South East and West Region
NHS Forth Valley
Local Supervising Authority
Annual Audit Report – 2014-2015
Monitoring the Standards of Supervision &
Midwifery Practice
Yvonne Bronsky LSAMO Jan 15
Page 1 of 21
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.
Each Health Board in Scotland fulfils the function of the LSA. It is therefore responsible
for ensuring that statutory supervision of all midwives, as required in the Nursing and
Midwifery Council Order (2001)1 and the NMC Midwives Rules and standards (2012)2,
is exercised to a satisfactory standard across the Board.
Supervisors of Midwives (SoM) are appointed by the LSA and the LSA function sits
within each Health Board within Scotland. 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. The South East and West Region will appoint a
LSA MO to carry out the functions of each of the LSAs within the South East and West
Region of Scotland namely, Ayrshire and Arran, Borders, Dumfries and Galloway, Fife,
Forth Valley, Greater Glasgow and Clyde, Lanarkshire and Lothian 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 the region, to ensure the
requirements of the NMC are being met (Rule 11, NMC 2012).
The LSA role is to:

Be available to women if they wish to discuss any aspect of their midwifery care
that they consider has not been addressed through other channels

Provide a framework of support for supervisory and midwifery practice

Receive Intention to Practise data for every practising midwife in the LSA

Ensure that each midwife meets the statutory requirement for practice

Provide initial and continuing education and training for SoMs
Yvonne Bronsky LSAMO Jan 15
Page 2 of 21

Investigate cases of alleged misconduct or lack of competence

Determine whether to suspend a midwife from practice, in accordance with Rule
14 of the Midwives Rules and standards (2012)

Lead the development of standards and audit of supervision
To enable each of the LSAs to deliver against their roles and responsibilities the
appointed LSAMO is responsible on their behalf to:

Lead the development of standards and audit of supervision

Appoint SoMs

Provide a formal link between midwives, SoMs and the statutory bodies

Provide a framework for supporting supervision of midwives and midwifery
practice

Participate in the development and facilitation of programmes of preparation and
ongoing development of SoMs

Ensure that SoMs are capable of meeting the competencies set out in the
Standards for Preparation of Supervisors of Midwives NMC (2014) 3
All practising midwives in the United Kingdom are required to have a named Supervisor
of Midwives (SoM). A SoM 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 SoM oversees approximately 15 midwives and is a professional that midwives
may go to for advice, guidance and support. The SoM 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).
Yvonne Bronsky LSAMO Jan 15
Page 3 of 21
Table One: SoM Ratios
Total number of midwives
practising
16
Total number of Supervisor of
Midwives (SoMs)
218
Ratio of supervisor of midwives to
midwives
1:14
New SoM appointments
2
SoM resignation(s)
0
SoM removal(s)
0
Table Two: Ratio Trends 2008 - 2014
Forth Valley
Yvonne Bronsky LSAMO Jan 15
2008- 2009- 2010- 2011
2012 2013-
2009
2010
2011
2012
2013 2014
12
12
14
13
14
16
Page 4 of 21
NMC Midwives Rules and standards (2012)
Rule 13 LSA Standard
The local supervising authority midwifery officer will complete an annual audit of the
practice of supervision of midwives within the LSA area to ensure the requirements of
the NMC are met.
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 self assessment monitoring tool was submitted to the LSA office two working weeks
prior to the audit. (Appendix 1) this was the first part of a triangulated approach which
was undertaken as part of the audit process.
Yvonne Bronsky LSAMO Jan 15
Page 5 of 21
Assessment of the LSA Standards for the Supervision of Midwifery
The LSA Standards for the Supervision of Midwives are incorporated into ten standards
for auditing purposes; each standard 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 the preparation of supervisors of midwives NMC (2014)
Standards for Medicines Management, NMC (2007)
Record keeping: Guidance for nurses and midwives, NMC (2009)
Summary of Outcome Findings
The audit process was undertaken by Yvonne Bronsky LSAMO, Joyce Jones LSA
Midwife, supported by SoMs from other LSAs within the South East and West Region
Feedback from Midwives/Student Midwives – 14 attended focus group





