Informal LSA Audit

2011 - 2012

Shetland LSA

29/03/2012

LSAMO - Mary Vance

North of Scotland Local Supervising Authority Consortium

Contents

1 Introduction..................................................................................................................... 3

2 Purpose of the Informal Audit.......................................................................................... 3

3 Supervisors key achievements and challenges from the previous year........................... 4

4 Evidence of progress with actions resulting from recommendations from the 2010-

2011 LSA audit report ..................................................................................................... 6

5 Evidence of progress with actions resulting from recommendations from the NMC

Review visit in July 2011................................................................................................. 8

6 Supervisory investigation process................................................................................. 14

7 Conclusion.................................................................................................................... 15

8 Appendices...................................................................................................................... i

Appendix 1: Notification of LSA Audit...............................................................................ii

Appendix 2: Informal Audit Programme........................................................................... iii

Appendix 3: Flowchart for SUIs.......................................................................................iv

Appendix 4: Trigger List ...................................................................................................v

1 Introduction

1.1 It is anticipated that Supervisors of Midwives (SoMs) work to a common set of

standards to empower midwives to practise safely and effectively and thereby protect

the public. Each year the Local Supervising Authority (LSA) is required to submit a

written report to the Nursing and Midwifery Council (NMC) to notify it about activities,

key issues, good practice and trends affecting maternity services in its area. To inform

this process the LSA Midwifery Officer (LSAMO) will undertake audits1 of maternity

services within the North of Scotland LSA Consortium.

1.2 The process for the informal LSA audit takes a self/peer review approach verification of

evidence by the LSAMO. Self/peer review is recognised as a powerful tool that

stimulates professional development and decentralises power creating awareness of

personal accountability. 2 3 4

1.3 The informal audit for Shetland LSA, which was scheduled to take place on

29/03/2012, went ahead as planned.

2 Purpose of the Informal Audit

2.1 The purpose of the audit was to

• To hear the supervisors key achievements and challenges from the previous year

• To review progress with actions resulting from recommendations from the

previous year’s LSA audit visit, with the team of supervisors of midwives.

• To review progress with actions resulting from recommendations from the NMC

Review visit in July 2011

• Have a discussion with the supervisors in relation to the LSA Database

• Have a discussion with supervisors in relation to the supervisory investigation

process in particular

− the process of identifying cases

1 NMC 2004 Midwives rules and standards p 31. London: NMC

2 Cheyne H., Niven C. & Mc Ginley M. 2003 The peer project: a model of peer review. British Journal of Midwifery. 11

(4) 227-232.

3 Malkin K.F. (1994) A standard for professional development: the use of self and peer review; learning contracts and

reflection in clinical practice. Journal of Nursing Management. 2 (3) 143-148.

4 Ackerman N. (1991) Effective peer review. Journal of Nursing Management. 22 (8) 48A-49D.

4

− the process of notifying the LSAMO of all SUIs and supervisory

investigations

− the decision making process of whether or not to investigate

− the use of the LSA Database in relation to the investigation process

− data in support of the local process – e.g. range of samples of reviews

undertaken to date

− identification of good practice and how this is cascaded

− identification of trends and how they are acted upon/ monitored

• Have a discussion with the supervisors in relation to annual LSA statistical

returns for the annual report to the NMC

3 Supervisors key achievements and challenges from the previous

year

3.1 Key Achievements include

• The profile of statutory supervision has been raised to executive level at the

Health Board.

