NMC Quality assurance framework: England, Scotland, Northern Ireland and Wales

NMC Quality assurance framework: England, Scotland, Northern Ireland and Wales Extraordinary follow up review Bangor University 21-23 June 2016 371029/North Wales Extraordinary/2017 Page 1 of 52

2015-16 Extraordinary review of performance in mitigating key risks identified in the NMC Quality Assurance framework for nursing and midwifery education Programme provider Bangor University Programmes monitored Registered Midwife - 36M; Pre-Registration Nursing - Mental Health; Pre-Registration Nursing - Adult Date of monitoring event 21-23 June 2016 Managing Reviewer Lay Reviewer Registrant Reviewer(s) Peter McAndrew Carol Rowe Hugh O Donnell, Nicola Clark, Gibson D Cruz 371029/North Wales Extraordinary/2017 Page 2 of 52

Placement partner visits undertaken during the review Midwifery Practice Visits Caia Park, Wrexham, Community Midwifery Team 21 June 2016 Maternity Services, Maelor Hospital, Wrexham 21 June 2016 Denbigh Community Midwifery Team 22 June 2016 Llandudno Community Midwifery Team 22 June 2016 Midwifery services, Ysbyty Gwynedd Hospital, Bangor 22 June 2016 Mental Health Practice Visits Gwanwyn Ward, Older Persons Mental Health, Heddfan Unit, Maelor Hospital, Wrexham 21 June 2016 Clewedog Ward, Acute Mental Health Admissions, Maelor Hospital, Wrexham 21 June 2016 Swn y Coed, Community Rehabilitation Team, Grove Road, Wrexham 21 June 2016 Hafan Wen, Drug and Alcohol Unit (independent), Wrexham 21 June 2016 Hafod Community Mental Health Team, Rhyl 22 June 2016 Cynydd Ward, Rehabilitation Secure Ward, Ablett Unit, Ysbyty Glan Clwyd Hospital 22 June 2016 Home Treatment Team, Ablett Unit, Ysbyty Glan Clwyd Hospital 22 June 2016 Ty Llewellyn, Forensic Medium Secure Unit, BYN, Llanfairfechan 22 June 2016 Carreg Fawr, Open Rehabilitation Mental Health Unit, BYN, Llanfairfechan 22 June 2016 Cynan Ward, Acute Mental Health Admission Ward, Ysbyty Gwynedd 22 June 2016 Adult Practice Visits Erdigg Ward, Respiratory Unit, Maelor Hospital, Wrexham 21 June 2016 Prince of Wales Ward, Orthopaedic Surgery and Rehabilitation, Maelor Hospital 21 June 2016 371029/North Wales Extraordinary/2017 Page 3 of 52

Date of Report 05 July 2016 Emral House Nursing Home, Wrexham 21 June 2016 PHCT, Coedpoeth 21 June 2016 Denbigh Infirmary 22 June 2016 Ward 7, Medical, Ysbyty Glan Clwyd Hospital 22 June 2016 Endoscopy Unit, Ysbyty Glan Clwyd Hospital 22 June 2016 Colwyn Bay Community Hospital 22 June 2016 Moelwyn Ward, Respiratory, Ysbyty Gwynedd Hospital 22 June 2016 Tegid Ward, Surgical, Ysbyty Gwynedd Hospital 22 June 2016 Introduction to NMC QA framework The Nursing and Midwifery Council (NMC) The NMC exists to protect the public. We do this by ensuring that only those who meet our requirements are allowed to practise as a nurse or midwife in the UK. We take action if concerns are raised about whether a nurse or midwife is fit to practise. Standards for pre-registration education We set standards and competencies for nursing and midwifery education that must be met by students prior to entering the register. Providers of higher education and training can apply to deliver programmes that enable students to meet these standards. The NMC approves programmes when it judges that the relevant standards have been met. We can withhold or withdraw approval from programmes when standards are not met. Quality assurance (QA) and how standards are met The quality assurance (QA) of education differs significantly from any system regulator inspection. As set out in the NMC QA framework, which was updated in 2015, approved education institutions (AEIs) are expected to report risks to the NMC. Review is the process by which the NMC ensures that AEIs continue to meet our education standards. Our risk based approach increases the focus on aspects of education provision where risk is known or anticipated, particularly in practice placement settings. It promotes self-reporting of risks by AEIs and it engages nurses, midwives, students, service users, carers and educators. 371029/North Wales Extraordinary/2017 Page 4 of 52