All knew about statutory supervision
All had named SoM
All had met with named SoM in past year for annual review
SoMs accessible 24/7
SoMs seen as leaders within midwifery profession
Feedback from Users – 9 met during audit visit




Some had noted SoM noticeboard
Clean and friendly environment
All would recommend unit to friends and family members
One woman commented positively re information about Supervision she had
accessed via FV website
Yvonne Bronsky LSAMO Jan 15
Page 6 of 21
Q5. Overall how would you rate your experience of midwifery care?
80%
very dissatisfied
not very satis
satisfied
Very satisfied
N/A
Not Ans
60%
40%
20%
0%
AntenatallyAntenatallyAntenatally Labour in Labour at Postnatal Postnatal Postnatal
in hosp
comm
at home
hosp
home
in hosp
comm
at home
clinic
clinic
Recommendations

To ensure that activity undertaken by the team is appropriately badged as
supervision to improve the profile and understanding of supervision.

The team should present an annual report of their activities to the Board, to
support the understanding of the importance of the work they have undertaken in
the wider context.

Supervisors should to strengthen their contribution to Board meetings by
articulating their views and suggestions on topics related to Midwifery Practice

The SoM team should continue to build on their efforts to increase the profile of
Supervision with women. They may wish to explore whether it would be practicable to
publicise Supervision generally.
Yvonne Bronsky LSAMO Jan 15
Page 7 of 21
South East and West Region
NHS Forth Valley
Statutory Supervision of Midwives
Annual LSA Audit of Standards
NMC Midwives rules and standards 2012
September 2014
8
South East and West Region
Standard One
Rule 4 –
Intention to practise notifications are sent to the NMC by the annual submission date specified by the Council
Intention to practise notifications received after the annual submission date are sent to the NMC as soon as reasonably
Practicable
Measurement
SoM team self assessment, comments
and supporting evidence




Template advice sent to Supervisees to
remind completing and return of NITP
Midwives NITP within Forth Valley were
completed on time.
Review of LSA database
Completion of supervisor monthly
timesheet. LSAMO has access to
database
LSA verification and
comments
Database verified
Verbal verification received from
midwives present at review
Database checked by LSAMO, all
midwives have notified their ItP to
named Som
September 2014
9
Met
MET
Partially
Met
Not Met
South East and West Region
Standard Two
Rule 6 – All records relating to the care of the woman or baby must be kept securely for 25 years
SoM team self assessment, comments
and supporting evidence







Electronic Matsys system, can be
viewed on day of audit
NHS Forth Valley Policy on record
keeping
All investigation, SoM Review of care
sent to LSAMO who keeps for 25 years
LSA Database; all staff have own login
and personal passwords
Data protection policy
Learn Pro module data protection
(certificate from SoM who has
completed module)
Evidence from Database re SOM prep
(Midwives exemption)
LSA verification and
comments
Verified through observation of
MATYS system
Record keeping policy – currently due
for update Sept 2014
All SoMs input onto LSA database
frequently
September 2014
10
Measurement
Met
MET
Partially
Met
Not Met
South East and West Region
Standard Three
Rule 9 – Each practising midwife within its area has a named SoM from among the SoMs appointed by the LSA
At least once a year a SoM meets each midwife for whom she is the named SoM to review the midwife’s practice
and to identify her education needs
All SoMs within its area maintain records of their supervisory activities, including any meeting with a midwife
All practising midwives within its area have 24 hour access to a SoM
Measurement
SoM team self assessment, comments
and supporting evidence







