSA database to ensure a consistent approach to data storage • Have robust processes in place for the transfer of documentation currently held by some

individual SoMs. Support for the framework of supervision

• Monitor compliance that a consistent approach to the implementation of the LSAMO UK National and West Midlands guidance happens in everyday practice.

• Monitor the provision of supervision across the LSA to ensure midwives and women have equal access to a SoM at all times.

• Action plans following the audits need to provide clearer evidence of development and review.

• The variety of audit models proposed for the coming year need to be robust enough to ensure the monitoring and completion of actions from previous audits takes place

• Monitor the impact in delivery of supervision across the LSA, where there are discrepancies in payment for carrying out the role.

• Make easily available to the public information about the process for removing from appointment the LSAMO and the appeal procedure.

Acknowledgements The NMC would like to thank everyone who participated in the review.

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2 Introduction The NMC is the statutory body for the regulation of nurses and midwives. We exist to safeguard the health and wellbeing of the public. We do this by maintaining a register of nurses and midwives, setting standards for education, practice and statutory supervision, and giving guidance and advice to the professions. We aim to inspire confidence by ensuring that the nurses and midwives on our register are fit to practise and by dealing swiftly and fairly with those who are not. The NMC is empowered to carry out these functions by the Nursing and Midwifery Order 2001(The Order)2. The NMC has responsibility under The Order for setting the Rules and standards related to how LSAs (appendix 1) carry out their function3. The NMC wishes to know of any concerns that may impact upon the health and wellbeing of women and families, such as poor midwifery practice. Also of concern to the NMC would be where the clinical environment was not a safe and supportive place for the provision of care or as an appropriate learning environment for pre-registration midwifery students. The purpose of this review (appendix 2) has been to examine the function of the West Midlands LSA. 2.1 The West Midlands LSA The West Midlands LSA covers the areas of Shropshire and Staffordshire in the North to the southern borders of Herefordshire, Worcestershire and Warwickshire, in the South. Borders also include Wales in the West to Derbyshire and Leicestershire in the East. The population of approximately 5 million people live in both rural and densely populated inner city area. Whilst many of the cities such as Birmingham, the Black Country, Stoke and Coventry have historically had ethnically diverse communities, this is a new emerging challenge for rural towns such as Hereford, Shrewsbury, Warwick and Nuneaton which all have large East European populations settling within their communities with increased numbers particularly over the latter 2 years. The LSA Team

• Ian Cumming – LSA / SHA Chief Executive • Peter Blythin - SHA Director of Nursing and Workforce* • Barbara Kuypers – LSAMO • Toni Martin – LSA Project Midwife • Gwen Greenwood – LSA Administrator • Lynda Cox – Assistant LSA administrator

The current structure of the LSA team is key to ensuring effective delivery of statutory supervision across the LSA. It would be important that this structure is supported in the longer term as this would assist with Strategic and Business Continuity. *It is recognised that the CEO is responsible for the LSA but at the time of the review the CEO was still undertaking his orientation to the SHA, so the Director of Nursing and Workforce was key to the continuing function of the LSA. 2 The Nursing and Midwifery Order 2001, SI 2002 N0 253 3 The Nursing and Midwifery Order 2001, Part VIII, Articles 42 and 43

Map of the West Midlands LSA

2.2 Maternity services in the West Midlands LSA There are 15 Trusts providing Maternity Services in West Midlands. Five of these Trusts have Obstetric and Neonatal Services across 2 or 3 sites. Other Trusts have a single Obstetric facility with a portfolio of Midwifery Led Units. The largest Trust providing Maternity Services is Heartlands Foundation Trust with over 12,500 births across 3 sites, Birmingham, Solihull and Sutton Coldfield. The smallest Trust is at Hereford with 1900 births, one of the most isolated units, providing for a market town and rural community. Across the West Midlands, over the last three year period, the birth rate has increased. This increase has not been matched with an appropriate increase in midwife funded posts resulting in the pro-rata ratio of midwives to births rising marginally to 33.2 births per whole time equivalent (WTE) midwife. Birmingham and the Black Country towns of Walsall, Wolverhampton and Dudley have experienced the greatest uplifts in the births; however, this is matched by the cities of Stoke in the North and particularly in Coventry in the South, as these services also have seen increases in new populations mostly from Eastern Europe settling in their communities. The smaller towns of Hereford, Warwick and Burton also have had increases in activity and although small, this has impacted on the birth to midwife ratios quite considerably. The biggest impact of rising activity against WTE Midwife posts can be seen in these Trusts. Conversely, the increase in the midwifery establishment at Dudley can be seen to have continued to assist the

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Trust in bringing down their ratio well below 1:40, which it was in the previous supervisory year 2006 -2007, whilst the outlier over 1:38 is now Heartlands and Solihull.

