Statutory Supervision of Midwives
Local Supervising Authority Standards for
England
London Local Supervising Authority Audit Tool
TRUST:
DATE OF AUDIT:
The LSA audit tool is divided into four domains. 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 http://www.lsamoforumuk.scot.nhs.uk
To complete this audit tool, all electronic evidence that is submitted should be embedded against each relevant domain along with text to provide
relevant / explanatory comments. If evidence is available in hard copy format, this will be viewed on the day of the audit visit.
The completed London LSA audit tool needs to be submitted to Kevin Saunders kevin.saunders2@nhs.net at least 2 weeks before the date for
your LSA audit. Please refer to the Guidance for Supervisors of Midwives for completing the London LSA tool, which includes information on
preparing for the LSA audit and instructions for embedding electronic documents. Both the London LSA tool and the Guidance document are
available on the http://www.londonlsa.org.uk
1
London LSA Audit Tool Criteria Revised November 2015
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.
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London LSA Audit Tool Criteria Revised November 2015
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 cross-referencing
 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 and 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
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London LSA Audit Tool Criteria Revised November 2015
Domain 1: The Interface of Statutory Supervision of Midwives and Clinical Governance
Supervisors of Midwives support midwives in providing a safe environment for the practice of evidence based midwifery
Criteria to be audited
SoM team self
assessment
including their
comments and
submitted evidence
Measurement
LSA verification and
comments
Met
Requires
Improvement
Not Met
1a)
Evidence of SOM team
representation at
clinical governance
meetings – a selection
of minutes from the
following:
 maternity risk
 Labour Ward
forum
 MSLC
1b)
Evidence of an up to
date strategy for
statutory supervision of
midwives
1c)
Evidence of an action
plan to address the
recommendations of
the last LSA audit
SOM representation
demonstrated at 75 100% of all clinical
governance
meetings
SOM
representation
demonstrated at
50-74% of all
clinical
governance
meetings
SOM
representation
demonstrated at
less that 50% of
all clinical
governance
meetings
Up to date SOM
strategy available
SOM strategy is
not up to date
SOM strategy not
presented
Action plan
presented regarding
the
recommendations
from the previous
LSA audit
Action plan not
presented
1d)
Evidence that statutory
supervision of
midwives is featured in
The interface
between risk
management
Supervision of
Action plan
presented but
does not address
all the
recommendations
of the previous
LSA audit
Supervision of
midwives is
mentioned in the
Trust Risk
Supervision of
midwives is not
featured in the
Trust Risk
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London LSA Audit Tool Criteria Revised November 2015
Criteria to be audited
SoM team self
assessment
including their
comments and
submitted evidence
Measurement
LSA verification and
comments
Met
Requires
Improvement
the Trust Risk
management strategy
midwives is
accurately described
management
strategy
1e)
Evidence that there is
SOM interface with the
development and
dissemination of new
guidelines
New guidelines
published over the
year demonstrate
involvement of a
SOM in both
development and
dissemination
1f)
Evidence that the SOM
team have been
involved in audit
activities including:  Record keeping
 Administration
and storage of
controlled drugs
 Midwifery
practice
Evidence presented
that SOM team is
involved in all
aspects of audit –
record keeping
Administration and
storage of CDs
Midwifery practice
management
strategy but not
correctly
described
New guidelines
published over
the year have
SOM involvement
in either
development or
dissemination
(not both)
Evidence that one
audit has been
completed over
the year
1g)
Evidence presented to
demonstrate SOM
effectiveness in
ensuring safe practice
Evidence that the
SOM team have
raised concerns to
their employer
regarding resources
and equipment and
There is some
evidence that
SOMs have
raised concerns
to their employer
regarding
There is no
evidence that
such matters have
been escalated to
the employer
Not Met
There is no
evidence that the
SOM team have
been involved in
the development
or dissemination
of new guidelines
over the last year
There is no
evidence that the
SoM team have
been involved in
audit as expected
over the last year
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London LSA Audit Tool Criteria Revised November 2015