100% including bank staff have a
named SoM, evidence on database
Evidence from LSA database that
annual review took place
Monthly returns to LSAMO
Forth Valley Work plan records Som
Activities
Consultation of revision of code and
revalidation, SoMs gave feedback,
included in workplan
On call rota
SoM contact numbers in unit folder;
update attached. On day of audit can
review folder.
LSA verification and
comments
Database verified by LSAMO 98%
compliance with 2% explanations as
to reason for no Annual review being
undertaken.
Evidence in relation to supervisory
activity well populated and
triangulated through viewing of
meeting notes.
Workplan evidence is commendable
Monthly activity well populated by all
SoMs
September 2014
11
Met
MET
Partially
Met
Not Met
South East and West Region
Standard Four
Rule 9 Equitable and effective supervision for all midwives working within the local supervising authority
Support for student midwives to enable them to have access to a supervisor of midwives
Strategy to enable effective communication between all SoMs. This should include communication with SoMs in other LSAs
Monitor and ensure that adequate resources are provided to enable SoMs to fulfil their role
Consistency in the approach taken by SoMs to the annual review of a midwife’s practice which include the SoM undertaking an
assessment of the midwife’s compliance with the requirements to maintain midwifery registration
Ensure the availability of local systems to enable SoMs to maintain and securely store records of all their supervisory activities
Measurement
SoM team self assessment, comments
and supporting evidence







Each midwife has the same access and
availability to any SoM within Forth
Valley.
All midwives at a minimum receive, an
annual review, guidance on completing
NITP, quarterly newsletters
Update on documentation by
Supervisors on current themes.
All Student Midwives have a named
SoM
Work plan gives evidence of meetings
attended by SoMs and update at Som
Meeting. Contact/Squig/SOM
Strategy 2014-15
Soms allocated a day per month for
Supervision, evidence on monthly
LSA verification and
comments
Verified via LSA database
Verified by midwives attending the
audit
Verified by student midwives a on
the day of the audit
Commendable approach to ensuring
SoM representation noted and
contributed at meetings
September 2014
12
Met
MET
Partially
Met
Not Met
South East and West Region



returns, off duty, attendance at
meetings, Workplan.
All Forth Valley midwives use the
database ( an anonymous review
attached)
Secure individual access to PCs and
controlled access to shared drive; SoMs
have a secure cabinet for supervisory
storage.
Minutes of SoM meeting
Standard Five
Rule 10 Develop a system with employers of midwives and self employed midwives to ensure that a Local Supervising Authority
Midwifery Officer is notified of all adverse incidents, complaints or concerns relating to midwifery practice or allegations
of impaired fitness to practise against a midwife
SoM team self assessment, comments
and supporting evidence
LSA verification and
comments
Measurement
Met
Robust unit reports completed twice daily and
incidents highlighted on safeguard system. The
on call SoM is responsible for reviewing all
adverse incidents. evidence from a recent
Excellent process undertaken which
demonstrates robust monitoring of
adverse events review Confirmed by
September 2014
13
MET
Partially
Met
Not Met
South East and West Region
incident:
 Unit Report (attached informing of
incident)
 Safeguard report (IR1 -124145
generated) Safeguard system can be
reviewed
 Review of care sent to LSAMO
LSA Midwife as meeting the
standards set
Verified through SoM minutes and by
LSAMO when attending local
meetings
All incidents and complaints themed and
discussed at Bi monthly meetings;





Summary of complaints over two
months
Summary of IR1s
Template for summary and action from
verbal complaint
Independent Midwives link with the
contact SoM if working in Forth Valley;
2 Independent midwives carried out
care within Forth Valley in 2014
September 2014
14
South East and West Region
Standard Six
Supplementary Evidence of Statutory Supervision Representation by SoMs:


SoM representation at clinical governance meetings
Som representation at clinical guideline development
SoM team self assessment, comments
and supporting evidence
LSA verification and
comments
Measurement
Met
MET
Issues highlighted at Clinical Governance and
update on protocols are noted at Soms Bi
monthly meetings
 Minutes of SoM Meeting April 2014
 An SoMs attend Clinical governance
meetings
 Minutes attached
 SoMs are sent all protocols for
comment;
 Examples of correspondence and
comments
 SoMs developed homebirth protocol,
being updated at present, see attached
Evidence verified through minutes
available
September 2014
15
Partially
Met
Not Met
South East and West Region
Standard Seven
Supplementary Evidence to demonstrate SoM effectiveness in ensuring safe practice