Demonstrates the ratio of Births to Midwives from April 2005 to March 2009

RATIO BIRTHS to MIDWIVES

2005-2006

2006-2007

2007-2008

2008 2009

2005-2006

2006-2007

2007-2008

2008-2009

Worcestershire - Worcester 3851 5792 3925 3943 29.6 31.8 27.9 30.5

+

- Redditch 1756

i/c above 1696 1839 30.6 27.1 26.5 27.5

_

Herefordshire 1761 1846 1909 1881 29.6 31.8 37.7 *35.8 _

Shropshire 4988 5081 5129 5132 30.8 28.9 35.3 33.0 _

North Staffs - Stoke 5328 5435 5733 5664 29.8 29.0 36 33.5 _

South Staffs. - Stafford 2314 2384 2603 2439 28.9 32.6 35 34.8 _

- Burton 3551 3532 3817 3998 34.2 32.6 35.3 *36.4 +

Warwickshire - Nuneaton 2652 2530 2374 2385 37.0 36.1 34.5 *35.7

+

- Warwick 2617 2641 2678 2663 38.4 33.8 37 *35.5

_

- Coventry 4624 5194 5314 5633 30.1 31.9 35.5 33.9

_

HEFT - Heartlands & Solihull 6969 7120 7546 7585 37.0 37.6 41 *38.4

_

HEFT - Sutton Coldfield 3235 3355 3489 3527 32.7 32.4 33 32.5

_

Birmingham - City 3457 3481 3522 3533 34.7 35.6 32.5 *35.3 +

- Sandwell 2594 2543 2830 2394 34.7 35.6 32.0 29.9

_

Birmingham - Women's 6963 6835 7309 7296 32.8 34.5 34.3 29.7

_

Dudley 4142 4269 4475 4544 38.2 40.1 35.6 *36.1 +

Walsall 3693 3764 3733 3656 29.5 32.7 31 33.6 +

Wolverhampton 3316 3588 3620 3719 32.2 29.7 32.5 30.3 _

WEST MIDLANDS TOTAL 67811 69390 71702 71831 32.8 32.9 36.8 33.2

-

A number of the services have recently opened Midwifery Led Units which are establishing themselves in the community. Stoke, Stafford, Dudley and the Birmingham Women’s have alongside Midwifery Led Units (MLUs) whilst Shropshire, has a portfolio of alongside and standalone MLUs, lastly Burton has a stand alone MLU at Lichfield and is also planning an alongside MLU at Burton in the near future. Towns in rural areas without MLU facilities appear to the have the greatest numbers of home births with Herefordshire and Shropshire, Warwick and Worcester having the largest percentages. Over 440 women had births without the aid of an obstetrician or a midwife in attendance either at home or in transit to hospital. Some women would have been attended by ambulance crew. Reports of women choosing free-birthing with no attendant with them at the time of the birth is increasing. Two women chose this way of birthing during 2007 – 2008 and in each circumstance letters were written to the families informing them of the services nearby them and how to contact support in emergencies.

West Midland Trusts providing Maternity Services

Obstetric & Midwifery Services Midwifery Led Units Worcestershire - Worcester - Redditch Herefordshire - Hereford Shropshire - Shrewsbury & Telford 4 Stand alone & 1 Alongside North Staffs - Stoke 1 Alongside South Staffs - Stafford 1 Alongside - Burton & Lichfield 1 Standalone Warwickshire - Nuneaton - Warwick Integral - Coventry Birmingham - Heartlands & Solihull - Good Hope Birmingham - City - Sandwell Birmingham - Women’s 1 Alongside Black Country - Dudley Integral - Walsall - Wolverhampton

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3 The NMC review of West Midlands LSA 3.1 Decision for review The West Midlands LSA was given a risk score of 31 after the annual report to the NMC was risk scored. Further details regarding the NMC risk framework for reviewing LSAs can be found on the NMC website, www.nmc-uk.org. The risk analysis showed: RED SCORE

• Limited information or description provided on maternal death trends within LSA and interface with supervisory framework.

AMBER SCORE

• No description of complaints process. 4 Review findings The purpose of the review is to verify that the LSAs are meeting the required standards and to enable concerns that may impact upon protection of the public and safety of women and their families to be highlighted and give recommendations for action. This review assessment has been made from information provided to the review team by the West Midlands LSA and with meeting with key stakeholders. A summary of key documents reviewed are listed in appendix 6 and the review documents are now stored in hard copy or electronically at West Midlands LSA. Positive elements identified during the review included:

• Statutory supervision has a high profile at SHA level. • Leadership is regarded as proactive. • Adoption of the LSAMO UK national guidelines. • Employment of a project midwife to support the function of the LSA was particularly highly

valued. • Focussed development for SoMs related to investigations and report writing. • Workshops to facilitate continuing professional development. • Recommendations highlighted from the LSAs participation in the NMC pilot of the

framework for reviewing LSAs have been addressed. • A risk register identifying specific LSA risks is in place. • Enthusiasm around supervision at every level across the LSA.

Challenges to the LSA

• The succession planning and training of SoMs to address the inconsistent ratio of supervisors to supervisees across the LSA. This will support the NMC standard of 1 SoM to 15 supervisees.

• Ensuring that opportunities for the continuing professional development of SoMs are available to address the issues identified in this report of varying levels of detail in the report writing related to supervisors annual reports to the LSA.

• The varieties of proposed audit models for the coming years are robust enough to ensure the monitoring and completion of actions from previous audits.

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5 Conclusion The review team would like to commend the LSA team for all their efforts to ensure that this review ran efficiently. West Midlands LSA should include information in their annual report to the NMC regarding how the recommendations related to supporting continued development of statutory supervision are being actioned. It is particularly important that plans are in place for the training of new supervisors to assure succession planning and the reduction of supervisor to supervisee ratios to a maximum of 1:15. This report will be published on the NMC website.

