Healthcare Inspectorate Wales Local Supervising
Authority (LSA) response and action plan to the
Nursing and Midwifery Council report on the review of
the LSA, April 2009
The Nursing and Midwifery Order 2001 requires a Local Supervising Authority
(LSA) to provide statutory supervision for all midwives practising in its
geographical area. In Wales, the Local Supervising Authority is the Welsh
Assembly Government. Healthcare Inspectorate Wales (HIW) has delegated
responsibility from the Welsh Assembly Government to carry out the functions
of the LSA in Wales. The LSA in Wales aims to support midwives in their
practice through a model of statutory supervision that has clear standards and
processes to protect the public but which also proactively supports midwives
to provide with confidence, a high standard of midwifery care with informed
choice for women.
The Nursing and Midwifery Council (NMC) sets standards for midwifery
practice and for Local Supervising Authorities. The LSA standards are set out
in Midwives Rules and Standards (NMC 2004). All LSAs are required by
Midwives Rule 16 to provide an annual report to the NMC detailing how it has
met the standards in a reporting year. The NMC risk assesses each report
and gives a risk score of green, amber or red, against each of the 54
standards that are explicit within the rules.
In addition to monitoring the achievement of standards through Local
Supervising Authority annual reports, the NMC undertakes a review of a
sample of LSAs each year.
NMC review visit April 2009
The NMC risk assessed the LSA in Wales against the Annual Report 2007/08.
Two areas of concern were identified by the NMC and risk scored ‘amber’.
The two areas of concern highlighted were:
• Maternity service/s within the LSA under review by NMC or other
stakeholder or special measures in place
• High or low percentage of supervised practice programmes described
The LSA for Wales Annual Report 2007/08 that gave rise to the risk scores
and subsequent decision to undertake a review can be seen at:
www.hiw.org.uk. The NMC review team visited in April 2009 to review
documentary evidence and to meet with stakeholders.
The LSA team was pleased to participate in the review. The LSA in Wales has
always been proactive in identifying and sharing good practice as well as
taking action to develop and make improvements. It takes an open and
transparent approach to its work through the content of its annual reports and
by information exchange and sharing of experience, actions and outcomes
through the LSA/Contact Supervisors of Midwives forum and the annual
workshop for Supervisors of Midwives. The LSA in Wales volunteered and
subsequently participated in the NMC pilot audit of the LSA standards in
The philosophy that underpins the work of the LSA in Wales is protection of
the public through enabling midwives to be competent and confident in their
practice. The LSA team supports a cycle of review and audit and believes that
this contributes to ensuring standards are met. The LSA in Wales uses its
annual reports to document achievements and evidence that standards have
been met as well as highlighting areas for ongoing improvement and
development. The LSA team is reassured that its own monitoring and audit
processes are sound in that the developmental recommendations made by
the NMC review team are ones that the LSA itself has previously identified
and for which initial action plans have been proactive and follow up work
ongoing and constructive.
In advance of the NMC review visit in April the LSA team completed a self-
assessment against the NMC standards. This self-assessment is included as
an appendix to the LSA Annual Report 2008/09 and can be seen at:
The final report from the NMC review team was sent to the LSA in September.
The NMC review team’s report can be seen in full at www.nmc-uk.org The
report highlights some very positive aspects about the LSA in Wales and the
way in which it functions and strives to meet NMC standards. These include:
• Adoption of the National LSAMO/UK Forum Guidelines
• Separate Healthcare Inspectorate Wales guidelines for statutory
supervision of midwives for local (Wales) use
• The 1:15 ratio of Supervisors of Midwives to midwives is met as an
LSA wide standard with the majority of maternity services providers
achieving this standard on an individual basis
• Leadership awards received by Supervisors of Midwives from Wales
and the importance paid to attendance of Supervisors of Midwives on
• Anticipated use of the new electronic database for the LSA by summer
• User-friendly policy files that are available in both hard copy and
• The selection, appointment and payment of service users to support
the function of the LSA
• Development of Pb Wikki websites to disseminate information
electronically and facilitate discussion and sharing of information
• The all-Wales approach to learning and policy development
• Development of the role of the Contact Supervisor of Midwives over the
past five years
• The cohesiveness of the working of the LSA team
The review team makes three recommendations to meet the NMC standards.
Additional recommendations are made in support of continued development.
Recommendations in order to meet the NMC standards
The review team makes the following three recommendations in order to meet
all fifty four NMC Standards in full:
Rule 12 Standard 5.8. - ‘Monitor the provision of protected time and
administrative support for Supervisors of Midwives’ (Standard partially met)
1. Ensure Supervisors of Midwives have protected time to undertake their
supervisory role and measure the impact when they are unable to take
their protected time due to other priorities.
