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Evidence Criteria

Guidance for Evidence criteria

Standard 1 - Women Focused Maternity Services

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

Criterion 1.1

Supervisors of Midwives participate in ‘Maternity User forums’ to ensure , , that the views, and voice of service users inform the development of maternity services.

Criteria for achievement (CNST 3.1.5)

·         Supervisors participate in Maternity Users Forums to ensure that the views and voice of service users inform the development of services.

·         Supervisors participate in groups such as: Labour Ward Forum, Policy groups, Clinical Governance,  Risk Management, MSLC, Perinatal Mortality & Obstetric Audit

.

Comments

Criterion 1.2

Information is available to women including local arrangements for statutory supervision

Criteria for achievement

·            Information available to women provides relevant information regarding local arrangements for supervision

Comments

Criterion 1.3

There is a working philosophy that promotes women and family centred care enabling choice and decision making in individualised clinical care.

Criteria for achievement (CNST 4.1.1)

Guidelines developed by the multi-professional team, including a supervisor, reflect woman and family centred practice that enables individualised care planning and involvement in care

Philosophy of care

Records of supervision involvement regarding decision making in women’s care.

Comments

Criterion 1.4

Supervisors support midwives in promoting informed decision–making about care for women and families.

Criteria for achievement (CNST 4.1.1, 8.1.1)

Supervisors are available to offer guidance and support to midwives.

·            In-service training programmes are available for midwives to ensure their practice is updated and contemporary.

·           Supervisors ensure there is up-to-date appropriate literature and research available and that midwives have access to evidence based databases, etc.

·    , 0;,        Guidelines developed by the multi-professional team reflect woman and family centred practice that enables individualised care planning and involvement in care

Comments


Criterion1.5

Supervisors support midwives in respecting the right of women to refuse any advice given and develop an individualised care plan.

Criteria for achievement (CNST 4.1.1, 8.1.1)

·            Midwives feel confident to inform supervisors about dilemmas in care provision.

Solutions reflect the risk assessments undertaken.

Comments


Standard 2 - Supervisory Systems

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

Criterion  2.1

The supervisory team should be such as to provide a ratio no greater than 1:15 supervisors to midwives.

Criteria for achievement (CNST 8.2.3)

·            Ratio of supervisors to midwives does not exceed 1:15.

·            Rota for 24-hour on-call.

·            Apportion supervisees equitably

Comments

Criterion 2.2

Employers provide designated time for Supervisors of Midwives to undertake their role

Criteria for achievement

Time for supervisory activities is allocated to supervisors and there is evidence of administrative support).

Comments


Criterion 2.3

LSA processes are followed in the nomination and selection and appointment of Supervisors of Midwives.

Criteria for achievement

·            Publish recruitment, selection and appointment procedure.

·            Midwives are encouraged to consider becoming supervisors.

·            Commission adequate places for preparation course.

·            The selection process identified in the national guidance is followed.

·            Trainee Supervisors attend a validated training programme (supported by the LSA)

Comments

Criterion 2.4

Supervisors of Midwives work within the framework of LSA standards, policies and guidelines.

Criteria for achievement

·            Annual Report produced using LSA template, and submitted to LSA by mid-May each year

·            Annual statistics produced and analysed.

·            Action Plans from confidential enquiries

·            Investigations undertaken in a timely manner

·            Advised of new Intention to Practice forms by 20th each month

Comments


Criterion 2.5

LSA guidelines and policies are accessible to midwives and the public

Criteria for achievement

·            All supervisors can access guidelines and use appropriately.

·            Consistent and equitable supervision of midwives is maintained

·             Midwives are aware of the role of statutory supervision and how to contact a supervisor.

Comments

Criterion 2.6

Supervisors of Midwives receive the Intention to Practise (ITP) forms, check for accuracy and validity prior to forwarding them to the LSA, or entering on the LSA database, within the agreed time frames.

Criteria for achievement

·            Midwives complete form and submit to their own supervisor.

·            Supervisor checks and signs form.

·            Unit collects all ITP forms, sorts into alphabetical order and sends original to LSA by 20th (31st) March.

·            As above, but forms submitted to LSA by 20th (10th) of each month.  (Guidelines say 20th)

Comments


Criteria 2.7

Supervisors of Midwives review midwives’ eligibility to practise annually, confirming such through the NMC registration service.

Criteria for achievement

·            System in place to ensure register checked within a week of midwife’s date of re-registration.

·            Change forms submitted to LSA on time.

·            Midwife writes to NMC and Register is maintained correctly.