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6 Evidence of standards being met / partially met/ not met. Rule 4 – Notifications by Local Supervising Authority Local supervising authority standards - In order to meet the statutory requirements for the supervision of midwives, a local supervising authority will: Standard Judgement

Evidence Source

1.1 Publish annually the name and address of the person to whom the notice must be sent.

Standard met

Guideline K ‘Guideline for the completion of the Intention to Practice from by a registered midwife’, seen via LSA Forum website Seen email sent from Gwen Greenwood 27 January 2009 sent to contact SoMs and HoMs and LMEs copied in. Confirmed in minutes of West Midlands LSA Link/LME/Contact SoMs Meeting 5 March 2009

1.2 Publish annually the date by which it must receive intention to practise forms from midwives in its area

Standard met

Guideline K ‘Guideline for the completion of the Intention to Practice from by a registered midwife’ seen via LSA Forum website Seen email sent from Gwen Greenwood 27 January 2009 sent to contact SoMs and HoMs and LMEs copied in. Confirmed in minutes of West Midlands LSA Link/LME/Contact SoMs Meeting 5 March 2009

1.3 Ensure accurate completion and timely delivery of intention to practise data to the NMC by the 20th of April each year.

Standard met

LSA database seen on-site. SoMs reported workshops organised to train in use of database. Evidence of LSA database training confirmed in minutes of West Midlands LSA Link/LME/Contact SoMs Meeting 11 September 2008.

1.4 Ensure intention to practise notifications, given after the annual submission, are delivered to the NMC by the 20th of each month.

Standard met

LSA database seen on-site. Data uploaded daily to the NMC.

Review team commentary – The input of the administrative assistants supports the notification process well. Discussion with SoMs confirmed that the LSA database and web site are appreciated and useful tools for SoMs in the West Midlands LSA. Training was given to the SoMs to use the database in order to be prepared for the uploading of ITPs. Recommendations Rule 4:

• No recommendations.

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Rule 5 – Suspension from Practice by a Local Supervising Authority

Local supervising authority standards - To demonstrate there are mechanisms for the notification and investigation of allegations of a midwife’s impaired fitness to practise, a local supervising authority will: Standard Judgement Evidence Source

2.1 Publish how it will investigate any alleged impairment of a midwife’s fitness to practise.

Standard met

LSA National Forum (UK) Guideline L ‘Guideline for an Investigation of a midwife’s fitness to practise by a SoM on behalf of the LSA’. www.midwife.org.uk Confirmed by SoMs, evidence of use also seen in investigations.

2.2 Publish how it will determine whether or not to suspend a midwife from practice.

Standard met

LSA National Forum (UK) Guideline I ‘Guidance for supervisors on suspension of midwives from practice’. www.midwife.org.uk

2.3 Publish the process for appeal against any decision.

Standard met

West Midlands Standards and guidelines: 6, policy for appeal against supervisory decisions. On LSA Midwifery Officer’s Forum UK website. Guidelines L ‘Guideline for an Investigation of a midwife’s fitness to practise’ and I ‘Guidance for supervisors on suspension of Midwives from Practise’. www.midwife.org.uk

2.4 Ensure that midwives are informed in writing of the outcome of any investigation by a local supervising authority.

Standard met

National LSA guidelines. Guidelines L ‘Guideline for an Investigation of a midwife’s fitness to practise’ and I ‘Guidance for supervisors on suspension of Midwives from Practise’ www.midwife.org.ukTemplate to send to midwife seen Actual letter seen dated May 2009

Review team commentary There was clearly a good deal of input from the LSA team, especially by the project midwife to facilitate these processes. Recommendations Rule 5:

• No recommendations.

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Rule 9 - Records Local supervising authority standards - To ensure the safe preservation of records transferred to it in accordance with the Midwives rules, a local supervising authority will: Standard Judgement Evidence Source

3.1 Publish local procedures for the transfer of midwifery records from self-employed midwives.

Standard met LSA National Forum (UK) Guideline H– ‘Procedure for the transfer of midwifery records from self-employed midwives’. On LSA website www.midwife.org.uk

3.2 Agree local systems to ensure SoMs maintain records of their supervisory activity.

Standard met Described by SoMs to review panel members. Using LSA database also use own secure PCs Locked cabinets used to store paper copies of documentation.

3.3 Ensure SoMs records, relating to the statutory supervision of midwives, are kept for a minimum of seven years.

Standard met SoMs aware of need to keep records for 7 years. Use of database will help this At Birmingham Women’s Hospital (BWH) SoMs were able to express where records are kept on an individual basis and have recently discussed storage which is now being addressed more robustly.

3.4 Arrange for supervision records relating to an investigation of a clinical incident to be kept for a minimum of 25 years.

Standard met Able to store records with LSAMO if necessary. LSA National Forum (UK) guideline B ’Guidance for retention and transfer of records relating to statutory supervision’, on LSA website www.midwife.org.ukVerified on discussion - stored locally in a locked cabinet or sent to the LSA Office for storage

3.5 Publish local procedures for retention and transfer of records relating to statutory supervision.

Standard met LSA National Forum (UK) Guideline B www.midwife.org.uk ‘Retention and transfer of records relating to statutory supervision’. SoMs aware of process, confirmed on discussion with midwives.