• Risk management meetings open to all staff

• SoMs are involved in policy development for the Health Board which has been

driven by strategic direction and incident reviews. eg guidelines for

− Home birth

− Cardiotocograph

− Declining treatment against medical advice

• Two student SoMs commenced course at Robert Gordon University, one has

completed the course and is awaiting notification from the university, he other will

complete the course later this year

• Training sessions

− new policies

− explanation of the audit process and findings

3.2 Planned activity includes

• Case note review at risk management meetings

• Finalise development of guidelines for

− Perinatal mental health

− Early pregnancy loss

5

3.3 Challenges include

• midwives perception of how practice is being scrutinised through supervision and

risk management

• conflict of roles for consultant midwife who is a Supervisor of Midwives and has a

management role

4 Evidence of progress with actions resulting from recommendations from the 2010-2011 LSA audit report

STANDARD RECOMMENDATION ACTION PROGRESS Achieved

2 SoMs need to ensure that

the strategy for

supervision is ratified and

then implemented

Strategy to be formatted as per

NHS Shetland policy.

Strategy to be presented at

ANMAC for discussion.

Strategy to be presented at

Clinical Governance Committee.

Strategy to be presented to NHS

Shetland health board for

ratification.

March 2011 Strategy formatted as per NHS Shetland policy.

It has been presented and passed by ANMAC with no

changes.

The Strategy has been presented to Clinical Governance

Committee and will now go to the Strategy and Redesign

Committee on May 8th 2012 for ratification.

MET

2 SoMs should monitor the

secretarial support

available to them in their

administrative role.

All SOM’s record amount of time

spent doing secretarial tasks

monthly in Supervisory statistics

sheet.

March 2011 All SOM’s complete activity sheets. These are

then audited for secretarial time. Maternity Unit ward clerk

also used as workload allows.

Activity sheets continue to be completed. Maternity Unit

ward clerk still used as time permits. Consultant Midwife’s

secretary used as necessary.

MET

7

STANDARD RECOMMENDATION ACTION PROGRESS Achieved

5 SoMs should consider

having a shared space on

Health Board Intranet for

maternity

services to include

information/ tools for

supervision, risk

management , notes of

meetings etc

Kate Kenmure and Elaine

McCover to liaise with IT

department re supervisory space

on the intranet.

March 2011 NHS Shetland IT department currently

reviewing use of intranet.

Review now complete Kate Kenmure and Elaine McCover

will liaise with IT department re intranet space. The SOM’s

will discuss the use of space on the North of Scotland

Consortium web page as an interim measure.

MET

5 Evidence of progress with actions resulting from recommendations from the NMC Review visit in July

2011

Recommendation Action Target Key Performance Indicators

Progress On Action

Supervisor of midwives role, workload and administrative support

1 Ensure that SoMs continue to get identified and protected (designated) time for supervision.

If they are unable to do this ensure there are clear reporting mechanisms for SoMs and that these are used to alert the LSAMO

LSA will ensure that supervisors of midwives receive an appropriate amount of protected time to enable them to undertake their supervisory role.

SoMs will report to LSAMO when they are not able to get identified and protected time for supervision

Reporting mechanism to be set up in order to alert LSAMO

LSAMO will monitor whether or not the Supervisors of Midwives receive their protected time at the annual LSA audit

LSAMO will impact assess the effect of Supervisors of Midwives not being able to take their protected time

5 hours per week

100% of supervisors receive protected time

LSA has knowledge of when Supervisors of Midwives are unable to take protected time and the impact this has on supervision and public protection.

All SOM’s record protected time on Supervision Activity sheets.

If allocated time cannot be taken due to clinical workload the SOM informs her line manager and the LSAMO.

March 2012 Remains as above SOM’s continue to complete Supervision Activity sheets informing line manager and LSAMO if allocated time cannot be taken due to workload.

SOM’s will discuss introducing a balance score card to record information from April to March.

9

Recommendation Action Target Key Performance Indicators

Progress On Action

2 Monitor and audit the arrangements for 24 hours availability of a SoM for midwives and women

Supervisors undertake an audit of response times to all calls made through the on call rota

31/03/2012 Audit demonstrates that midwives and the public are able to contact a SoM within a reasonable time frame.

ON-call SOM rota available in each midwifery area.