Criteria to be audited
SoM team self
assessment
including their
comments and
submitted evidence
Measurement
LSA verification and
comments
Met
Requires
Improvement
with respect to
escalating concerns
regarding lack of
equipment and
resources
1h)
There is evidence
presented that there are
clear processes for
reviewing concerns
regarding midwifery
practice
that there are clear
outcomes as a result
resources and
equipment but
there has been no
follow up or
practice change
as a result
Evidence is not
clear regarding
the process for
SOM team to
review all
incidents and
complaints
regarding
midwifery practice
1i)
Evidence presented
that the SOM team
undertake SOM
investigations (as per
rule 10 MRS 2012, NMC
2012)
Evidence that FTP
spread sheet and
LSA database are
maintained and up to
date
Evidence that
FTP spread sheet
and LSA
database are not
maintained and
up to date
No FTP spread
sheet has been
presented
75 – 100% SOM
investigations have
been completed
within 45 days
50 - 74% of SOM
investigations
have been
completed in 45
days
Less that 50% of
SOM investigations
have been
completed in 45
days

SOM investigations
are completed as
per guidance
(within 45 days)
Evidence that there
is a clear process for
SOM team to review
all incidents and
complaints which
highlight concerns
regarding midwifery
practice
Not Met
There is no
evidence that
there is a process
in place to review
incidents and
complaints
regarding
midwifery practice
concerns
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London LSA Audit Tool Criteria Revised November 2015
Criteria to be audited
SoM team self
assessment
including their
comments and
submitted evidence
Measurement
LSA verification and
comments
Met
Requires
Improvement
Not Met

outcomes such a
LSA practice
programmes and
local action plans
are managed
appropriately
LSA database has
been maintained by
each SOM involved
a SOM investigation
50% of all SOM
investigations
over the last year
have been
inputted on to
LSA database
Less than 50% of
all SOM
investigations
over the last year
have been
inputted on to the
LSA database

Investigations are
allocated fairly
amongst the SOM
team
Investigations are
fairly allocated
amongst the SOM
team
The majority of
SOM
investigations
have been
allocated to the
same SOMs
A small proportion
of the team are
undertaking more
than 50% of all
SOM
investigations

Draft SOM
investigation
reports are edited
by the relevant
LSA support SOM
All draft SOM
investigation reports
have been reviewed
by the relevant LSA
support midwife
LSA support
midwife reviewing
majority of SOM
investigation
reports
LSA support
midwife reviewing
less than half of
all SOM
investigation
reports
There is evidence
that SOMs are
involved in all
incidents where
there are concerns
regarding midwifery
practice in the Risk
Management
Less that 50% of
incidents
reviewed by Risk
Management
team include a
SOM in the
process to review
midwifery practice
No evidence
exists of a SOM
involved in any
Risk Management
investigations
1j)
Evidence that SOMs
provide expertise
regarding review of
midwifery practice
concerns in relation to
Trust clinical
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London LSA Audit Tool Criteria Revised November 2015
Criteria to be audited
SoM team self
assessment
including their
comments and
submitted evidence
Measurement
LSA verification and
comments
governance processes
1k)
Evidence that all
members of the SOM
team have attended an
update or training over
the year regarding
undertaking a SOM
investigation
Met
process
75 -100% SOM team
presented in their
PREP that they have
attended a FTP
update / master
class
Requires
Improvement
Not Met
50 - 74% SOM
team presented in
their PREP that
they have
attended a FTP
update / master
class
Less than 50%
SOM team
presented in their
PREP that they
have attended a
FTP update /
master class
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London LSA Audit Tool Criteria Revised November 2015
Domain 2: The Profile and Effectiveness of Statutory Supervision of Midwives
Supervisors of Midwives are directly accountable to the Local Supervising Authority for all matters relating to the statutory
supervision of midwives and a local framework exists to support the statutory function
Criteria to be audited
SoM team selfassessment including
their comments and
submitted evidence
2a)
Evidence to demonstrate
that SOMs are responsible
for ensuring that the LSA
database is updated and
maintained
The LSA audit team will
review this evidence on the
LSA database as part of the
audit process
LSA
verification
and comments
Measurement
Met
Partially Met
Not Met
SoM to Midwife
ratio of 1:15 or
less
Ratio of SoM to
Midwife > 1:15
and up to 1:19
Ratio of SOM to
midwife is > 1:20