Review team commentary Electronic records are stored on a secure site; however it was apparent that not all SoMs are entering the supervisory records from their supervisory reviews onto the LSA database but storing them on their own computer system. Developmental recommendations Rule 9:

• Monitor the use of the LSA database to ensure a consistent approach to data storage. • Have robust processes in place for the transfer of documentation currently held by some

individual SoMs.

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Rule 11 - Eligibility for Appointment as a SoM Local supervising authority standard- In order to ensure that SoMs meet the requirements of Rule 11 a local supervising authority will: Standard Judgement Evidence Source

4.1 Publish their policy for the appointment of any new SoMs in their area.

Standard met LSA National Forum (UK) Guideline C – Guideline for the nomination, selection and appointment of SoMs www.midwife.org.ukAppointment letter to new SoMs

4.2 Maintain a current list of SoMs.

Standard met Database seen

4.3 Demonstrate a commitment to providing continuing professional development and updating for all SoMs for a minimum of 15 hours in each registration period.

Standard met Study events calendar on local LSA website http://www.lsa.westmidlands.nhs.uk/ LSA annual report SoMs identified they meet with LSAMO to decide their supervisory training needs for the following year. Able to choose from events calendar what they wish to do. On the whole are able to be released to do the CPD.

Review team commentary It was noted that there was a good programme for continuing professional development for SoMs, a calendar of events can be viewed on the local LSA website. The CPD is well facilitated by the Project Midwife. The Project Midwife has provided support for the LSAMO which has been recognised and valued by SoMs. Supervisory team away days are being supported by LSA funding for 2years. Recommendations Rule 11:

• No recommendations.

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Rule 12 - The Supervision of Midwives Local supervising authority standard - To ensure that a local framework exists to provide equitable, effective supervision for all midwives working within the local supervising authority, and that a SoMs is accessible at all times a local supervising authority will: Standard Judgement Evidence Source

5.1 Publish the local mechanism for confirming any midwife’s eligibility to practise.

Standard met Guideline J on National database www.midwife.org.uk. Use verified by talking with SoMs. Use HR process which is audited for compliance. Midwife registrations are checked by named SoMs monthly, especially now there is a need for annual fees to maintain registration.

5.2 Implement the NMC’s rules and standards for supervision of midwives.

Standard met SoMs able to articulate how they meet this standard Identified that this is met in each of the LSA audits. LSA audit process confirmed awareness. Sample of LSA audit reports seen by review team Implementation of NMC Rules and standards confirmed by SoMs

5.3 Ensure that the SoMs to midwives ratio reflects local need and circumstances (will not normally exceed 1:15).

Standards met

LSA meets the standard set by the NMC. However, a number of Trusts sit between 1:15 and 1:20 Evidence from Birmingham Women’s Hospital of their robust recruitment strategy to address this locally.

5.4 Set up systems to facilitate communication links between and across local supervising authority boundaries.

Standard met On LSA website. website http://www.lsa.westmidlands.nhs.uk On discussion, SoMs describe dissemination of information – meetings, emails. SoMs links are across the national boarder in to Wales, especially around self-employed midwives, the preparation of SoMs programmes and transfer of women

5.5 Enable timely distribution of information to all SoMs.

Standard met Use of Contact Supervisors to disseminate information. E-mails to Contact supervisors for dissemination seen. Systems include the use of link and contact supervisors and meetings of SoMs with the LSAMO.

5.6 Provide a direct communication link, which may be electronic, between each SoMs and the local supervising authority midwifery officer.

Standard met Emails seen to verify dissemination of information. Notes of meetings. SoMs confirmed this is effective.

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Rule 12 - The Supervision of Midwives (continued) Local supervising authority standard - To ensure that a local framework exists to provide equitable, effective supervision for all midwives working within the local supervising authority, and that a SoMs is accessible at all times a local supervising authority will: Standard Judgement Evidence Source

5.7 Provide for the local supervising authority midwifery officer to have regular meetings with SoMs to give support and agree strategies for developing key areas of practice.

Standard met Notes of meeting seen. Events calendar seen. presentation slide related to communication SoMs away days supported by LSA to develop strategies

5.8 Monitor the provision of protected time and administrative support for SoMs.

Standard met SoMs have negotiated time within own trusts. Different models throughout LSA. Verified through annual audit of maternity services. evidence of this being monitored was seen in the LSA audit reports and confirmed by the SoMs – however there is verbal evidence from SoMs that they have no administrative support. Supervisory teams are remunerated in different ways, calling into question equity of valuing the role of SoMs and the potential impact this may have in carrying out their function.

5.9 Promote woman-centred, evidenced-based midwifery practice.

Standard met Evident in BWH’s presentation – frequent referral to NICE guidelines and SoMs work to pre-empt the publication of NICE guidelines

5.10 Ensure that SoMs maintain accurate data and records of all their supervisory activities and meetings with the midwives they supervise.