SoM interface with audit activities
Evidence to demonstrate SoMs are involved in networking activities
SoM team self assessment, comments
and supporting evidence
LSA verification and
comments
SoMs within Forth Valley involved in audits and
educational updates:
 Documentation audit monthly by SoMs
(Themes discussed at SOM Meetings
see Minutes) Awaiting system that will
report review and trends. Unit themes
attached for 2014
 Controlled drug audit
 SOMs developed Midwives exemption
workbook and have annual update for
2014. Both attached
 Presentation on Ogilvie syndrome
which was given at SoM meeting in
August 2014
Good evidence of audits being led
and undertaken by SoMs which have
assured public protection in relation
to documentation errors and
medicine management error
awareness and learning
Over the last year SoMs involved in various
activities outwith Forth Valley:
 Contact SoM minutes from September
2014
 SQUIG minutes attached Feb 2014
 All SoMs in Forth Valley attended the
September 2014
16
Measurement
Met
MET
Partially
Met
Not Met
South East and West Region
Investigations process update training
session on 5th March 2014
 An SoM attends Maternity services
Liaison Meetings
September 2014
17
South East and West Region
Standard Eight
Supplementary Evidence to demonstrate SoM development of leadership skills



SoM involvement in identifying and encouraging future SoMs to undertake preparation programme
SoM involvement in providing mentorship, support and preceptorship for student midwives, student SoMs and newly
qualified SoMs
Leadership on SoM initiatives across the Board
SoM team self assessment, comments
and supporting evidence
LSA verification and
comments
Measurement
Met
MET
Over the last few years the ratio has improved
to ensure compliance of NMC standards.
Currently we are at 1:13.2. In previous years
this has been up to 1:17.
 SOM module, advertised on notice
board. 2completed course last year and
2 commenced in September 2014
 SOMs ask supervisees at annual review
 List of Tutorials given to Student Soms
 Evidence of support given to Student
Som during training, see tutorial list and
an example
 Actively participate in protocols, e-mail
evidence
Partially
Met
Not Met
Excellent evidence of support during
and after preparation programme for
new SoMs
Midwives attending the audit verified
that they had been approached and
encouraged by their named SoM to
consider applying for the
preparation course
September 2014
18
South East and West Region
Standard Nine
Evidence to demonstrate SoMs interface with users of maternity services





SoM involvement with MLSC
SoM accessibility to users e.g. user strategy, user involvement, user questionnaires
SoM advocacy for women i.e. in care planning
SoMs supporting women’s choices
SoMs proactive in the promotion of Normal Birth
SoM team self assessment, comments
and supporting evidence




SoM attends MSLC and gives update,
Minutes attached from MSLC, this also
reflects user involvement.
User questionnaires distributed prior to
audit
Minutes from holistic care group
promoting normality.
SoM completed homebirth leaflet
LSA verification and
comments
Good evidence of role of SoM within
MSC group, active participation and
influence within this group
September 2014
19
Measurement
Met
MET
Partially
Met
Not Met
South East and West Region
Standard Ten
Evidence to demonstrate SoMs are responsible for ensuring that the LSA database
is updated and maintained
SoM team self assessment, comments
and supporting evidence
LSA verification and
comments
LSA database accessed and evidence
of compliance verified
The LSA audit team will review the
following evidence on the LSA
database as part of the audit process





SoM /Supervisee caseload
SoM PREP/CPD activities
ITPS are uploaded
Annual supervisory reviews
Personal details of supervisees
September 2014
20
Measurement
Met
MET
Partially
Met
Not Met
South East and West Region
September 2014
21