Every midwife in
the maternity unit
has a named
SOM
Every midwife has
a current ITP
There are < 5
midwives who do
not have a named
SOM
There is 1 midwife
who does not
have a current
ITP
There are >5
midwives who do
not have a named
SOM
There are > 5
midwives who do
not have a current
ITP
Every midwife has
had an annual
review in the last
12 months within
the maternity unit
There are < 5
midwives in the
maternity unit
whose annual
reviews are out of
date
99 – 80% of SOM
team completed
PREP activities
on database as
well as their
activity sheet on
the LSA database
There are >5
midwives in the
maternity unit who
annual reviews
are out of date
Every SOM has
completed their
PREP activities
on the database
as well as their
monthly activity
sheet on LSA
database
<80% of SOM
team have
completed PREP
activities on
database as well
as their activity
sheet on the LSA
database
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London LSA Audit Tool Criteria Revised November 2015
Criteria to be audited
SoM team selfassessment including
their comments and
submitted evidence
2b)
Evidence to demonstrate
resources to support
effective statutory
supervision of midwives
LSA
verification
and comments
Measurement
Met
Partially Met
SOM on call list
demonstrates that
all members of
the SOM
participates in the
on call rota
Review of activity
sheets
demonstrate that
all SOMs have
designated time
per month for
supervisory
activities
SoM on call list
demonstrates that
1 SOM does not
participate in on
call rota
2 or more SOMs
do not participate
in the on call rota
Review of activity
sheets
demonstrate that
99% to 80% of
SOMs have
designated time
per month for
supervisory
activities
There is
occasional
administrative
support for the
SoM Team
There is an area
for SOMs to use
for supervisory
activities but not
available at all
times
Not every student
cohort has a
named SOM
Review of activity
sheets
demonstrate that
<80% of SOMs
have designated
time per month for
supervisory
activities
There is
designated
administrative
support for the
SOM team
There is a
designated area
for SOMs to use
for supervisory
activities
Every student
midwife cohort
has a named
SOM
Not Met
There is no
administrative
support for the
SoM Team
There is NO
designated area
for SOMs to use
for supervisory
activities
None of the
cohorts of student
midwives has a
named SOM
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London LSA Audit Tool Criteria Revised November 2015
Criteria to be audited
SoM team selfassessment including
their comments and
submitted evidence
2 c) Evidence to
demonstrate SoMs are
involved in networking
activities
LSA
verification
and comments
Measurement
Met
Partially Met
Not Met
Arrangements for
changing named
SOM are evident
and midwives are
aware
Arrangements for
changing named
SOM are evident
but midwives are
not aware
Every SOM has
attended a sector
meeting in the last
year
75% or above
SOMs have
attended a sector
meeting in the last
year
There are no
arrangements for
changing named
SOM are evident
and midwives are
not aware
< 75% of SOMs
have attended a
sector meeting in
the last year
SOM team can
demonstrate
communication
with London LSA
Every SOM has
attended a
conference in the
last 2 years
2 d) Evidence of an action
plan, following the LSA
audit, which includes
evidence of progress and
achievement of actions
There is an up to
date action plan –
with evidence of
progress and
achievement of
actions
SOM team do not
communicate with
London LSA
Less than half of
SOM team have
attended a LSA
conference in the
last year
There is an action
plan but no
evidence of
progress and
achievement of
actions
No SOM have
attended a LSA
conference in the
last year
There is NO an
action plan but no
evidence of
progress and
achievement of
actions
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London LSA Audit Tool Criteria Revised November 2015
Criteria to be audited
SoM team selfassessment including
their comments and
submitted evidence
2 e) Evidence to
demonstrate SoMs are
following LSA guidance in
relation to nomination,
selection, appointment of
future SoMs and
succession planning in
order to achieve the ratio of
1:15 (supervisor to
midwife)
2 f) Evidence to
demonstrate proactive and
supportive supervisory
initiatives:
LSA
verification
and comments
Measurement
Met
Partially Met
Not Met
Nomination,
selection and
appointment of
future SOMs
occur as per LSA
guidance
Nomination,
selection and
appointment of
future SOMs does
not occur as per
LSA guidance
There is a robust
succession plan
demonstrated
There is not a
robust succession
plan demonstrated
SoM team create
regular and varied
opportunities for
midwives to
reflect on practice
Reflective
sessions are
offered by the
team on an ad
hoc basis.