Standard met BWH audit their performance against LSA ‘Standards for Statutory Supervision of Midwives’ (Dec 2007) and then discuss these as a team

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Rule 12 - The Supervision of Midwives (continued) Local supervising authority standard - A local supervising authority shall set standards for SoMs that incorporate the following broad principles: Standard Judgement Evidence Source

5.11 SoMs are available to offer guidance and support to women accessing maternity services.

Standard met LSA leaflet on supervision seen electronically as well as seen displayed during the Review Team’s visit to the Birmingham Women’s Hospital. The leaflet is given to women at booking. Two panellists met with three user representatives - all three were members of their local MSLC and one of the women was a lay auditor for the LSA and sat on the selection panel for the Preparation of SoMs course. The users confirmed the following: notice boards in hospitals in the LSA have information for

women about the supervision of midwives Some Trusts use a feedback system to enable women to

comment on their experience of care SoMs wear name badges indicating their status as a

SoMs. women were aware of the support midwives receive from

SoMs women had a good understanding of the purpose of

supervision one woman stated that she thought supervision was a

management process but now knew that it was not information on supervision is given to women at booking.

5.12 SoMs give advice and guidance regarding women-centred care and promote evidence-based midwifery practice.

Standard met On discussion SoMs confirmed that they are involved with policy development Midwives confirmed that they use NICE guidelines and discuss evidence-based practice with women. Proforma for annual review asks about contemporary practice Confirmed by SoMs through policy being involved with policy writing Midwives confirmed that they use NICE guidelines and can talk with women about evidence based practice. Proforma for annual review asks about contemporary practice

5.13 SoMs are directly accountable to the local supervising authority for all matters relating to the statutory supervision of midwives.

Standard met Guidance on LSA website. http://www.lsa.westmidlands.nhs.uk/ Self assessments seen by the review team Sample of LSA audits and reports seen by review team.

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Rule 12 - The Supervision of Midwives (continued) Local supervising authority standard - A local supervising authority shall set standards for SoMs that incorporate the following broad principles: Standard Judgement Evidence Source

5.14 SoMs provide professional leadership.

Standard met Examples given by SoMs re national awards, involvement in strategy development, making things happen and as change agents Some midwives did say they see SoMs as more of a friend and others felt that leadership was difficult to evidence. Some Trusts have held a supervisors week to raise the profile of supervision Some said that if they use a reactive model of supervision it is seen as punitive/ more managerial whereas by using a proactive model supervision is seen more positively

5.15 SoMs are approachable and accessible to midwives to support them in their practice.

Standard met Agreed by midwives no formal on-call in place - SoMs availability obtained through hospital switchboard SoMs audit process and have established that midwives are always able to get hold of an SoMs within 10 minutes

Review team commentary Not all maternity services are able to meet the recommended 1:15 NMC ratio for LSAs. The review team is aware that there were different approaches to accessing a SoM, for midwives as well as women, this needs to be monitored for equity of access. There is good evidence of active user involvement in the audit process. The review team heard that their experience of their engagement of maternity services was one of inclusion and partnership – all felt their views were listened to. They said there was a huge push to try and ensure women are enabled/ empowered to make decisions about their care. One of the women said that some midwives had told her that having the current LSAMO in post was a very positive experience for them. Recommendations Rule 12:

• Promote the training of SoMs so that succession planning can support the NMC ratio of 1:15 SoMs to midwives.

• Monitor the provision of supervision across the LSA to ensure midwives and women have equal access to a SoM at all times.

• Monitor the impact in delivery of supervision across the LSA, where there are discrepancies in payment for carrying out the role.

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Rule 13 - The Local Supervising Authority Midwifery Officer Local supervising authority standards - In order to discharge the local supervising authority supervisory function in its area through the local supervising authority midwifery officer, the local supervising authority will: Standard Judgement Evidence Source

6.1 Use the NMC core criteria and person specification when appointing a local supervising authority midwifery officer

Standard met Confirmed by NMC. Evidence seen by LSAMO reviewer.

6.2 Involve a NMC nominated and appropriately experienced midwife in the selection and appointment process

Standard met Confirmed by NMC. . Evidence seen by LSAMO reviewer

6.3 Manage the performance of the appointed local supervising authority midwifery officer

Standard met Performance managed by Director of Nursing and Workforce for the West Midlands SHA.

6.4 Provide designated time and administrative support for a local supervising authority midwifery officer to discharge the statutory supervisory function

Standard met Evidenced through presentation and verbal evidence from the Director of Nursing and Workforce Development.

6.5 Arrange for the local supervising authority midwifery officer to complete an annual audit of the practice and supervision of midwives within its area to ensure the requirements of the NMC are being met.

Standard met All audits were available to view electronically, seen by review panel. Presentation for audit cycle which included the development of a variety of models to use in the future in order to focus on particular issues. The aim is to ‘drill down’ on specific issues of concern rather than reviewing everything. The review team viewed a number of SoM annual supervisory reports to the LSA and noted a variety of approaches to report writing with different levels of detail and quality.

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Review team commentary A sample of LSA audits and reports were seen by the review team and noted that the action plans following the audits need to provide clearer evidence of development and review. The review team had concerns about the proposed variety of different models to be used each year in the LSA audit process and the potential risk that actions from previous audits may not be addressed, progressed or monitored. A sample of SoM self assessments against the NMC Standards for statutory supervision were seen by the review team. However there needs to better accuracy in the completion of the self assessment forms by supervisory teams as some teams stated that they had met a criteria when it was evident from the evidence they gave that they had not. Developmental recommendations Rule 13:

• Action plans following the audits need to provide clearer evidence of development and review

• provide training in report writing skills to assist SoMs in compiling their annual supervisory report to the LSA

• the variety of audit models proposed for the coming year need to be robust enough to ensure the monitoring and completion of actions from previous audits takes place.

