Matrix of Evidence

Evidence Suggestion

Criteria

Women’s focus group / user group mortality notes of meeting

1.1, 3.1

Risk management meetings minutes

1.1

Labour ward forum minutes / terms of reference

1.1

MSLC minutes

1.1

Perinatal minutes

1.1

Audit meetings minutes / attendance / programme

1.1, 3.1,3.5, 5.2

Guideline development and circulation process

1.3, 3.1, 3.5, 5.2

Evidence

Criteria

Information leaflets

1.3, 5.2

Guideline minutes

1.3, 5.2

Informed Choice leaflet

1.3, 1.4, 5.4

Guideline database

1.4, 5.4,

List of  information leaflets for women

1.4, 5.4

Notes from meetings of supervisors with women

1.4, 1.5, 3.4, 5.4

Training needs analysis

1.4, 4.6

Mandatory training attendance lists

1.4, 4.6

Letters of non attendance at mandatory training

1.4

Supervisors phone call supports / log

1.5

Consent form policy

1.5

Ratio 1:15     Supervision / midwife

2.1, 2.3

Supervisors on-call rota 24 hour

1.4, 2.1, 3.3, 3.4, 4.1

Supervision questionnaire completed

2.1, 2.2, 2.10, 2.12,2.13,2.14,2.16, 3.1

Evidence of succession planning

2.1, 3.1, 3.5

Minutes of supervisors meetings and action plans

2.2, 2.9, 3.3, 3.4, 5.1

Midwives Audit - 20-30 forms to be submitted to LSA – one month prior to monitoring visit.

2.2, 4.2

Evidence of selection and nomination process

2.3, 3.2, 3.3

Annual Report submitted by mid-May each year.

2.4, 5.14

Monthly monitoring from of changes

2.4

Supervisors can access Supervision guidelines

2.5

CSOM advises changes to ITP’s  by 20^th month

2.6

CSOM advises all ITP’s 20^th March each year

2.6

Policy for checking NMC registration and re-registration

2.7

Supervision meeting dates set in advance

2.9

Supervisors complete 15 hours of study every 3 years.

2.10,2.13

Strategy for supervision

2.11, 5.12

Action Plan developed following audit

2.11

Evidence of administrative support

2.15

Supervisors involved in Induction programmes for midwives

3.6

Supervisors teach on mandatory update

3.6

Supervisors are involved with university, course board, exam board and curriculum planning

3.6

Evidence that midwives can change supervisor

4.2

% of annual midwives reviews

4.3

Evidence that 33% of midwives received questionnaires

4.4, 4.5

Supervision of student midwives

4.7

Evidence of new equipment training

5.1

Contingency staffing plans

5.1, 5.6

Business case for equipment / staffing

5.1,5.6

Audit of controlled drugs

5.5

Supervisory investigation

5.7, 5.8, 5.9, 5.10, 5.11, 5.13,

Maternity Risk management Strategy

5.12

Record keeping Audit

5.14

Minutes reflecting clinical trials

5.15

Evidence

Criteria

CNST Standards:                                     Level 1

                                                                 Level 2

                                                                 Level 3

1.1.1/3.1.1/4.1.1/6.1.2/8.1.1

2.2.4/4.2.1/6.2.1/7.2.1/8.2.2/8.2.3

2.3.1/6.3.1/8.3.1

LSA MO to respond

·            Template for Annual Report – awaiting NMC

·            Supervision Guidelines on website

·            Guidance regarding transfer and storage of supervisory records

2.4

2.5

2.8