Reflective
sessions offered
on ad hoc basis
prior to the audit
date
Any local action
plans have been
signed off in the
LSA database
Any local action
plans have not
been signed off in
the LSA database
There is an
absence of
supportive action
plans
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London LSA Audit Tool Criteria Revised November 2015
Criteria to be audited
SoM team selfassessment including
their comments and
submitted evidence
Please include any other
local examples to
demonstrate proactive
supervisory initiatives
LSA
verification
and comments
Measurement
Met
Partially Met
Not Met
Student Midwives
have a SoM, have
had a significant
meeting (maybe
in a group
situation) and are
aware of how to
contact both their
own and an oncall supervisor if
required
Student midwives
have a cohort
SoM know who it
is but have not
had a significant
meeting with
her/him, and are
aware of how to
contact a
supervisor if
required
Student midwives
cannot identify
their named SoM
have not met with
them, and are
unclear about
contacting a SoM
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London LSA Audit Tool Criteria Revised November 2015
Domain 3: Team Working, Leadership and Development
Supervisors of Midwives provide professional leadership and nurture potential leaders
Criteria to be audited
SoM team self
assessment, including
their comments and
submitted evidence
LSA verification and
comments
Measurement
Met
Partially Met
Not Met
Attendance at SOM
meetings
There is a
minimum of 75%
attendance at
SoM team
meetings over
the year by each
SoM
Attendance at
SoM team
meetings
averages 60 –
80%
Attendance at
SoM team
meetings is
sporadic by
many team
members. Any
meeting is
cancelled
because of not
being quorate
Equitable SOM
caseloads (cross ref
2a)
There is equity in
caseloads with
variation
between
supervisors
caseloads not
exceeding six
midwives
Caseloads are
unevenly spread
with variation in
up to 10
midwives seen.
Plans to address
this are in place
Caseloads show
wide variation
with no plan in
place to improve
equity
3 a) Evidence of effective and equitable teamwork
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London LSA Audit Tool Criteria Revised November 2015
Criteria to be audited
SoM team self
assessment, including
their comments and
submitted evidence
LSA verification and
comments
Measurement
Met
Partially Met
Not Met
FTP investigation
spread sheet to
demonstrate equity in
allocation of
investigation
workload
(Cross ref 1d)
The investigation
workload is
evenly spread
throughout the
team
Investigation
workload is
mainly spread
out, some SoMs
not undertaking
investigations
because of
conflict with
substantive post.
Investigations
are generally
done by a few
members of the
team
Facilitated away day
to develop SOM team
The team have
attended an
away day with at
least 90% of
SoMs in
attendance.
There are clear
outputs from the
day
Team away day
with 70 – 90%
attendance by
SoMs. Outputs
from the day are
present but not
well defined
No team away
day, or is poorly
attended (<70%)
and few or no
outputs apparent
from day
The SOM team is an
example of effective
teamwork and transfer
these skills to
ensuring high quality
multidisciplinary team
work
Meetings are run
effectively i.e.
defined agenda,
actions, decision
making, run to
time, process for
agenda and
minute taking
and distribution,
terms of
reference agreed
and kept to
Meetings run
reasonably well,
there is an
agenda and
minutes which
are distributed.
Actions may not
be clear or
followed up to
ensure
completion.
Terms of
reference are not
Meetings are not
well run.
Minutes and
agenda are
managed in an
ad hoc way.
Actions are not
followed up and
meetings are not
described as
productive by the
majority of the
team.
Teams should include
any other evidence
that shows team
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London LSA Audit Tool Criteria Revised November 2015
Criteria to be audited
SoM team self
assessment, including
their comments and
submitted evidence
LSA verification and
comments
Measurement
Met
Partially Met
Not Met
well known by
the team
functioning in a
cohesive and effective
manner to support
midwifery practice
and services
3b) Examples to include the demonstration and development of leadership skills
SoM involvement in
identifying and
encouraging future
SoMs to undertake the
preparation of
Supervisors of
Midwives course
Cross ref with 2e
SoM involvement in
providing mentorship,
support and
preceptorship for
student midwives,
student SoMs and
newly qualified SoMs
and post qualifying
midwives
Teams show
awareness of
recruitment
needs and are
constantly talent
spotting and
developing
midwives
Teams recruit in
an adhoc way
when need is
pressing
Teams struggle
to recruit and
show few
initiatives in
developing staff
SoM team are
engaged in
strategies to
support
Midwives,
students, student
SoMs and newly
qualified
midwives in
practice and in
understanding
Team are
involved in
teaching and
support
strategies for
midwives,
students, student
SoMs and newly
qualified
midwives but
may not reach all
Teaching and
support
strategies are
are limited to
midwives
mandatory
training sessions
16
London LSA Audit Tool Criteria Revised November 2015
Criteria to be audited
SoM team self
assessment, including
their comments and
submitted evidence
LSA verification and
comments
Measurement
Met
Partially Met
supervision
groups, or that
many from any
one group
Strategies
include
developing skills
in working with
women at risk of
knowing less
(English is not
their first
language),
vulnerable
women, keeping
normality in the
face of
complexity
Leadership on SOM
initiatives across the
Trust
SoM team
demonstrate
active leadership
in a variety of
initiatives to
improve the
quality of the
service as
Supervisors
rather than in
substantive
roles. Can
Not Met
Strategies tend
to be restricted
to classroom
teaching
sessions
Team
demonstrate
leadership in
initiatives, but
this is limited in
range and
unclear with
respect to
substantive
posts. Results
may not be very
well presented
Team leadership
is limited to
initiatives that
are dependent
on SoMs
substantive post.