Comments

Criterion 2.8

Supervisors of Midwives maintain records of supervisory activities that are stored for seven years in such a way as to maintain confidentiality.

Criteria for achievement

·            Policy for the storage of supervisory records is maintained.

·            Evidence of storage for 7 (seven) years. 

·            Secure arrangements to ensure confidentiality is maintained..

·            Policy in place for transfer of midwifery records when midwife leaves/retires, etc.

Comments

Criterion 2.9

Regular meetings between Supervisors of Midwives are convened to share information in a timely fashion and the proceedings are recorded.

Criteria for achievement

·            Meeting dates fixed in advance.

·            All supervisors have an opportunity to attend regularly.

·            Meetings are minuted and action plans formulated.

Comments

Criterion 2.10

Evidence exists that all Supervisors of Midwives engage in networking locally, regionally and nationally.

Criteria for achievement

·            Attendance at LSA study events and meetings.

·            Attendance at national events.

·            Evidence of study, which includes practice and supervisory issues.

Comments

Criterion 2.11

There is a local strategy for supervision and an action plan is developed following audit.

Criteria for achievement

·            There is a local strategy for Supervision.

·            Action plan following LSA supervision audit

.

Comments

Criterion 2.12

Each Supervisor of Midwives has a direct line of communication to the LSA for support and advice.

Criteria for achievement

·            Direct lines of communication are established and supervisor are aware of open access for support and advice

Comments

Criterion 2.13

Each Supervisor of Midwives completes at least 15 hours of approved study in each registration period

·            Submission of completed supervision update form to LSA at end of 3 (three) years.

Comments

Criterion 2.14

Each Supervisor of Midwives meets with the LSA Midwifery Officer locally and through LSA events.

Linked with Criteria 2.10

Comments



Criterion 2.15

Secretarial support is provided for Supervisors of Midwives in their administrative role.

Criteria for achievement

Evidence of Dedicated administrative support for supervision (and there is evidence of administrative support)

Comments


Criterion 2.16

The practice of statutory supervision by each Supervisor of Midwives is subject to audit by the LSA and appropriate action is taken if their performance falls below an acceptable standard.

Criteria for achievement

·            An annual self-audit form will be completed by each supervisor.

Comments


Standard 3 - Leadership

Supervisors of Midwives provide professional leadership and nurture potential leaders.

Criteria

Criterion 3.1

Supervisors of Midwives are perceived as innovators and leaders of midwifery.

Criteria for achievement (CNST 8.2.3)

·            Local initiatives involving supervisors.

·            Leadership development courses

Comments

Criterion 3.2

Through peer or self-nomination future Supervisors of Midwives are identified and supported in their nomination.

Linked to 2.3

Comments

Criterion 3.3

Appropriate mentorship mechanisms are in place to provide leadership for student supervisors undertaking the preparation course.

Criteria for achievement

·            A mentor is chosen by the student supervisor and is available to her throughout the programme.

·            The student supervisor joins the supervisory group, who are all available for support

Comments

Criterion 3.4

Preceptorship is provided for newly appointed Supervisors of Midwives to enable their development as leaders.

Linked with 3.3

Comments

Criterion 3.5

There are supervisory mechanisms to support leadership development in a variety of ways.

Linked with 3.1

Comments

Criterion 3.6

Supervisors of Midwives contribute to the development, teaching and assessment of programmes of education leading to registration as a midwife and the continuous professional development of all midwives.

Criteria for achievement

·            Allocation of supervisors to support student midwives.

·            Involvement with HEIs re return to practice courses and assessment.

·            Involvement in curriculum planning.

·            Involvement in strategy groups to conduct training needs analysis/commissioning.

·            Ensuring midwives remain updated and undertake continuous professional development.

Comments

Standard 4 - Equity of Access to Statutory Supervision of Midwives

Supervisors of Midwives are approachable and accessible to midwives to support them in their practice.

Criteria

Criterion 4.1

There is 24-hour access to Supervisors of Midwives for all midwives irrespective of their employment status.

Link to 1.4

Comments

Criterion 4.2

Each midwife has a named Supervisor of Midwives, of her/his choice, with the option to change to another.

Criteria for achievement

·            Annual form for each supervisor showing midwives supervised and number of reviews achieved.

·            Intention to practice form

·            Welcome letter to new midwives

Comments


Criterion 4.3

Each midwife attends a supervisory review, at least annually, in which her/his individual practice is reviewed and any education and development needs are identified and a written action plan agreed.

Criteria for achievement

·                     Number of reviews achieved.

