Job summary The Audit and Guidelines Midwife will work within the Governance and Assurance Team and will be responsible for ensuring the co-ordination of the production and updating of evidence based guidelines (including SOPS and patient information leaflets) and will support the clinical audit programme by maintaining a robust schedule of the programme of audits for Maternity Services. This will include supporting compliance with the requirements of the Maternity Incentive Scheme and the Saving Babies Lives Care Bundle. Working collaboratively with the multi-disciplinary team, the post-holder will have overall responsibility within the Maternity Services in leading and supporting the delivery of audit requirements, ensuring that the audit programme is consistent with the national standards and expectations. The post holder is expected to work flexibly across all locations of the Trust. Main duties of the job The post holder will be required to: o Draft reports in relation to audit and/or special projects to relevant groups and committees at local, Trust Board and external (LMNS) level and actively participate in forums and meetings in relation to the role. o Set, monitor and maintain excellent standards of care within the Service in collaboration with the MDT. o Maintain their own professional and personal development, including in relation to the NMC registration and revalidation requirements. o Act in accordance with the NMC Code of Professional Conduct for Nurses, Midwives and Health Visitors and Scope of Professional Practice. o Work clinically as required during periods of high acuity. o Participate in statutory and mandatory training relevant to the post. o Ensure confidentiality at all times, only releasing confidential information obtained during the course of employment to those acting in an official capacity. o Promote equal opportunities for staff and clients in accordance with Epsom and St Helier University Hospital NHS Trust Policies. o Be aware and work within the policies of Epsom and St Helier University Hospitals NHS Trust carrying out such duties as may be required, and are consistent with the responsibility of the grade. About us We operate two busy general hospitals, Epsom HospitalandSt Helier Hospital, andrun services from other locations, includingSutton Hospital. St Helier Hospital is home to theSouth West Thames Renal and Transplantation UnitandQueen Mary's Hospital for Children, while Epsom Hospital is home to theSouth West London Elective Orthopaedic Centre (SWLEOC). Both Epsom and St Helier hospitals haveAccident and Emergency departments (A&E)andMaternity services (Obstetrics). Epsom and St Helier have around 3,800 births annually. Acute and planned maternity services are offered across to hospital sites (Epsom General Hospital and St Helier Hospital) as well as in the community setting. Both units have a birth centre adjacent to Labour Ward. Date posted 18 March 2025 Pay scheme Agenda for change Band Band 7 Salary £51,883 to £58,544 a year per annum pro rata incl HCAS Contract Permanent Working pattern Full-time Reference number 343-6982854-UB-RB Job locations All Sites Epsom KT18 7EG Job description Job responsibilities AUDIT The post holder will lead on and/or support all audit activity undertaken within Maternity Services. This will include undertaking various audits and co-ordinating any associated recommendations and action plans. This includes a requirement to: Assist with, and provide expert advice on, the CNST Maternity Incentive scheme specifically in relation to any associated audit requirements, e.g. the Saving Babies Lives Care Bundle. Maintain a maternity-wide schedule of regular audits. Promote and maintain cohesive working relationships with obstetricians, the neonatal team (medical and nursing) anaesthetists and other specialists. Work with the Clinical Director, Director of Midwifery and Gynaecology Nursing, the Lead Midwife for Clinical Governance and Assurance, the Obstetric Audit Lead, the Trust Audit and Effectiveness Team and Trust-Wide Quality Team to ensure audit projects are prioritised and undertaken in a timely manner. Ensure, with the divisional management team, that the Maternity Service is compliant with identified national quality standards, ensuring robust mechanisms are in place to assess adherence, and that measures are implemented to make changes. Work collaboratively with the multi-disciplinary team to identify and ensure appropriate audit programmes are initiated in relation to clinical guideline adherence and in response to clinical incident investigation/trend analysis/national quality standards and recommendations, whilst coordinating and implementing any identified improvements in partnership with the senior management team. Participate in inter professional working to ensure annual audit programmes incorporate audit and effectiveness projects to meet the organisations governance objectives. This will include using national benchmarking data e.g., Royal College Guidelines, NICE recommendations, NCEPOD, NMPA, NHSLA, CNST and CQC outcomes and regulations. Use the Trust agreed reporting and recording process to ensure that all audits are registered appropriately, where relevant. Ensure that audit findings and recommendations are presented to the multi-disciplinary team through meetings and audit days. Provide methodological support to teams, including sampling, data collection, data analysis, data reporting, dissemination, action planning and change management necessary for the improvement of clinical practice. Assist the Division to fulfil its obligations in relation to CQC and other external standards, including the management of any emergent risks. GUIDELINES The post holder will be required to facilitate the development, implementation and review of clinical and management guidelines, SOPS and information leaflets across maternity services by: Maintaining up to date guidance for the development, implementation and review of clinical and other guidelines. Coordinate the maternity guideline review group meetings. Production of the regular guideline newsletter. Ensuring that all guidelines are in date by maintaining a log of expiry dates and authors and ensuring authors are reminded to update their guidance in a timely manner. Maintain a robust repository of guidelines both current and archived to ensure these are