Women are provided with information on where and how to contact a SOM at booking

March 2012 On call rota displayed within Maternity Unit and emailed to all midwives. A rota is also available at hospital reception. This audited on a six monthly basis.

Women receive NMC, North of Scotland LSA consortium booklets and business card with Supervisor’s contact details on them. Midwives discuss how women may contact an SOM at booking.

3 Ensure that the SoM to midwife ratio reflects local need and circumstances (will not normally exceed 1:15)

No action required 1:8 achieved

LSA Data Base accurately reflects case load ratios

Fully achieved - evidence on the LSA Data Base

March 2012 As above.

Investigations and reporting of incidents

4 Ensure all supervisors are appropriately trained, prepared and supported for their role in a supervisory

• LSAMO provides workshops in supervisory investigations

• LSAMO to proceed with plan to implement training in report writing

100% attendance at workshops

Audit number who attend the workshops

All Shetland SOM’s and student SOM’s took part in training for Supervisory investigations in August 2011 in Lerwick.

Continued support with incidents available

10

Recommendation Action Target Key Performance Indicators

Progress On Action

investigation

following supervisory investigations

• LSAMO to give continued support to SoMs

from LSAMO

March 2012 Remains as above.

5 Ensure their incident reporting and recording systems and procedures include a process to inform the LSAMO if the issue has the potential to result in a SoM investigation

Review of case done weekly, if not before depending on the case.

In place/ ongoing

Documented evidence of reporting system available to LSAMO at LSA audits

LSAMO is informed through the LSA Database of all SUIs, Maternal Deaths and supervisory investigations

Shetland use Datix reporting system, there are issues to be addressed with staff reporting incidents as they arise which will be reiterated to staff over the coming few weeks.

Trigger List and incidents give consideration to SOM and LSAMO input as does attendance at Clinical governance meetings which has SOM input

March 2012 Continue to use Datix system for reporting adverse incidents using a Trigger List. SOM’s have designed a Supervisory Investigation Toolkit which incorporates a Trigger List, SUI flowchart, Guideline L and Guideline L (a). A copy of this is kept in the supervision cabinet in the Maternity Unit office.

6 Ensure that all the SoMs monitor and audit the requirements of rule 7.1, (reporting of serious incidents). Using the national LSAMO Forum (UK) guideline and the local

Local procedures are in place for reporting SUIs, maternal deaths and supervisory investigations

In place/ ongoing

All Supervisors of Midwives monitor and audit the requirements of rule 7.1,

Documented evidence

A copy of this is in each local area

March 2012 Continues as above.

11

Recommendation Action Target Key Performance Indicators

Progress On Action

procedures that are in place and the LSA database (as appropriate) as part of this process

available at LSA Audits

User involvement

7 Further develop the mechanisms for involving service users in all LSA audits, local supervisory audits and the procedures for the preparation of SoMs

Ask users if they are interested in being involved in LSA audits.

Provide information on how to become involved with LSA Audits

Ongoing

At least one service user agrees to be involved in audits

Currently involved in Maternity Forum meetings and local audits as required.

Consider presentation on SOM role at next planned meeting of Maternity Forum.

March 2012 Service users currently attending Maternity Forum meetings One SOM always present at meetings.

Kate Kenmure has engaged with local media to promote Maternity service.

The SOM’s plan to give a presentation to the local Maternity Forum.

The SOM’s will seek to identify women who may wish to help design a service users questionnaire.

8 Further develop the mechanisms for informing service users and the public

Extra hard copies of the annual report will be printed to ensure copies are in

Ongoing It is evident at LSA audits that service users and the public are better informed

Women informed at booking and details given of how to contact a SOM, via NMC

12

Recommendation Action Target Key Performance Indicators

Progress On Action

about statutory supervision all clinical areas. about statutory supervision leaflets and NOS leaflet

March 2012 Supervision is discussed with women at booking. Women are given the NMC, North of Scotland consortium LSA leaflets and a business card with SOM’s contact details.