Our role is to ensure that pre-registration education programmes provide students with the opportunity to meet the standards needed to join our register. We also ensure that programmes for nurses and midwives already registered with us meet standards associated with particular roles and functions. The NMC may conduct an extraordinary review in response to concerns identified regarding nursing or midwifery education in both the AEI and its placement partners. The published QA methodology requires that QA reviewers (who are always independent to the NMC) should make judgments based on evidence provided to them about the quality and effectiveness of the AEI and placement partners in meeting the education standards. QA reviewers will grade the level of risk control on the following basis: Met: Effective risk controls are in place across the AEI: The AEI and its placement partners have all the necessary controls in place to safely control risks to ensure programme providers, placement partners, mentors and sign-off mentors achieve all stated standards. Appropriate risk control systems are in place without need for specific improvements. Requires improvement to strengthen the risk control: The AEI and its placement partners have all the necessary controls in place to safely control risks to ensure programme providers, placement partners, mentors and sign-off mentors achieve stated standards. However, improvements are required to address specific weaknesses in AEI s and its placement partners risk control processes to enhance assurance for public protection. Not met: The AEI does not have all the necessary controls in place to safely control risks to enable it, placement partners, mentors and sign-off mentors to achieve the standards. Risk control systems and processes are weak; significant and urgent improvements are required in order that public protection can be assured. It is important to note that the grade awarded for each key risk will be determined by the lowest level of control in any component risk indicator. The grade does not reflect a balance of achievement across a key risk. When a standard is not met an action plan must be formally agreed with the AEI directly and, when necessary, should include the relevant placement partner. The action plan must be delivered against an agreed timeline. 371029/North Wales Extraordinary/2017 Page 5 of 52

Quality Assurance Fitness for Practice Practice Learning Admissions & Progression Resources Summary of findings against key risks 1.1 Programme providers 1.1.1 Registrant teachers have have inadequate resources experience / qualifications to deliver approved commensurate with role. programmes to the standards required by the NMC 1.2 Inadequate resources 1.2.1 Sufficient appropriately available in practice qualified mentors / sign-off mentors / settings to enable students practice teachers available to support to achieve learning numbers of students outcomes 2.1 Inadequate safeguards are in place to prevent unsuitable students from entering and progressing to qualification 3.1 Inadequate governance of and in practice learning 3.2 Programme providers fail to provide learning opportunities of suitable quality for students 3.3 Assurance and confirmation of student achievement is unreliable or invalid 4.1 Approved programmes fail to address all required learning outcomes that the NMC sets standards for 2.1.1 Admission processes follow NMC requirements 3.1.1 Evidence of effective partnerships between education and service providers at all levels, including partnerships with multiple education institutions who use the same practice placement locations (Bangor and Glyndwr AEIs) 3.2.1 Practitioners and service users and carers are involved in programme development and delivery 3.3.1 Evidence that mentors, sign-off mentors, practice teachers are properly prepared for their role in assessing practice 4.1.1 Students achieve NMC learning outcomes, competencies and proficiencies at progression points and for entry to the register for all programmes that the NMC sets standards for 4.2 Audited practice 4.2.1 Students achieve NMC placements fail to address practice learning outcomes, all required learning competencies and proficiencies at outcomes in practice that progression points and for entry to the NMC sets standards for the register for all programmes that the NMC sets standards for 5.1 Programme providers' internal QA systems fail to provide assurance against NMC standards 5.1.1 Student feedback and evaluation/ Programme evaluation and improvement systems address weakness and enhance delivery 2.1.2 Programme providers procedures address issues of poor performance in both theory and practice 3.2.2 Academic staff support students in practice placement settings 2.1.3 Programme providers procedures are implemented by practice placement providers in addressing issues of poor performance in practice 3.3.2 Mentors, sign-off 3.3.3 Records of mentors and practice mentors / practice teachers are able to teachers are accurate attend annual updates and up to date sufficient to meet requirements for triennial review and understand the process they have engaged with 5.1.2 Concerns and complaints raised in practice learning settings are appropriately dealt with and communicated to relevant partners Standard Met Requires Improvement Standard Not met 371029/North Wales Extraordinary/2017 Page 6 of 52