Lacks range no
evidence of
results
17
London LSA Audit Tool Criteria Revised November 2015
Criteria to be audited
SoM team self
assessment, including
their comments and
submitted evidence
LSA verification and
comments
Measurement
Met
Partially Met
Not Met
demonstrate
results of such
work.
Representation from
SOM team to Trust
Board to present
Annual Report
Members of the
SoM team, other
than the HoM
present the
teams annual
report, which
incorporates the
LSA audit
recommendation
s and findings, to
the Trust board
Annual report or
the LSA audit
report are
presented to the
board may be by
the HoM.
There is no
presentation to
the Trust Board
Representation on
LSA wide
projects/initiatives
which could include:
-Conference planning
-Piloting new tools
-Task specific working
parties
-Hosting Network
Meetings
SoM team are
actively engaged
with the LSA in
attending and
supporting at
least two
events/teaching/i
nitiatives.
(Some may be
by email).
SoM team attend
LSA conference
and other LSA
teaching
opportunities.
Minimal
feedback/contrib
ution to initiative
development
Team attend
LSA conference,
engagement with
LSA outside of
this is limited
Team should Include
other local examples
of team working &
Midwives are
able to recognise
and value the
contribution that
Midwives
understand and
believe that
SoMs are active
Midwives have
little sense of the
contribution that
SoMs make to
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London LSA Audit Tool Criteria Revised November 2015
Criteria to be audited
SoM team self
assessment, including
their comments and
submitted evidence
LSA verification and
comments
Leadership
development
Measurement
Met
Partially Met
Not Met
their SoM team
make to the life
of the unit
in the unit but
are not able to
clearly describe
the contribution
they make to the
life of the unit
the life of the unit
and any
initiatives that
the team have
involved in
There is SoM
representation
on at least two
AEI meetings
SoM team attend
one AEI meeting
may be in
substantive role
No SoMs attend
any AEI meeting
SoMs teach on
student Midwife
course each
year
Supervisors may
have some input
on student
midwives course
Supervisors do
not teach
student
midwives
3c) Evidence to demonstrate SoM interface with AEIs, examples could include:
SoM involvement in
curriculum
development and
curriculum review of
education
programmes
Teaching/assessing
initiatives to support
student midwives in
the supervisory
framework
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London LSA Audit Tool Criteria Revised November 2015
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
SoM team self
assessment, including
their comments and
submitted evidence
LSA verification and
comments
Measurement
Met
Partially Met
Not Met
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
The SoM team
will work well
with women
when
opportunities
present
themselves and
try to advocate
for women’s
views on some
projects
The SoM team
work with
women
effectively when
asked to, tend
not to advocate
for women’s
views in project
work/service
development
4a) Examples should include:
SOMs are
ambassadors for
treating women with
kindness and respect
and lead on
improvements in
partnerships with
service users and
management
Contacts
between SoMs,
Midwives and
Women are not
all led by
Supervisors but
show midwives
and women find
Contacts
between SoM’s
and women and
midwives tend to
be initiated by
SoM’s
Team have
limited evidence
of contacts with
women and
midwives
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London LSA Audit Tool Criteria Revised November 2015
Criteria to be audited
SoM team self
assessment, including
their comments and
submitted evidence
SoM involvement with
the user forums such
as the MSLC
The SOM team
actively recruit for
their user forums
such as the MSLC
SoM are accessible to
women, e.g. web link,
user strategy, user
information
LSA verification and
comments
Measurement
Met
the team
accessible and
approachable
The SoM team
have a minimum
90% attendance
at MSLC
meetings and
are active
contributors eg
sharing their
LSA audit and
annual report
and seeking
MSLC
contributions
The SoM team
are actively
involved in
recruitment for
the MSLC or
other user
groups
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
Partially Met
Not Met
SoM team attend
the MSLC on 75
– 90% of
occasions.