·                     Reasons for non-achievement of 100%.

·                     Action plan in place to achieve the standard.

·                     Inclusion of date on Intention to Practise form.

Comments

Criterion 4.4

Midwives’ views and experience of statutory supervision are elicited regularly, at least once in every 3 years, and outcomes inform the local strategy for supervision.

Criteria for achievement

LSA Midwives’ Audit form is distributed to a different third of midwives in the Unit each year and audit forms are collected and forwarded to the LSA MO.

Comments

Criterion 4.5

Confidential supervisory activities are undertaken in rooms that ensure privacy.

Criteria for achievement

·            Supervisory reviews to be under taken in an appropriate environment

Comments

Criterion 4.6

Supervisors support midwives in maintaining clinical competence and the development of new skills.

Link to 1.4

Comments

Criteria 4.7

Student midwives are supported by the supervisory framework.

Criteria for achievement

·               Supervisors undertake teaching sessions with student midwives during their training.

·               Student midwives are allocated a named supervisor

Comments

Standard 5 - Midwifery Practice

Supervisors of Midwives support midwives in providing a safe environment for the practice of evidence based midwifery.

Criteria

           

Criterion  5.1

Supervisors of Midwives are involved in formulating policies, setting standards and monitoring practice and equipment.

Criteria for achievement

·            Equipment training is given

·            Equipment is maintained.

·            Supervisors make employers aware when inadequate resources may compromise public safety.

·            Supervisors of Midwives participate in audit

Comments

Criteria 5.2

Supervisors of Midwives participate in developing policies and evidence-based guidelines for clinical practice.

Link to 1.3

Comments

Criterion 5.3

Supervisors of Midwives ensure that midwives are made aware of new guidelines and policies and that all midwives have access to documentation in electronic or hard copy.

Criteria for achievement

·            Newsletter

·            Process for dissemination of guidelines

Comments

Criterion 5.4

Supervisors of Midwives participate in reflective activities that inform and support midwives in practice.

Link 1.4

Comments

Criterion 5.5

Supervisors undertake audit of the administration and destruction of controlled drugs.

Criteria for achievement

·            Audit undertaken

Comments

Criterion 5.6

Supervisors of Midwives make their concerns known to their employer in the maternity service when inadequate resources may compromise public safety.

Link 5.1

Comments

Criterion 5.7

When allegations are made of suspected sub-optimal care an investigation is undertaken by a Supervisor of Midwives and the midwife is offered the support of a named Supervisor of Midwives.

Criteria for achievement

·            SOMs undertake an investigation when allegations are made.

·            The midwives are offered support from another SOM.

·            The LSA is informed if supervised practice is recommended.

·            Action plan and learning outcomes agreed with the midwife.

·            Where professional misconduct or intractable incompetence is alleged, a full report is submitted to the LSA.

·            Reports to LSA when serious untoward incidents occur.

·            Reports to Strategic Health Authority of SUIs and follow-up action plans.

·            Participation in critical incident investigations.

·            Participation in Maternity Services and Trust’s Clinical Governance Framework.

Comments

Criterion 5.8

Pro-active approaches are used to support midwives when deficiencies in practice have been identified.

Linked to criteria 5.7

Comments

Criterion 5.9

The recommendation for a midwife to undertake a period of supervised practice is discussed with the LSA Midwifery Officer, who is also informed when such a programme is completed.

Linked to criteria 5.7

Comments


Criteria 5.10

Allegations of serious professional misconduct are reported to the LSA Midwifery Officer together with a full written report and recommendations and these records are retained for 25 years.

Linked to criteria 5.7

Comments

Criteria 5.11

Supervisors of Midwives notify managers of investigations being undertaken and of action plans agreed.

Link to 5.7

Comments

Criteria 5.12

Clinical Governance strategies acknowledge statutory supervision of midwives.

Criteria for achievement (CNST 1.1.1)

·            Risk management strategy

·            Supervision strategy

Comments


Criteria 5.13

The LSA Midwifery Officer is informed of any serious incident relating to maternity care or midwifery practice.

Linked to criteria 5.7

Comments

Criteria 5.14

Audit of record-keeping of each midwife takes place annually and outcome feedback is provided.

Criteria for achievement

·            Appropriate documentation

Comments

Criteria 5.15

Supervisors support midwives participating in clinical trials ensuring that the Midwives rules and standards and the Code of Professional Conduct are adhered to.

Criteria for achievement

Evidence of ethical approval of clinical trials and supervisory input in the process.

Comments

   

Adopted with the permission of the South of England LSAMO