Introduction Introduction to Bangor University s programmes The college of health and behavioural sciences at Bangor University comprises the following schools and academic centres: the school of healthcare sciences; the school of medical sciences; the school of psychology; and, the school of sport, health and exercise sciences. The school of healthcare sciences ( the school ) delivers pre-registration nursing and midwifery programmes and has two main campuses at Bangor and Wrexham. The Bangor campus is set within the main university campus and the Wrexham campus is situated adjacent to Wrexham Maelor Hospital. The school was founded at Bangor University in 1990 following the integration into the university sector of NHS education services for healthcare professions. Since its formation the school has continued to maintain close links with Betsi Cadwaladr University Health Board (BCUHB), which provides practice placements for the majority of the undergraduate pre-registration nursing and midwifery students. BCUHB practitioners make up the major part of the post-registration student body. The school provides a pre-registration programme for nurses: BN (Hons) nursing (three years) in adult nursing; mental health nursing; learning disabilities nursing and children's nursing. The school also provides a BM (Hons) midwifery (three year) programme. The school was approved to deliver the pre-registration nursing programme which meets the NMC Standards (2010) in May 2012 and the mental health field in December 2012. The pre-registration programmes are influenced by the All Wales Initiative which has provided a collaborative approach to the development of the nursing and midwifery curricula since 2001. This has enabled NHS Wales and the education and practice placement providers to develop a shared approach to recruitment and selection, educational audit, evaluation mechanisms and the assessment of clinical practice. The school has ensured that this national approach has been complemented by a more localised curriculum development process that has given ownership to stakeholders for the development of the future nursing and midwifery workforce. In 2013 Bangor University successfully won the contract to be the single provider for nursing and midwifery education in North Wales, delivering all four fields of preregistration nursing in addition to pre-registration midwifery education. This has resulted in an increase in student numbers. Bangor University has been under scrutiny since an NMC unscheduled extraordinary review took place in July 2015. The extraordinary review was as a result of escalating concerns reported to the NMC by the university arising from concerns raised by students in relation to the care of patients in placement areas in BCUHB. The extraordinary review concluded that NMC key risks and standards had not been met in relation to resources, practice learning and fitness for practice, and that quality assurance required improvement. The university identified an action plan of 371029/North Wales Extraordinary/2017 Page 7 of 52

compliance in relation to the standards not met which was agreed with the NMC and implemented to protect the public. This extraordinary follow up review took place over three days to determine whether Bangor University meets the NMC key risk themes and standards to protect the public. The review considered the progress made by the university against the action plan of compliance following the NMC extraordinary review in July 2015. The review involved meetings and telephone interviews with a range of stakeholders, visits to placement areas and the review of documentation. The practice placement visits selected covered a wide geographical area and provided the opportunity to visit a wide selection of hospital and community based placement experiences in both urban and rural settings. Our findings demonstrate that two of the key risk themes, admission and progression and fitness for practice, are not met. These are described below in relation to the relevant theme. In relation to the not met key risk themes the university must identify and implement an action plan which will ensure that the NMC standards and requirements are met and that public protection is assured. Bangor University identified and implemented an action plan to ensure that the key risks themes in relation to admission and progression and fitness for practice are met. A follow up review visit took place at Bangor University of 14 February 2017 and confirmed that the key risks are met. Resources: met Summary of public protection context and findings We conclude from our findings that the university has adequate appropriately qualified academic staff to deliver the pre-registration nursing and midwifery programmes to meet NMC standards. We found that the lead midwife for education (LME) is able to effectively undertake the strategic requirements of the role. The school has effectively secured additional academic staff resources to meet the future demands of increased commissions and the increasing challenges of practice learning. The new joint appointment of a professor of practice learning with BCUHB offers an exciting opportunity to transform practice learning. We conclude from our findings that there are sufficient appropriately qualified mentors and sign-off mentors available to support the number of students on nursing and midwifery pre-registration programmes. Admissions and progression: not met We conclude from our findings that procedures for the selection of students do not meet the NMC requirements. We found a service user who had participated in student selection days for the pre-registration midwifery programme had not undertaken any training including equality and diversity training. This is contrary to the relevant NMC standards and also equality and diversity legislation. Procedures must be revised to ensure that all participants in the selection process have undertaken the required preparatory training. 371029/North Wales Extraordinary/2017 Page 8 of 52

Our findings confirm that procedures to address issues of poor performance in both theory and practice are well understood and implemented effectively. We found that the cause for concern process is effective and provides a strong supportive partnership to give the student the best possible opportunity to maximise their potential and ensures protection of the public. The university has a fitness to practise policy and procedure, which is robust and effective, and meets NMC requirements. Our findings confirm that good health and good character self-declaration forms are completed by students on an annual basis. These compulsory procedures are undertaken in order to protect the public. Our findings confirm the university has effective policies and procedures in place for the management of poor performance in both theory and practice which are clearly understood by staff and students, and contribute towards effective protection of the public. A follow up visit to Bangor University on 14 February 2017, to review progress made against the action plan, confirmed that there are systems and processes in place to ensure that service users and carers undertake training including equality and diversity training prior to participating in the selection of students. The standard is now met. Practice learning: met Our findings confirm that the university and BCUHB have worked successfully together on the action plan that was agreed after the extraordinary review in July 2015 to effectively undertake practice learning and placement management. There is strong evidence of effective partnership working between education and service providers at a strategic level. There is a greater emphasis on quality assurance and clinical governance, and clinical leadership has been significantly strengthened. In the midwifery services, there is a 100 percent compliance with mandatory training. In the nursing services mentors have on average a 90 percent compliance with mandatory training. Nurse managers are confident that nurses will achieve 100 percent compliance over the next three months. We conclude from our findings that the contribution of service users and carers to the assessment strategy in the nursing and midwifery pre-registration programmes has been strengthened through the introduction of feedback to students on the care that the student has been involved in delivering. We conclude from our findings that mentors and sign-off mentors are properly prepared for their role. There is a clear understanding held by sign-off mentors about assessing and signing-off competence to ensure students are fit for practice to protect the public. We found that mentors and sign-off mentors are able to attend annual updates sufficient to meet the requirements for triennial review and to support the assessment of practice. BCUHB, in partnership with the university, has produced a protocol for mentorship arrangements to make responsibilities and accountability explicit to all involved in mentorship arrangements. We conclude from our findings that mentor registers are complete, accurate and up to date. We found that additional resources have been provided as an investment to 371029/North Wales Extraordinary/2017 Page 9 of 52