2. Ensure Supervisors of Midwives receive adequate administrative
support in order to effectively carry out their supervisory role
Rule 13 Standard 6.4 – ‘Provide designated time and administrative support
for a Local Supervising Authority Midwifery Officer to discharge the statutory
function’ (Standard partially met)
3. Ensure adequate administrative support for the LSA team in order to
ensure they are able to carry out their role efficiently and effectively
Appendix 1 details the LSA’s action plan to achieve these three standards in
Recommendations to support continued development
The NMC review team also makes a number of recommendations to support
the continuing development of the LSA. Prior to the review visit the LSA itself
had already identified these as priority areas and was implementing action
plans. A summary of these actions follows:
i ‘Ensure that HIW guidelines for statutory supervision as well as the
recently adopted LSAMO UK Forum Guidelines are embedded into
All Supervisors of Midwives in Wales have a copy of the LSAMO UK Forum
Guidelines. The Guidelines have been introduced and discussed at the
LSA/Contact Supervisors of Midwives Forum meetings since their adoption
(see agendas and notes of the meetings). The meeting of 10th March 2009
discussed Guideline L in detail. LSA audit in 2009/10 will examine
implementation of the Guidelines across Wales.
ii ‘Monitor the notification process and submission of ITP data with the
transfer over to the new electronic database’.
The LSA audit 2009/10 will audit use of the database in a number of areas
including Intention to Practise Notifications and the way in which these are
transmitted to NMC.
iii ‘Expand on the NMC LSA ratio of Supervisors of Midwives to midwives
(1:15) to individual maternity services to avoid variation across the
Variation in ratios, providing the minimum standard is achieved, is accepted
by the LSA as each maternity services provider has different needs.
Maintaining the ratio of Supervisors of Midwives to midwives at the minimum
standard at least, is an ongoing priority for the LSA. A strategy for proactive
recruitment of Supervisors of Midwives will continue in all maternity services
providers but particularly in areas where the ratio is near to the 1:15
standards. Compared to the reporting year 2007/08, ratios were more even
across maternity services providers in 2008/09 with each achieving the
minimum standard of (normally) 1:15.
The LSA welcomes the review team’s recommendation to the NMC that the
1:15 ratio of Supervisors of Midwives to midwives is reviewed to ensure that it
continues to meet requirements and enables effective supervision.
iv ‘Ensure appropriate mechanisms are in place to raise concerns when
protected time for supervisory duties is not able to be taken’.
(see action plan for recommendation 2 in appendix 1)
vi ‘Raise awareness of professional leadership that is associated with the
role of the Supervisor of Midwives’.
Supervisors of Midwives in Wales have been instrumental in leading a
number of initiatives aimed at enhancing midwifery practice and hence care
for women. They have also actively led teams of midwives and other
healthcare professionals to prepare for and implement changes in the NHS in
Wales. Supervisors of Midwives from Wales won a number of awards in
2008/09 that acknowledge their leadership skills. The LSA will continue to
encourage Supervisors of Midwives to raise their profile within the Health
Boards in which they work as well as more broadly. The line between
management and supervision can be a fine one however and it may well be
that in attempting to ensure that midwives and others understand the
difference, the leadership skills of Supervisors of Midwives retain a lower
vii ‘Clarify the difference between supervised practice and developmental
support to ensure the most appropriate outcome is used following a
The clarification between supervised practice and developmental support is
already made by the NMC in the NMC Circular 32/2007, ‘Standards for
supervised practice of midwives’. The LSA implemented the standards with
immediate effect from the date of publication. Eleven midwives undertook a
period of developmental support in 2008/09.
viii ‘Ensure timely communication of concerns about midwifery issues to
The LSA will continue to notify the NMC of relevant concerns about midwifery
issues. The review team confirmed that the LSA met this standard in full and
the evidence was verified by the NMC Midwifery Advisor.
ix ‘Seek to change the title ‘Head of LSA’ to ensure clarity about the role
across the UK, outside the LSA’.
Although the title of the post is an organisational and management issue for
HIW, not an NMC regulatory matter, the Senior Management Team of
Healthcare Inspectorate Wales considered this recommendation. The
decision reached was that the title ‘Head LSA’ accurately reflected the
managerial role of the post and was already embedded in the new
organisational structure for HIW and should therefore remain.
x ‘Ensure the requirements of supervision are taken into account in the
development of an all-Wales data set in order to provide the
consistency required for audit reports and the identification of trends
that affect midwifery practice to be reported on in a timely manner’.
The Welsh Assembly Government has an ongoing project to review the
maternity services data set and the LSA has contributed through meetings
with the project officer. The project officer is an experienced Supervisor of
Midwives with an obvious understanding of the information needs of all
stakeholders. Supervisors of Midwives also report that newly installed
computerised data systems in Health Boards will enable collection and
recording of a wider range of comparable statistics.
More detail regarding plans in place and actions already implemented to
develop the work of the LSA in Wales is given in the LSA Annual Reports
2007/08 and 2008/09 (see www.hiw.org.uk) .
The LSA will continue to support midwives and Supervisors of Midwives to be
proactive in meeting challenges and in continuing to strive for excellence in
midwifery practice and supervisory practice in Wales. The LSA intends to
implement the recommendations to meet the NMC standards, made by the
NMC review team in its report dated September 2009, by the dates set out in
the action plan (see appendix 1 to this report).
The LSA sincerely thanks all those who participated in the review and gave
evidence to the review team.
Gillian Harris, LSA Midwifery Officer
Jean Keats, LSA Midwifery Officer October 2009