accessible to the governance and legal teams as requested. Support the development of patient information leaflets in partnership with the MNVP. Job description Job responsibilities AUDIT The post holder will lead on and/or support all audit activity undertaken within Maternity Services. This will include undertaking various audits and co-ordinating any associated recommendations and action plans. This includes a requirement to: Assist with, and provide expert advice on, the CNST Maternity Incentive scheme specifically in relation to any associated audit requirements, e.g. the Saving Babies Lives Care Bundle. Maintain a maternity-wide schedule of regular audits. Promote and maintain cohesive working relationships with obstetricians, the neonatal team (medical and nursing) anaesthetists and other specialists. Work with the Clinical Director, Director of Midwifery and Gynaecology Nursing, the Lead Midwife for Clinical Governance and Assurance, the Obstetric Audit Lead, the Trust Audit and Effectiveness Team and Trust-Wide Quality Team to ensure audit projects are prioritised and undertaken in a timely manner. Ensure, with the divisional management team, that the Maternity Service is compliant with identified national quality standards, ensuring robust mechanisms are in place to assess adherence, and that measures are implemented to make changes. Work collaboratively with the multi-disciplinary team to identify and ensure appropriate audit programmes are initiated in relation to clinical guideline adherence and in response to clinical incident investigation/trend analysis/national quality standards and recommendations, whilst coordinating and implementing any identified improvements in partnership with the senior management team. Participate in inter professional working to ensure annual audit programmes incorporate audit and effectiveness projects to meet the organisations governance objectives. This will include using national benchmarking data e.g., Royal College Guidelines, NICE recommendations, NCEPOD, NMPA, NHSLA, CNST and CQC outcomes and regulations. Use the Trust agreed reporting and recording process to ensure that all audits are registered appropriately, where relevant. Ensure that audit findings and recommendations are presented to the multi-disciplinary team through meetings and audit days. Provide methodological support to teams, including sampling, data collection, data analysis, data reporting, dissemination, action planning and change management necessary for the improvement of clinical practice. Assist the Division to fulfil its obligations in relation to CQC and other external standards, including the management of any emergent risks. GUIDELINES The post holder will be required to facilitate the development, implementation and review of clinical and management guidelines, SOPS and information leaflets across maternity services by: Maintaining up to date guidance for the development, implementation and review of clinical and other guidelines. Coordinate the maternity guideline review group meetings. Production of the regular guideline newsletter. Ensuring that all guidelines are in date by maintaining a log of expiry dates and authors and ensuring authors are reminded to update their guidance in a timely manner. Maintain a robust repository of guidelines both current and archived to ensure these are accessible to the governance and legal teams as requested. Support the development of patient information leaflets in partnership with the MNVP. Person Specification Qualifications Essential Registered Midwife with current NMC registration First degree or significant equivalent clinical experience Evidence of continuing professional development Desirable Masters degree or working towards Management qualification/course Experience Essential Up to date knowledge and understanding of current National and Regulatory requirements relating to maternity, Clinical Governance issues and clinical and professional issues Experience of clinical audit and implementing evidence-based care Evidence of implementing change in clinical practice Desirable Previous experience in an audit role. Knowledge Essential An understanding of audit and research based midwifery practice Knowledge of key NHS initiatives in relation to Healthcare Governance Knowledge of Safety actions in relation to CNST Skills Essential Excellent verbal, written and interpersonal communication skills Computer skills Good presentation skills Experience of gathering and analysing detailed information Ability to analyse problems and implement solutions Ability to prioritise and meet deadlines Desirable Able to write complex reports Person Specification Qualifications Essential Registered Midwife with current NMC registration First degree or significant equivalent clinical experience Evidence of continuing professional development Desirable Masters degree or working towards Management qualification/course Experience Essential Up to date knowledge and understanding of current National and Regulatory requirements relating to maternity, Clinical Governance issues and clinical and professional issues Experience of clinical audit and implementing evidence-based care Evidence of implementing change in clinical practice Desirable Previous experience in an audit role. Knowledge Essential An understanding of audit and research based midwifery practice Knowledge of key NHS initiatives in relation to Healthcare Governance Knowledge of Safety actions in relation to CNST Skills Essential Excellent verbal, written and interpersonal communication skills Computer skills Good presentation skills Experience of gathering and analysing detailed information Ability to analyse problems and implement solutions Ability to prioritise and meet deadlines Desirable Able to write complex reports Disclosure and Barring Service Check This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions. UK Registration Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window). Additional information Disclosure and Barring Service Check This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions. UK Registration Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window). Employer details Employer name Epsom and St Helier University Hospitals NHS Trust Address All Sites Epsom KT18 7EG Employer's website https://www.epsom-sthelier.nhs.uk/work-for-us (Opens in a new tab)