maintain robust mentor records and to provide assurance that students are only supported by nurses and midwives who are eligible to undertake the mentor role and protect the public. Fitness for practice: not met We conclude from our findings that students achieve the NMC learning outcomes and competencies for entry to the nursing and midwifery parts of the professional register. Students who emerge from the programme are considered fit for practice by employers and education commissioners. External examiners confirm the quality of the programme, the effective level of academic support provided to students and the rigor of the assessment of practice which enable students to achieve the statutory requirements. We concluded that there are no appropriate processes in place to verify that students experience a 24-hour cycle of care in the pre-registration nursing programme to meet NMC requirements. Measures must be put in place to evidence that all students meet this statutory requirement. A follow up visit to Bangor University on 14 February 2017, to review progress made against the action plan, confirmed that there are systems in place to verify that students experience a 24-hour cycle of care in the pre-registration nursing programme. The standard is now met. Quality assurance: met We conclude from our findings that all modules and programmes are subject to programme evaluation and that there is an evaluation of practice experience. Our findings confirm that there is clear evidence that issues are followed through to resolution and that feedback is provided to students and placement providers on action taken. There are appropriate and robust processes in place to ensure that external examiners fulfil all aspects of their role including monitoring the assessment of practice. We conclude from our findings that concerns and complaints raised in practice learning settings are appropriately dealt with and communicated to relevant partners. The school may wish to consider how students awareness of concerns and complaints processes can be enhanced. Summary of areas that require improvement 14 February 2017. A follow up visit to Bangor University, to review progress made against the action plan, confirmed that there are systems and processes in place to: ensure that service users and carers undertake training including equality and diversity training prior to participating in the selection of students; and, verify that students experience a 24-hour cycle of care in the pre-registration nursing programme. The key risk areas identified below are now met. The following areas are not met and require urgent attention: 371029/North Wales Extraordinary/2017 Page 10 of 52

Training must be provided for service users and carers to prepare them for participating in the selection process for pre-registration nursing and midwifery students, and this must include equality and diversity training. Procedures must be implemented to ensure that students on the preregistration nursing programme experience a 24-hour cycle of care. Summary of areas for future monitoring The nurse and midwifery lecturer resources are maintained at a level which enables the programmes to be effectively delivered. All participants involved in the selection process for pre-registration nursing and midwifery students have undertaken appropriate training, and this must include equality and diversity training. Mentor records are complete, accurate and up to date. Mandatory training is maintained at an appropriate level of compliance. Students on the pre-registration nursing programme experience a 24-hour cycle of care and that this is appropriately verified. Students are aware of and understand the new complaints procedure for issues in practice settings. Summary of notable practice Resources None identified Admissions and Progression None identified Practice Learning None identified Fitness for Practice None identified Quality Assurance None identified Summary of feedback from groups involved in the review Academic team Pre-registration nursing programme We found that academic staff are committed and enthusiastic about the programme. They told us they are assured that the programme develops graduates who are 371029/North Wales Extraordinary/2017 Page 11 of 52