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Rule 15 - Publication of Local Supervising Authority Procedures Local supervising authority standard - To ensure incidents that cause serious concern in its area relating to maternity care or midwifery practice are notified to the local supervising authority midwifery officer, a local supervising authority will: Standard Judgement Evidence Source

7.1 Develop mechanisms with NHS authorities and private sector employers to ensure that a local supervising authority midwifery officer is notified of all such incidents.

Standard met Evidence given from SHA maternity team around process for SUI which includes maternal deaths. Guideline on LSA website SUI policy in place however this is a SHA policy and not an LSA one - no mention of the supervisory process in the policy Data base for tracking investigations LSA National Forum guideline L ‘Guideline for an Investigation of a midwife’s fitness to practise’ www.midwife.org.uk

7.2 Publish the investigative procedure.

Standard met Guideline L ‘Guideline for an Investigation of a midwife’s fitness to practise by a SoM on behalf of the LSA’ www.midwife.org.uk. Supervisors confirmed knowledge of this.

7.3 Liaise with key stakeholders to enhance clinical governance systems.

Standard met Evidence given via presentation and SHA maternity team. Evidence of liaison with Patient Safety Quality Group.

7.4 Publish the process for the notification and management of complaints against any: - local supervising authority midwifery officer - SoMs

Standard met Guideline on LSA website.

Guideline G ‘Process for the notification and management of complaints against a SoM or an LSAMO including appeals.’

www.midwife.org.uk

7.5. Publish the process for removing from appointment a: -SoMs -local supervising authority midwifery officer

Standard met Guideline D ‘Guidance on poor performance and deselection of a supervisor of midwives’, On www.midwife.org.uk

SHA Human Resources policy for LSAMO. Although published, these were more difficult to find and access

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Rule 15 Publication of Local Supervising Authority Procedures (continued) Local supervising authority standard – To ensure incidents that cause serious concern in its area relating to maternity care or midwifery practice are notified to the local supervising authority midwifery officer, a local supervising authority will: Standard

Judgement Evidence Source

7.6 Publish the process for appeal against the decision to remove a: officer - SoMs - local supervising authority midwifery

Standard met www.midwife.org.uk. LSA National UK Forum Guideline G ‘Process for the notification and management of complaints against a SoM or an LSAMO including appeals,’ applies to SoMs.

SHA human resources policies for the LSAMO. These were more difficult to find and access

7.7 Ensure that the following are informed of the outcome of any local supervising authority investigation of poor performance, following its completion: - local supervising authority midwifery officer - SoMs

Standard met Guideline L ‘Guideline for an Investigation of a midwife’s fitness to practise by a SoM on behalf of the LSA’ www.midwife.org.uk. Guideline on LSA website. http://www.lsa.westmidlands.nhs.uk/ Evidence seen in case reports.

7.8 Consult the NMC for advice and guidance in such matters

Standard met Confirmed by NMC and LSAMO panel members.

Review team commentary Generally the publications of LSA procedures are covered by National guidelines available on www.midwife.org.uk. The process for the removal from appointment an LSAMO is not well explained within current National UK Forum guidelines or other accessible documentation. Accessing the SHA website to locate the policy was more problematic. Developmental recommendations Rule 15:

• Make easily available to the public information about the process for removing from appointment the LSAMO and the appeal procedure.

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Rule 16 - Annual Report - Local supervising authority standard - Written, annual local supervising authority report will reach the Midwifery Committee of the NMC, in a form agreed by the Nursing and midwifery Council, by the 1st of June of each year. note this rule has been amended and the deadline is now the end of September each year) Each local supervising authority will ensure their report is made available to the public. The report will include but not necessarily be limited to: Standard Judgement Evidence Source

8.1 Numbers of SoMs appointments, resignations and removals.

Standard met Database seen. Reported in annual report.

8.2 Details of how midwives are provided with continuous access to a SoMs

Standard met BWH very clear about how to contact a supervisor out of hours, supported by presentation in the morning. LSA audit reports detail this.

8.3 Details of how the practice of midwifery is supervised.

Standard met LSA Standards for the statutory supervision of midwives (December 2007) standard 2 on LSA website. http://www.lsa.westmidlands.nhs.uk Detailed in annual reports undertaken by the LSA.

8.4 Evidence that service users have been involved in monitoring supervision of midwives and assisting the local supervising authority midwifery officer with the annual audits.

Standard met Email evidence from lay auditor Met with lay auditors Email from lay auditor

8.5 Evidence of engagement with higher education institutions in relation to supervisory input into midwifery education.

Standard met One Link SoMs is a Lead Midwife for Education (LME). The review team met with three LMEs (two of the universities being represented had teachers as SoMs) The LME confirmed supervisory input from supervisors in the LSA - SoMs from clinical areas teach on the midwifery courses. Midwifery students confirm that they are supported by the supervisory framework SoMs are involved when any concerns about a midwife are expressed.

8.6 Details of any new policies related to the supervision of midwives.

Standard met Working group comprising of three SoMs, a POSOM and the LSA Project Midwife have met to review the current LSA Guidelines (May 09). Recommendations made – guidelines to be placed on LSA website for ease of access and provide additional training to enhance learning.