Contribution is
limited
SoM team attend
less than 50 %
of MSLC
meetings
SoM team are
occasionally
helpful to MSLC
recruitment
SoM team do not
participate in
MSLC
recruitment
SoM team have
posters up and
information on
the website.
NMC leaflet is
available in ad
hoc way
The team are not
well publicised in
the unit and
women have a
mixed
experience of
getting hold of a
supervisor, NMC
leaflet is not
available
Web information
is present, not
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London LSA Audit Tool Criteria Revised November 2015
Criteria to be audited
SoM team self
assessment, including
their comments and
submitted evidence
LSA verification and
comments
Measurement
Met
Supervisors are
easy to find on
the Trust web
pages and have
a range of
welcoming
information
available to
women including
when to call,
how to call and
links to a variety
of useful
information
Examples of SOM
advocacy for women
for example, care
planning and
supporting women’s
choices including
place of birth
SOMs are proactive in
the promotion of
SoM team
demonstrate
multiple
examples of
involvement in
supporting
women’s choices
including care
planning and
multi-disciplinary
working, may
include place of
birth, vulnerable
women etc
The team have a
strategy and
action plan
Partially Met
necessarily easy
to find and
limited in
content. Contact
details are clear
and when to call
Not Met
Information
about services
on the web is
poor quality,
limited and hard
to find
Limited
examples
presented of
care planning
and supporting
women’s choices
Team do not
present
examples of
supporting
women’s choices
or participation in
care planning
Team support
normal birth and
are engaged
Team support
normal birth but
evidence of
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London LSA Audit Tool Criteria Revised November 2015
Criteria to be audited
SoM team self
assessment, including
their comments and
submitted evidence
Normal Birth
LSA verification and
comments
Measurement
Met
Partially Met
Not Met
around
supporting
normal birth,
show leadership
in the area, and
are looking at
ways to facilitate
midwifery led
care.
with some
activity, but have
limited strategy
and leadership
activity limited or
absent or
unclear in
relation to
substantive role
Environments for
care are
orientated to the
needs of service
users and are
flexible even
when high levels
of intervention
are required
Some
environments
are womencentred, others
less so and there
are plans to
address those
that need
development
Environment for
care is medical
and
institutionally
orientated,
inflexible and
there are no
plans for change
4 b) Evidence to demonstrate SoM activities in response to user surveys/views and action plans, any other evidence
Service Users views
are sought out to
drive service
development
The SoM team
collect
information
about service
users views and
formulate an
action plan on
the basis of this
Service users
views are sought
out but there is
lack of action on
the results
Service users
input is collected
by the Trust,
SoM’s are aware
of this and may
support it but the
team do not
make use of the
data
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London LSA Audit Tool Criteria Revised November 2015
Criteria to be audited
SoM team self
assessment, including
their comments and
submitted evidence
LSA verification and
comments
Measurement
Met
Partially Met
Not Met
SoMs have been able
to access the views of
seldom heard and
vulnerable groups of
women.
Service users
who are hard to
reach are
actively sought
out for their input
Service users
who are harder
to reach are not
well represented
in such activities/
feedback
There is no
attempt to reach
a variety of users
of the service
Users’ input has been
accessed during the
development of SoM
strategy and
guidelines
The SoM team
act to engage
users in service
developments
including
guidelines,
leaflets,
refurbishment,
re-organisation
etc
Service users
input is sought
on some
occasions to
support service
developments
but tends to be
limited
Service users
input is collected
by the Trust,
SoM’s are aware
of this and may
support it but the
team do not
make use of the
data
No reference or
acknowledgeme
nt is made of the
lay auditors
contribution to
previous audits
Women and
families are
generally not
informed when
an investigation
into their care is
undertaken
4c) Supervisory
investigations should
include the offer to
the family of obtaining
their account of their
experience
The lay auditors
report is included
in the team
strategy
Women whose
care is subject to
investigation are
all offered the
opportunity to
contribute to the
process and are
fedback to
The Lay auditors
report is not
specifically
attended to in
the teams
strategy
Some families
are contacted
when their care
is subject to
investigation but
this is not
monitored and
they may not be
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London LSA Audit Tool Criteria Revised November 2015
Criteria to be audited
SoM team self
assessment, including
their comments and
submitted evidence
LSA verification and
comments
Measurement
Met
Partially Met
Not Met
asked if they
wish to
contribute
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London LSA Audit Tool Criteria Revised November 2015