confident and fit to practise. We were told that they have an effective working relationship with practice placement providers. This relationship ensures that students experience safe and effective practice learning experiences and enables them to address any issues of concern related to student learning in a prompt and effective manner. Academic staff informed us that the programme is contemporary and facilitates the development of knowledge and skills to ensure that student nurses are able to care for a range of service users. Practice partners are involved in classroom teaching. We were told that the university is very supportive in enabling the development of lecturers which has facilitated a number of lecturers to complete higher degrees including doctorates (23 25). The academic team told us that they have a link lecturer role and the recently introduced workload allocation model recognises the importance of this role. They told us they have engaged in a comprehensive programme of re-auditing all practice learning environments and have been involved in the development of a more user friendly escalation of concerns policy which is now clearly visible within all practice learning areas (23 25). Pre-registration midwifery programme The academic team told us they have sufficient staff to deliver the pre-registration midwifery programme. We found that the academic team now comprises four full time midwifery lecturers, one of whom is the LME, and a 0.2 whole time equivalent (WTE) practice education facilitator (PEF). Another 0.5 WTE PEF is to join the team in July 2016. Three of the full time lecturers hold an NMC recorded teaching qualification, with the other full time lecturer and 0.2 WTE PEF due to complete a teaching qualification in August and September 2016 respectively. The student commissions have increased from 18 to 23 students per year, and when the 0.5 WTE PEF joins the teaching team in July 2016, there will be a staff:student ratio of 1:14. The programme team confirmed that attrition is low, approximately one student per cohort, and all students who were moved from Glan Clwyd Maternity Hospital have remained on the programme (26, 28). The academic team are enthusiastic in their approach to learning and teaching and supporting the students. They undertake a link lecturer role and are passionate about providing a quality student experience and being available to students on a regular basis (26). The LME told us that she has 50 percent protected time to undertake the strategic role and has been receiving external mentoring support from an experienced LME at another university (34). With the exception of the LME, the teaching team are all relatively new to the role, having recently completed their teaching qualifications or are in the process of doing so. All of the teaching team have worked, solely, within the local maternity units prior to commencing at the university (26). Mentors/sign-off mentors/practice teachers and employers and education commissioners Commissioners told us that the quality of the nursing and midwifery pre-registration programmes remains high. Students who were exiting the programmes are 371029/North Wales Extraordinary/2017 Page 12 of 52

considered to be fit for practice and the majority are employed locally. Commissioners told us that the university and BCUHB are working in close partnership to meet some of the challenges that had been previously identified (32). Pre-registration nursing programme Managers and employers told us that students are fit for practice and purpose on successful completion of the programme. The perceived quality of new graduates is supported by the high number of students who achieve employment locally on completion of the programme. Practice managers told us that they are proactive in ensuring that staff who are not currently mentors, are encouraged to complete mentorship training, and that existing mentors are encouraged to become sign-off mentors (41 59). Mentors told us that they are well prepared and updated for their role and have ample opportunity to complete annual updates. Mentors have a clear understanding of their role and responsibility in supporting students learning and in the summative assessment of essential skills and competence. Mentors expressed satisfaction with the partnership arrangements which exist with the university and are especially positive with the support provided by link lecturers. Mentors told us that they have been encouraged and supported to participate in a wide range of mandatory training opportunities and that this has had a positive impact on their morale and commitment. Mentors informed us that the amended escalating concerns policy is more user friendly and provides greater clarity regarding how concerns should be managed. Mentors told us that things are much better and that there is better partnership working with academic staff from the school (27, 41 59). Pre-registration midwifery programme Midwifery managers in the placement areas told us that they have taken responsibility for increasing the uptake of mandatory training and there is now 100 percent compliance. They informed us that the mentor preparation programme runs six times a year and that they make every effort to support midwives to attend (27, 35 40). Mentors told us that there is a strong partnership between the university and BCUHB which includes monthly meetings which involves revisiting the action plan. PEFs told us that the midwifery mentor register is updated monthly and all mentors receive an annual update, the date of which is recorded in the new assessment of practice documentation for student midwives. The updated version is sent to all link lecturers and the LME every month (35 40). Mentors told us that the new assessment of practice document was introduced into the midwifery programme in September 2015 for year one and year two students. Students studying year three of the programme continue on the previously approved documentation. They told us the two different types of assessment documentation did not cause any issues. The mentors understand the new practice assessment documentation as this is discussed at both annual updates and during mandatory training. Mentors told us that they receive protected time in practice when allocated to a student. All mentors were able to describe the raising concerns process for a student who was not progressing or where issues were encountered in practice (35 40). 371029/North Wales Extraordinary/2017 Page 13 of 52