8.7 Evidence of developing trends affecting midwifery practice in the local supervising authority.

Standard met minutes of meetings seen LSA presentation to the review panel identified challenges related to trends The review team became aware of inconsistency in the definition of ‘born before arrival’, which would impact on the collection of any stats in this area.

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8.8 Details of the number of complaints regarding the discharge of the supervisory function.

Standard met Annual Report Presentation

8.9 Reports on all local supervising authority investigations undertaken during the year.

Standard met Annual Report. Variety seen as documentary evidence

Review team commentary A working group are to review the current LSA guidelines. Midwifery students are supported by the supervisory framework, although the model used varied throughout the LSA e.g. in one university students are allocated to a SoMs by cohort whereas in another students are individually allocated. SoMs are involved when any concerns about a midwife are expressed. In order to collect accurate data to monitor developing trends, there needs to be more consistency/ clarity in the definition of ‘born before arrival’ (BBA). It was apparent that some SoMs were viewing this as born before arrival at intended place of delivery whereas others viewed this as born before the arrival of a midwife, regardless on intended place of delivery. Recommendations Rule 16:

• No recommendations.

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Appendix 1 – The Local Supervising Authority (LSA) LSAs are organisations that hold statutory roles and responsibilities for supporting and monitoring the quality of midwifery practice through the mechanism of statutory supervision of midwives. The primary responsibility of a LSA is to safeguard the health and wellbeing of women and their families. LSAs sit within an organisation such as a NHS authority, and this varies in each country of the United Kingdom:

• England the LSA is the Strategic Health Authority • Northern Ireland the LSA is the Public Health Agency • Scotland the LSA is the Health Boards • Wales the LSA is Healthcare Inspectorate Wales

The chief executive of the organisation is responsible for the function of the LSA. Each LSA must appoint a practising midwife to the role of LSAMO. The statutory requirements for this person and role are also set by the NMC (www.nmc-uk.org). The LSAMO is employed by the LSA to put its responsibilities into practice and this function cannot be delegated to another person or role. The LSAMO has a pivotal role in clinical governance by ensuring that the standards for supervision of midwives and midwifery practice meet the requirements set by the NMC. Apart from the NMC the LSA is the only organisation that can suspend a midwife from practice and can only do so pending referral to the NMC with allegations of misconduct or persistent lack of competence. Supervisors of midwives (SoMs) are experienced midwives who have undergone additional education and training in the knowledge and skills needed to supervise midwives. SoMs can only be appointed by a LSA, not by an employer, and as such are acting as an independent monitor of the safety of midwives’ practice and the environment of care provided by the maternity services. By appointing SoMs the LSA ensures that support, advice and guidance are available for midwives and women 24-hours a day, to increase public protection. SoMs are accountable to the LSA for all their supervisory activities and their role is to protect the public by enabling and empowering midwives to practise safety and effectively. They also have a responsibility to bring to the attention of the LSA any practice or service issues that might undermine or jeopardise midwives’ ability to care for women and their babies safely. Every midwife practising in the UK is required to have a named SoMs who is from the LSA in which she practises midwifery most each year. This LSA is described as the midwife’s main area of practice and every midwife is required to notify her/his intention to practise (ITP) to this LSA each practice year. A practice year runs from the 1 April to the 31 March.

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Appendix 2 - The NMC Framework for reviewing LSAs The NMC sets the rules and standards for the function of the LSA which are detailed in the Midwives Rules and Standards. The NMC has a duty to verify that the LSAs are meeting the required rules and standards and this will be achieved through the “NMC framework for reviewing LSAs” (www.nmc-uk.org). The purpose of the review is to verify that the LSAs are meeting the required standards. Any concerns raised from the review that may impact on safeguarding the health and wellbeing of women and their families will be highlighted. Recommendations for action will be given.

The review should target serious issues and concerns identified in the LSA profile but may also include exploration of key themes highlighted by the NMC. The review aims to be both formative (an aid to development) and summative (a check that a required standards are being met). As part of the review, the review team will assess:

• the function of the Local Supervising Authority • the function of statutory supervision of midwives • information from the LSA profile and self assessment form • concerns which may affect protection of the women, babies and their families • concerns in relation to the learning environment of student midwives.

The review team should:

• verify that the Midwives rules and standards are being met • explore key themes identified by the NMC • visit one or more maternity services if deemed appropriate due to the reasons for

the review • meet with stakeholder groups including the LSAMO, midwives, supervisors of

midwives, users of maternity services, lay organisations and representatives, Directors and Heads of Midwifery, Directors of Nursing, Chief Executive of the Health Board and LSA

• observe evidence of examples of best practice within the function of the LSA • explore any other areas of concern or interest during the course of their visit.

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Appendix 3 - The review team Name: Claire Bonnet Role in review team: Chair and lay reviewer Other roles: Solicitor Name: Mary Vance Role in review team: LSAMO reviewer Other roles: LSAMO Name: Helen Meehan Role in review team: Midwife registrant Other roles: Midwife and Supervisor of Midwives Name: Dr Susan Way Role in review team: NMC Representative Other roles: Midwifery Advisor NMC Observer Name: Jane Kennedy Role in review team: Observer Other roles: Consultant Midwife

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Appendix 4 - Key people met during the review

• The Chief Executive Officer sent apologies, by letter, in anticipation of the review. • SHA Director of Nursing and Workforce development • LSA team – LSAMO, LSA project midwife • Directors of nursing • Supervisors of midwives • Consultant midwives • Heads of midwifery • Contact supervisors of midwives • Higher education institutions representatives • Service users • Midwives • Obstetricians • Provider Trust CEO • Student midwives • A Trust providing maternity services (Birmingham Women’s Hospital Foundation

Trust) • Independent midwives were invited but unable to attend.