Posters are currently displayed within the Maternity Unit and all health centres promoting supervision.

SOM’s will investigate the possibility of designing a web page linked with the North Of Scotland LSA consortium.

SOM’s will consider attaching stickers to all hand held Maternity notes with SOM contact details.

Promotion and sharing of best practice

9 Ensure widespread promotion and attendance on the leadership development programmes to enhance the leadership skills of all SoMs

Explore appropriate on-line courses in leadership

Ongoing Evidence from Personal Development Plans

One SoM has undertaken the Open University module in developing leadership potential.

March 2012 SOM’s continue to discuss how to develop leadership strategies

13

Recommendation Action Target Key Performance Indicators

Progress On Action

within the supervisory framework.

One SOM attended the NES midwifery leadership event in November 2011.

10 Explore further opportunities to promote and share the evidence of its improved and innovative practices across the consortium, at professional networking events in Scotland and at conferences across the UK.

Identify appropriate events/ forums for the sharing of good practice/ innovation

Ongoing Evidence is provided through the LSA Audits and annual report to the NMC of the continued promotion and sharing of improved and innovative practices across the consortium, at professional networking events in Scotland and at conferences across the UK.

Supervision links to Orkney and Western Isles in place.

March 2012 Supervisory links with Orkney and Western Isles maintained with Island forum.

SOM attends SQIG quarterly

SOM’s will continue to actively investigate opportunities to present good practice.

14

6 Supervisory investigation process

6.1 SoMs are notified of serious incidents via a variety of sources i.e.

• Datix

• Verbally by midwives to the Contact SoM

• Ad hoc i.e. being in the unit when an incident occurs

6.2 The SoMs said that the midwives are getting better at entering incidents onto Datix and

that they themselves feel confident that they are aware of all incidents/ cases that

arise. The SoMs also said that they were planning a study day for staff looking at

scenarios.

6.3 SoM’s in Shetland have designed a Supervisory Investigation Toolkit which

incorporates a Trigger List, SUI flowchart, Guideline L (a) and Guideline L (see

appendices 3 & 4). This is an excellent development which is to be commended

6.4 Review of records is undertaken on a weekly basis, if not before depending on the

seriousness of an incident/ event. When it is identified that a supervisory investigation

is required the SoMs notify the LSAMO through the LSA Database.

6.5 In order to develop knowledge and skills in the investigation process in accordance

with guideline L all Shetland SoM’s and student SoM’s took part in a workshop in

August 2011 delivered by the LSAMO.

6.6 A discussion was held on the use of the LSA Database. The SoMs are experienced in

using the Database for entering intention to practice forms however the process of

notifying the LSAMO of SUIs needs to be strengthened as very few SUIs are entered

onto the LSA Database.

6.7 A discussion was also held on the format and content of the annual report for practice

year 01/04/2011 – 31/03/2012 in accordance with guidance received from the Nursing

and Midwifery Council. This year the LSAMO will provide a report template that the

SoMs will complete then submit to the LSAMO for inclusion in her report to the NMC for

the North of Scotland. The SoMs will be able to use their report to update the Shetland

clinical governance committee of supervisory activities in Shetland.

15

7 Conclusion

7.1 The SoMs are to be commended for their efforts in further developing the supervisory

framework within Shetland LSA.

7.2 There was good evidence of progress with actions resulting from recommendations

from the 2010-2011 LSA audit report and from the recommendations from the NMC

Review visit in July 2011.

7.3 However the SoMs need to address the following recommendations made by the

LSAMO

• The SoMs need to ensure that the planned actions which address the

recommendations the 2010-2011 LSA audit reports are progressed and actioned.

• The SoMs need to ensure that the planned actions which address the

recommendations from the NMC Review visit in July 2011 are progressed and

monitored.

