The post holder will be working with the Director of Midwifery in developing, implementing and monitoring seamless clinical governance pathways, which fosters multidisciplinary working across the directorate. Working closely and collaboratively with the Maternity Services Management team to ensure effective communications systems are in place and to ensure excellent standards of care and compliance with national and local standards, and act as the lead and central point of contact for Maternity's divisional governance activities.

Develop programmes of work to ensure that the Trust meets the outcomes set by the Care Quality Commission, NHS England, NHS Resolution (Maternity Incentive Scheme), any other national, service-specific or local performance frameworks and other emerging Maternity Services national drivers.

Main duties of the job

An exciting opportunity has arisen for a Band 8a Maternity Governance Lead. The post holder will be working with the Director of Midwifery in developing, implementing and monitoring seamless clinical governance pathways, which fosters multidisciplinary working across the directorate. Working closely and collaboratively with the Maternity Services Management team to ensure effective communications systems are in place and to ensure excellent standards of care and compliance with national and local standards, and act as the lead and central point of contact for Maternity's divisional governance activities.

The postholder will develop programmes of work to ensure that the Trust meets the outcomes set by the following:

Care Quality Commission

NHS England

NHS Resolution (Maternity Incentive Scheme)

Saving Babies Lives Care Bundle

NICE Quality Standards

Ockenden Immediate and Essential Actions

Any other national drivers and service-specific or local performance frameworks

About us

Northampton General Hospital is one of the largest employers in the area and we are on an exciting journey. All of our divisions are committed to doing things better, with more efficiency as we update, modernise, and advance. We have also entered into a Group Model with neighbouring Kettering General Hospital NHS Foundation Trust and become University Hospitals of Northamptonshire.

Our Excellence Values

Compassion

Accountability

Respect

Integrity

Courage

We want to recruit the best people to deliver our services across the University Hospitals of Northamptonshire and help to unleash everyone's full potential. As an organisation, we value how we communicate and promote our vacancies to all communities.

We are a Defence positive trust, supporting our reservists, veterans, spouses and partners.

The Hospital Group encourages applications from people who identify from all protected groups, especially those from BAME, Disabled and LGBTQ+ backgrounds as these are underrepresented in our hospitals.

We understand that we need to work with colleagues from diverse backgrounds and make sure the environment they work in is inclusive and collaborative.

We have active Networks that promote and support colleagues from all backgrounds.This ensures everyone feels supported and has a sense of belonging working for Kettering and Northampton General Hospitals.

Job description

Job responsibilities

Main Tasks

Acting as a self-relating practitioner who horizon scans to ensure the maternity governance activities remain in line with current best practice.

Support and develop a culture of informed questioning, challenge, trend analysis triangulation, challenge and assurance to ensure lessons are learned and the division changes practice in a way which has a positive effect on patient, outcomes, patient experience and supports the Trust ambition to reach zero avoidable harm.

The post holder is responsible for ensuring effective governance systems are in place across maternity and particularly guideline, audit, maternity dashboard and Maternity Incentive Scheme (MIS).

Working closely and collaboratively with the womens services management team to ensure effective communication systems are in place and to ensure excellent standards of care and compliance with national and local standards.

Support the Trust and Maternity Services in developing programmes of work to ensure that the Trust meets the outcomes set by the Care Quality Commission (CQC), NHS England and any other national, service-specific or local performance frameworks.

Work collaboratively with the midwifery management and consultant obstetricians to identify appropriate audit programmes are initiated in response to clinical incident investigations/trend analysis, and ensure that improvements are identified and implemented

Participate in local and national Audit programmes

Meet the Maternity Units obligations in relation to national clinical and quality standards (e.g. CQC, NHS Resolution, MIS Safety Actions (CNST), Ockenden and any other standards

Maintain robust assurance processes that meet local and national standards and that they are aligned to the Trusts governance processes and standards

Actively support the aggregation of the Divisional Dashboard and any other quality measures

Support the development of the maternity strategy

Responsibilities

Maintain a professional behaviour at all times and promote a positive image of the Trust at all times, in line with the Trust Values.

The post holder will be responsible for all aspects of clinical governance within Womens Services (Maternity Work with medical (obstetrics, gynaecology, neonatology and anaesthetic), midwifery and nursing teams to implement any changes and staff development requirements identified through governance processes

Assure data and information quality standards are met

Provide statistics on an adhoc, monthly and annual basis for the department and any other relevant organisations

Provide monthly, quarterly and yearly reports triangulating the information and data from clinical governance activity.