Appendix 5 - Programme for the review

NMC Review Framework

West Midlands LSA

Programme for Wednesday 8th July 2009

Venue - Osprey House Time Activity Personnel

8:00 Travel to Osprey House from Hotel

9:00 – 9:30 Coffee, Welcome and Introductions

Peter Blythin Barbara Kuypers

9:30 – 10:30 Introduction to the LSA Barbara Kuypers Toni Martin Gwen Greenwood Lynda Cox

10:30 – 11:30 West Midlands Maternity Team and the role of the LSA in Strategic Direction CEMACH Lead for West Midlands

Julie Grant Sue Hatton Jane Emson Fay Baillie Julie Maddocks

11:30- 12:00 Review Team in Camera

12:00 – 13:00 Meeting with Lay Representatives and LSA Lay Auditors

LSA User Representatives and other MSLC Leads

13:00 – 14:00 Lunch with invited guests Heads of Midwifery Contact Supervisors Lay Representatives

14:00 – 15:00 Group A) Heads of Midwifery Group B) Contact and Supervisors of Midwives

15:00 – 15:45 Independent Midwives

Co-operative

16:00 Meeting with West Midlands CEO and Director of Nursing and Workforce and LSAMO

Ian Cumming Peter Blythin Barbara Kuypers

17:00 Meeting with LSAMO 1-1 Barbara Kuypers

17:30 End of Day

18:00 Arrival back to Hotel

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NMC Review Framework

West Midlands LSA

Programme for Thursday 9th July 2009

Venue - Birmingham Women’s Hospital Foundation Trust Time Activity

Personnel

8:00– 9:00 Travel from Hotel to Birmingham Women’s Hospital Foundation Trust

Post Graduate Centre Seminar Room

9:00 – 9:30 Coffee Welcome and Introductions

Jane Owen Jenny Henry Sue Smithson CEO Chair

9:30 – 10:30 Birmingham Women’s Hospital Foundations Trust

BWH Team

10:30 Group 1:Meeting with Midwives (to include Sign Off Mentors) Group 2: Meeting with Student Midwives

BWH Team

11:15 Meeting with Supervisors of Midwives and Student Supervisors of Midwives.

BWH Team

12:00 Group 1:Meeting with Ann Kingscott as POSOM

Programme Lead Group 2: Meeting with Lead Midwives for Education

Ann Kingscott All Universities

13:00 Lunch with guests

All

14:00 Tour of Maternity Services

All

14:30 Review Team in Camera

Review Team Only

15:30 Feedback

Invited Guests from Trust and Universities Peter Blythin & Barbara Kuypers

16:30 Close of Day

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Appendix 6 - Documentary evidence viewed included the following:

• Final Local Supervising Authority Report 2007-8 Coventry • LSAMO Audit Report 2008-09 Coventry • Coventry report to the LSA 0809 • Final LSAMO report Shropshire 2007-08 • Shrewsbury and Telford report to the LSA Jan 2009 • LSAMO Audit report 2008-09: Shrewsbury and Telford, Jan 2009 • Presentation away day Birmingham Women’s Hospital 09 (power point) • Presentation plan, Birmingham Women’s Hospital 09 (power point) • Birmingham Women’s Hospital report to the LSA 2008-2009 • Final LSAMO report Sandwell 2007-08 • LSAMO Audit Report 2008-09 Sandwell and West Birmingham • Sandwell Annual Report to the LSA 2008 • Final LSA NMC Self Assessment 09-10 • LSA Annual Report to the NMC 2007-2008 • West Midlands LSA risk profile 2007-08 • West Midlands LSA supervisory investigation report, June 2009, investigating

Supervisor PC • West Midlands LSA supervisory investigation report, April 2009, investigating

Supervisor SR • West Midlands LSA supervisory investigation report, April 2009, investigating

Supervisor VT • Supervisory Investigation report template • Presentation – supervisory Investigation Workshop – Toni Martin • Supervised practice programme template • LSA investigation workshop session outline • Example letter to midwife following investigation July 09 • Supervisory investigation outcome of investigation letter to midwife, May 09 • LSA Audit report for Heart of England NHS Foundation Trust identifying supervisory

CPD topics that include standards for investigation and supervised practice • Supervisory investigation workshop 23 June 09 and evaluations • LSA study events calendar • West Midlands Standards and guidelines for SoMs • Appointment of SoMs • Email 31 October 08 – POSOM selection panels: September 09 course • NMC standards for the preparation and practice of SoMs • West Midlands LSA conference – Dimensions of midwifery practice 14 July 09 • Complaints investigations: report writing 16 June 09 and evaluations • Supervised practice – supervisors are you ready to address poor practice? 24 April

09 and evaluations • Continuing education for SoMs, Practice forum event 1 April 09 • Health records (record keeping) and evaluations • West Midlands LSA, face-to-face event 11 July 09 and evaluations • Email from lay auditor about experience of attending Birmingham Women’s Hospital.