Students Pre-registration nursing programme We found the students to be confident, articulate and objective, and they spoke in positive terms about the university and practice placement providers. They value their teaching and placement experiences and told us that they are acquiring the knowledge, skills and attributes to become competent registered nurses. Students told us that they receive good support in both the university and during practice placements and personal tutors are perceived to be a key resource. Adult students based at the Wrexham site told us that they did not always feel as if they were students of the university. They cited the main reasons for this was that they did not attend any teaching sessions at the university s main campus or interact with students who are based at the Bangor site. Students in the final year of the programme told us that they have achieved the necessary knowledge, skills and competence required to progress to registration. Newly qualified nurses also told us that they are confident about their competence and fitness for practice (41 59). Students told us that they feel supported during all periods of practice placement learning and are allocated a named mentor or sign-off mentor in advance of all practice placements. Students told us that they have good access to a comprehensive range of learning resources within the university and during practice placements. We were told that they experience a suitable range and breadth of practice learning opportunities and they effectively use spoke placements to add to their practice learning experiences. Students told us that they value the opportunity to engage in shared learning with students from other nursing fields during year one and two of the programme (41 59). Pre-registration midwifery programme Students told us that they feel supported in both theory and in practice. They told us that they work a minimum of 40 percent with their sign-off mentor in practice, with the majority working in excess of this minimum requirement. Students informed us that the programme prepares them to undertake the role of the midwife and nearly all would apply for jobs locally. Students told us that there are now more midwifery teachers and acknowledged the diversity of the different teaching styles and personalities. Students told us that there is an inconsistency of assessment information between the Wrexham and Bangor sites particularly with regards to the objective structured clinical examination (OSCE) assessment. They attributed this to the inexperience of the link lecturers on one site and felt that this was inequitable. Students on the other site told us that they are not aware of any issues faced by these students, but acknowledged that the experience of their link lecturers did mean that any information provided was detailed and accurate. Students told us that they verify their good health and good character status on an annual basis and that they are aware of the new raising and escalating concerns policy (33, 35 40). Service users and carers Pre-registration nursing programme We found that service users are involved in student selection, teaching and assessment in the university setting and they participate in programme boards. 371029/North Wales Extraordinary/2017 Page 14 of 52

Service users told us that they appreciate their involvement in the programme and feel that the voice of the service user is important. They told us that they feel valued for their contributions and are appreciated by students with whom they have been involved. We met an inpatient service user during a placement visit who was complimentary about nursing students who had helped to meet his care needs. He told us that students are committed, caring and interested in his feelings. He told us that students are respectful and demonstrate understanding and empathy when delivering nursing care (23 25, 41-59). Pre-registration midwifery programme The new assessment of practice documentation requires five formative feedback forms to be completed by service users on every student midwife each year of the programme. Currently feedback is ad hoc, and occasionally cards and letters are given which the students retain in their portfolio. Service users also provide feedback as part of the case loading practice that student midwives are required to undertake. Service users told us that they are invited to be involved in the selection and recruitment of student midwives. The service users are part of the interview process whereby their opinion of the suitability of the applicant is sought. We were told by a service user who had been part of the interview process that they had not received any formal training. Service users are also invited to attend programme boards and they told us they feel that their input is valued (26, 35 40). Relevant issues from external quality assurance reports There were no further adverse Healthcare Inspectorate Wales (HIW) inspection reports relevant to Bangor University or BCUHB since the NMC extraordinary review in July 2015. Follow up on recommendations from approval events within the last year NMC major modification report, school of healthcare sciences, Bangor University - registered midwife (three year programme), 18 September 2015 (3) Recommended for approval with one recommendation: A workload analysis is necessary to establish the sufficiency of the recently agreed midwife teacher resource. Potential risks for future monitoring included: A sufficiency of mentors following students re-location to two rather than three maternity hospital sites. Teacher resource is sufficient to deliver the curriculum and includes time for professional development. This recommendation and potential risks were considered as part of the extraordinary follow up review visit. We concluded from our findings that the midwifery teacher resource is sufficient to deliver the pre-registration midwifery programme and includes 371029/North Wales Extraordinary/2017 Page 15 of 52

time for lecturers to undertake appropriate professional development. Bachelor of Nursing (adult, child, mental health and learning disabilities) programme extension. NMC letter to Bangor University, 26 January 2016 The programme was originally approved by the NMC on 31 May 2012. The NMC letter confirmed the extension of the programme approval for intakes of students up to 31 August 2019 (4). Pre-registration midwifery, B Mid (Hons) Pre-registration midwifery (three year programme and 18 month programme programme extension, 26 January 2016 The programme was originally approved by the NMC on 12 July 2011. The NMC letter confirmed the extension of the programme approval for intakes of students up to 31 August 2019 (5). Specific issues to follow up from self-report NMC annual self-assessment programme monitoring report 2015-16, school of healthcare sciences, Bangor University, 30 November 2015 (6) Key issues for 2015-2016 annual monitoring: The following actions were identified during the NMC extraordinary review visit in July 2015 and an update provided in the self-report: The teaching resource for the delivery of the pre-registration midwifery programme must be strengthened to enable the programme to be effectively delivered to meet the standards for pre-registration midwifery education (NMC, 2009). Midwifery teaching staff has now increased to 4.5 WTE. Additional resources and support must be put in place to enable the LME to fulfil the statutory role. The increase of midwifery teaching staff to 4.5 WTE facilitates time for the LME to fulfil the statutory role. At a strategic level there should be stronger partnership working between Bangor University and BCUHB; including effective communication and management of governance issues related to clinical areas and practice learning environments. A new practice education quality assurance group was implemented from October 2015. The educational audit process should be strengthened to ensure that the audit process is effectively undertaken and that action plans are implemented and monitored to ensure completion. The practice education quality assurance group discussed this issue at their November 2015 meeting and a paper is to be presented to propose the establishment of a quality assurance audit group who will monitor the overall quality assurance process of the educational audit of practice placements. The number of nursing students identified for allocation in placement areas needs to be reviewed to ensure all students have an equitable opportunity to gain a wider experience of different patient groups in varying settings. 371029/North Wales Extraordinary/2017 Page 16 of 52