• The process of notifying the LSAMO of SUIs needs to be strengthened to ensure

all incidents are entered on the LSA Database

7.4 Having received this report the SoMs should now compile an action plan that

addresses the areas that require review and improvement, as well ad the LSAMOs

recommendations. This action plan with evidence of progress will be presented as

evidence at the audit for 2012- 2013.

7.5 This report will be published on the North of Scotland LSA Consortium website

i

8 Appendices

ii

Appendix 1: Notification of LSA Audit

Mary E. Vance, LSA Midwifery Officer North of Scotland LSA Consortium, Ar Taigh, 30 Crown Terrace, PORTGORDON, Moray, AB56 5RJ

NORTH OF SCOTLAND

LSA CONSORTIUM

Shetland Supervisors of Midwives Date: 02/12/2011 Your Ref: Our Ref: Enquiries to Carole Saich Extension: 6732 Direct Line: 01463 706732 Email: carole.saich@nhs.net

Dear All

Informal LSA Audit

I can confirm that the date for the informal LSA audit is 29/03/2012

The purpose of the audit is

� To hear the supervisors key achievements and challenges from the previous year

� To review progress with actions resulting from recommendations from the previous year’s LSA audit visit, with

the team of supervisors of midwives.

� To review progress with actions resulting from recommendations from the NMC Review visit in July 2011

� Have a discussion with the supervisors in relation to the LSA Database

� Have a discussion with supervisors in relation to the supervisory investigation process in particular

o the process of identifying cases

o the process of notifying the LSAMO of all SUIs and supervisory investigations

o the decision making process of whether or not to investigate

o the use of the LSA Database in relation to the investigation process

o data in support of the local process – e.g. range of samples of reviews undertaken to date

o identification of good practice and how this is cascaded

o identification of trends and how they are acted upon/ monitored

� Have a discussion with the supervisors in relation to annual LSA statistical returns for the annual report to the

NMC

Please do not hesitate to contact me if you have any queries or need clarification.

Yours sincerely

Mary Vance

LSA Midwifery Officer

North of Scotland LSA Consortium

iii

Appendix 2: Informal Audit Programme

LSAMO INFORMAL AUDIT

29TH March 2012

09:00 - 10:30 Audit

10:30 - 11:00 coffee

11:00 - 12:30 Audit

12:30 - 13:30 Lunch

13:30 - 14:30 Meet with midwives (Maternity Unit)

14:30 - 17:00 Audit (coffee break to be arranged)

iv

Appendix 3: Flowchart for SUIs

Inform

LSAMO

Critical

Incident/ Trigger list

Review

Notes/ Complete

Timeline

Discussion re joint

investigation

Complete SUI using

Guideline L (a)

Supervisory

Investigation

Enter midwifery

investigation on LSA

database

Investigation

Decision made re

Supervisory only or

joint investigation

One to one discussion

with named SOM/

Action plan developed

Time appropriate

review

Debrief team/

individuals

Record on LSA

database

No

investigation

v

Appendix 4: Trigger List

MATERNAL BABY

Maternal death up to one year Cord accident/ prolapse Resuscitation Forceps/ ventouse/ CS Unexpected significant maternal morbidity requiring transfer

Cord Ph < 7.2

Return to theatre Active neonatal resuscitation Significant infection/ wound infection Birth trauma 3rd/4th degree tears Term baby< 2.5kg Trauma to bladder or other organs Term baby> 5kg

Undiagnosed breech Unexplained still birth

PPH (more than 1l if no maternal compromise less than 1l if maternal compromise)

NND neonatal death

Shoulder dystocia Low apgar <6 at 5 minutes DVT/ PE Unexpected neonatal transfer

Drug Error Unplanned home birth

Uterine rupture BOTH

Eclampsia Delay in calling for assistance

BBA Delay following call for assistance

Re-admission of mother or baby Conflicts in decision making Maternal transfer

North of Scotland LSA Consortium is a collaboration between NHS Grampian, NHS Highland, NHS Orkney,

NHS Shetland, NHS Tayside and NHS Western Isles