Co-operate with the Information department in order that data produced by the relevant systems is clean and kept secure and confidential in line with Data Protection and Caldicott guidance

Work with the Divisional and Governance teams to ensure that policies and guidelines are updated regularly and out of date policies and guidelines are highlighted to the leads will in advance to ensure revision of these in a timely manner

Maintain a central database of policies and guidelines including SOPs

Produce regular reports to the Maternity Governance meet regarding policies and guidelines that are due to become overdue

In conjunction with the Trusts Clinical Governance team, oversee the assessment of compliance with the full range of NICE and RCOG guidance types and ongoing audit to evidence compliance

Responsibility for the co-ordination and upload of the Maternity Unit guidelines on the Intranet

Support the gathering of evidence for MIS (CNST), ensuring that regular reports are provided for the Trust Board regarding progress and that evidence is available in plenty of time for Board sign-off

Provide training on risk management, complaints, serious incidents and comprehensive investigations

Responsibility for Patients

Identify and escalate any anomalies to divisional / corporate leads for action

Ensure that learning from patient complaints and comments is shared to support development of the quality agenda and service improvement plans and strategies

Ensure patients who suffer harm whilst under our care, are managed in line with Being Open or Duty of Candour as indicated by level of harm

Facilitate and have continuing responsibility for the effective assessment, implementation and evaluation of all midwifery care in own sphere of clinical practice over a 24 hour period. Undertake the full role of the midwife including advanced decision making, using evidence based practice and highly developed skills.

Develop and adhere to the maternity units philosophy and models of care to ensure that all policies and procedures are implemented and to lead on the development of evidenced based woman centred midwifery practice, both in the hospital and community

Responsibility for Policy and Service Development

The post holder will provide the strategic overview and input regarding the following:

Promotion of audit within the Maternity Unit, working closely with the Audit Group/team to determine suitable topics for audit

The support of midwives and junior doctors with their various audit tasks in conjunction with the area managers and consultants

Liaise with the representatives from the University to determine suitable audit projects for student midwives

Provision of quality information from Maternity System C for use in audit projects across the unit

Produce monthly key performance indicator data and trend report for the Maternity Dashboard to enable accurate forecasting of performance and improving value delivered to patients

To regularly attend both maternity and divisional governance meetings

Meet the Maternity Units obligations in relation to CQC standards and the effective delivery of the Patient Care Improvement Plans, thereby supporting an improvement in the organisational CQC rating. Identifying and managing associated risk and issues as they arise

Provide audit data for presentation within the Governance meeting

Meet the Maternity Units obligations in relation to NHS Resolution, CNST (Maternity incentive scheme) safety actions to support the delivery of safer maternity care.

Administrative Management

Actively seek opportunities to utilise the views and contributions of patients and the public when developing action and improvement plans in response to change, whether as a result of trust or national strategy and development.

Identify and implement key projects and effective systems to monitor compliance with clinical governance requirements.

To ensure all clinical governance policies are regularly reviewed, updated and disseminated.

To monitor and evaluate action plans for serious incidents on a regular basis.

To ensure maximum learning is gained from all governance and quality work, and measures are taken to improve the quality of service to patients provided by the Division.

To actively work towards achieving standards set by the Division and to be proactive in identifying areas for improvement.

Responsibility for Financial and Physical Resources

The post-holder will have some awareness of the requirement to work in a way which is efficient and effective which adds value to the organisation and is in line with the budget

The post holder will ensure they have the skills, knowledge and competence to use physical resources appropriately and ensure all members of the team have the appropriate competence

The post holder will be responsible for managing the budget of their team.

Responsibility for Leading and Managing

To work within Trust values and ensure decisions made are aligned with the organisations objectives.

To work within trust policies, procedures and guidelines and where appropriate, assist with the development of these documents in line with changes to legislation or best practice.

Actively contribute to achieving the clinical governance goals of the maternity and gynaecology service and the trust standards for nursing and midwifery, ensuring that they are met and completing any audits that may be required.

To conduct appraisals and ensure all staff within your team, are compliant in mandatory and statutory training and records are kept up to date.

Act as an effective role model and mentor promoting excellence through practice.

Maintain an overview of the all the actions and requirements originating from complaints and PALS ensuring that evidence of actions required are transparent and available.

Ensure that processes and procedures are robust, contemporary and withstand external scrutiny in accordance with CQC Regulations and NHS Complaints Procedure.

Liaise with external regulatory and inspection bodies, such as the Care Quality Commission and Parliamentary and Health Service Ombudsman as necessary, providing timely information and attending interviews or meetings as required.

Provide overall assurance on the utilisation and maintenance of the DATIX Complaints and PALS databases to ensure quality and integrity of data stored.

Assist in the management of difficult and highly charged or emotional situations, for example concerning violent, abusive or disruptive patients.

Take an active part in attempting to achieve resolution of disputes concerning clinical care, having direct contact with patients, families and staff as indicated and appropriate.

Take an active part in investigating formal complaints under the NHS Complaints Procedure, analysing letters of complaint and the main points of issue, assessing the adequacy of investigation and potential learning points.

Person Specification

Education, Training & Qualifications

Essential

• Educated to Masters level or willing to undertake study
• Capsticks Diploma in Risk Management
• Previous experience of Governance
• Experience with the Datix Risk Management System
• Evidence of continuing professional development

Desirable

• Registered Midwife eligi
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