The health board is currently going through a restructure which is scheduled to be completed by April 2016 and once the restructure is agreed practice placements and student capacity will be reviewed within each professional speciality. The policies and procedures for raising and escalating concerns should be reviewed to ensure they are clear, comprehensive and understood by students who wish to raise concerns. The current escalation policy is being reviewed with the intention of making it more user friendly for students. It is intended to complete this process by January 2016 with the revised policy distributed to students to file in their portfolio. The mandatory training records of nurses and midwives, including mentors, require immediate action to ensure that all practitioners deliver safe practice, meet the requirements of registration, the NMC Code and mentor/sign-off mentor status. BCUHB are currently working to increase compliance to mandatory updating by the specified dates. Registers of mentors must be more accessible and provide accurate and up to date information that all mentors and sign-off mentors meet NMC requirements. Mentor registers across nursing and midwifery are being reviewed to ensure accurate and up to date information is recorded and that only the name of mentors and sign-off mentors that meet NMC requirements are recorded. The mentor register for the private and independent sector must provide a consistent and accurate record. The university reported that the registers for the independent sector have been updated to ensure consistency. There needs to be effective coordinated activity developed in relation to service user and carer engagement to ensure their contribution meets the requirements of contemporary practice. A service user/carer/relative feedback form is to be introduced for all September 2015 students at the commencement of their practice placements in February/March 2016. This will be followed by March cohorts during their new academic year commencing in March 2016. In the pre-registration midwifery programme urgent action needs to be taken to ensure that the practice assessment document (PAD) is robust, meets NMC standards and is approved by the NMC. The revised PAD was approved as a major modification by the NMC in September 2016. Feedback from students evaluations should be consistently provided to placement areas. A new electronic feedback evaluation will commence during 2016. The complaints procedure needs to be improved so that it provides a suitable avenue for students to raise issues; to ensure that all complaints are fully investigated and the outcomes and learning for the future are reported to all relevant individuals. A new Let us hear what you think process was implemented in October 2015. 371029/North Wales Extraordinary/2017 Page 17 of 52

All these key issues were reviewed in the extraordinary follow up review visit and reported on in the relevant parts of the report. Findings against key risks Key risk 1 Resources 1.1 Programme providers have inadequate resources to deliver approved programmes to the standards required by the NMC 1.2 Inadequate resources available in practice settings to enable students to achieve learning outcomes Risk indicator 1.1.1 - registrant teachers have experience / qualifications commensurate with role. What we found before the event Pre-registration midwifery programme The extraordinary review in July 2015 concluded that the teaching resource for the delivery of the pre-registration midwifery programme was below that which is required. The teaching resource for the delivery of the pre-registration midwifery programme must be strengthened to enable the programme to be effectively delivered to meet the Standards for pre-registration midwifery education (NMC, 2009). Additional resources and support was to be put in place to enable the LME to meet the statutory role (1). The university identified an action plan of compliance in relation to the standard not met which was agreed with the NMC and implemented to increase the number of academic midwifery staff members to facilitate the effective delivery of the Bachelor in Midwifery programme and meet NMC standards. This increase in staff members was to be in place before the start of the academic year (2015-16). The increase in WTE midwifery staff members will enable the LME the time required to fulfil the statutory role and meet NMC standards (2, 6-7). What we found at the event We found that all programme leaders, field leaders and the majority of lecturers supporting the pre-registration nursing and pre-registration midwifery programmes have an active NMC registration and a recorded teaching qualification. Programme leaders act with due regard. Academic staff members are enthusiastic and committed to their roles. We found that the school s governance procedures are robust and well 371029/North Wales Extraordinary/2017 Page 18 of 52

administrated and ensure that all midwifery and nursing lecturers with a professional qualification are registered with the NMC and have the relevant recorded teacher qualification or are working towards its achievement. The school has effectively secured additional academic staff resources to meet the future demands of increased commissions and the increasing challenges of practice learning. The new joint appointment of a professor of practice learning with BCUHB offers an exciting opportunity to transform practice learning (11-12, 21, 23 26, 28). Pre-registration nursing programme We found that lecturers involved in the delivery of the pre-registration nursing programme have the appropriate experience and qualifications commensurate for their role. The programme team told us that there are sufficient resources to deliver the programme effectively and that additional resources have been approved for new appointments to meet the increase in commissioned numbers of nursing students (12, 23 25, 28). Pre-registration midwifery programme We found that the midwifery lecturer resource has been significantly increased and will soon increase to 4.7 WTE lecturers in post. We were told that the commissioned number of midwifery students will be increased in 2016-17 and the new staff resource will give a staff student ratio of 1:14. We found that midwifery lecturers are enthusiastic and committed to student learning and they all undertake the link lecturer role. We also found that they are relatively inexperienced as an academic team and that this sometimes has a limiting effect on the degree of student support and guidance that can be provided. The midwifery programme team may benefit from a more equitable distribution of midwifery lecturers between the two campuses. This would enable the experience that exists to be more appropriately shared and facilitate them fulfilling the link lecturer role in areas other than where they have previously undertaken midwifery practice (26, 28). We found that the increase in midwifery lecturer numbers has enabled the LME to allocate more time to undertake the strategic requirements of the role. The LME told us that she has 50 percent protected time to undertake the strategic role and has been receiving external mentoring support from an experienced LME at another university. The LME attends strategic meetings within the university and is supported to attend external LME and network meetings. The LME confirms that she is consulted on all matters relating to midwifery education at the university. The current LME proposes to stand down from the position in the near future and a succession plan is being implemented to support the new LME who has already been designated (28, 34). We conclude from our findings that the university has sufficient appropriately qualified academic staff to deliver the pre-registration nursing and midwifery programmes to meet NMC standards. Risk indicator 1.2.1 - sufficient appropriately qualified mentors / sign-off mentors / practice teachers available to support numbers of students 371029/North Wales Extraordinary/2017 Page 19 of 52

What we found before the event Pre-registration nursing programme We found there were sufficient appropriately qualified mentors and sign-off mentors available to support the number of students (1). Pre-registration midwifery programme Some sign-off mentors allocated to student midwives were not up to date on the mentor register, and many were undertaking the mentorship preparation programme. The students reported that they often shared their sign-off mentor with other students, and students reported a lack of continuity of mentorship which created problems when completing practice assessment documentation (1). Due to the shortage of sign-off mentors, some midwives were being mapped against the sign-off register competencies, so that they could undertake the role of the signoff mentor based on their previous experience. The process for this was not transparent, nor was the achievement of the learning outcomes to achieve mentorship status (1). What we found at the event Pre-registration nursing programme We found that there are sufficient appropriately qualified mentors and sign-off mentors available to support the number of nursing students. Mentors and sign-off mentors demonstrated commitment and enthusiasm for their roles. We confirmed that there is enthusiasm for nurses and midwives to become mentors. Mentors and signoff mentors act with due regard and work with students for a minimum of 40 percent of the time. We found that the hub and spoke placement model is understood by students and mentors and is an effective strategy for widening students learning experiences. We found that there are no additional demands on practice placements from other health and social care professionals. Students in year three of the programme told us that they are allocated a sign-off mentor for the final management placement. We confirmed that all mentors are allocated a single student for each practice placement (19, 41 59, 92). Pre-registration midwifery programme We found that there are sufficient appropriately qualified midwifery sign-off mentors available to support the number of midwifery students on placements. All mentors undertake the NMC approved mentorship preparation programme. All students are assigned a sign-off mentor who meets the requirements as detailed in the Standards for pre-registration midwifery education (NMC, 2009). We found that mentors are enthusiastic and committed to undertake the role. Students told us that they work a minimum of 40 percent of the time with their sign-off mentor and they are normally allocated to the same shift pattern as their mentor. Student midwives told us that they also have a named supervisor of midwives (SoM) to support them during practice 371029/North Wales Extraordinary/2017 Page 20 of 52

placements (35 40, 42). We conclude from our findings that there are sufficient appropriately qualified mentors and sign-off mentors available to support the number of students on nursing and midwifery pre-registration programmes. Outcome: Standard met Comments: No further comments. Areas for future monitoring: The nurse and midwifery lecturer resources are maintained at a level which enables the programmes to be effectively delivered. Findings against key risks Key risk 2 Admissions & Progression 2.1 Inadequate safeguards are in place to prevent unsuitable students from entering and progressing to qualification Risk indicator 2.1.1 - admission processes follow NMC requirements What we found before the event The admission and progression processes were found to meet NMC requirements at the previous monitoring event and the extraordinary review visit (1, 147). Procedures to address issues of poor performance in both theory and practice were well understood and implemented effectively in the programmes reviewed (1). What we found at the event the event Pre-registration nursing programme We found that recruitment and admissions processes for the pre-registration nursing programme comply with NMC standards and requirements. Academic staff and practitioners told us they undertake equality and diversity training prior to participating in the selection and recruitment processes. The programme team told us that service users and carers have specific interview preparation, which includes equality and diversity training, and a register of this training is held in the school (23-25, 33-49). 371029/North Wales Extraordinary/2017 Page 21 of 52