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Audit, Guideline, Compliance and Quality Midwife

North Middlesex University Hospital NHS Trust
£49,178 to £55,492 Per annum inclusive HCAS (pro-rata if LTFT)
Closing date
24 May 2024

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Nurse, Midwife
Band 7
Contract Type
Full Time
North Middlesex Maternity: A career in Midwifery, not just a job.

The post of Audit, Guideline, Compliance and Quality midwife is role that will appeal to any midwife who has a passion for patient safety and governance. This role will provide an opportunity to be part of a team ensuring that the highest standards are set and that we are able to provide the best and safest care possible to the families that we provide care for.

We are looking for a midwife who has experience of developing and implementing guidelines, involvement in clinical audit, has experience of being involved with or implementing Quality Improvement (QI) initiatives and can demonstrate an excellent understanding of Clinical Governance.

Here at North Middlesex maternity, we can offer you a career, not just a job. Our midwives are supported in their learning and development to help them to reach their full potential. This includes secondment opportunities within specialist teams, shadowing opportunities with members of the senior team, leadership programmes and Chief Nurse fellowship programmes. There is also the chance to be part of the talent management process.

Main duties of the job

The post holder will co-ordinate and have oversight of clinical audit within the department and be able to present the findings to a multi-disciplinary audience.

They will lead on or work collaboratively on Quality Improvements initiatives, implementing, evaluating and reporting back on progress.

They will be required to review and update all existing guidelines in collaboration with the relevant teams with a strong focus providing robust, evidence-based guidance.

They will lead on the production and updating of patient information leaflets to ensure accessible and accurate information that is appropriate for the population of women using our service.

About us

NMUH North Middlesex University Hospital NHS Hospital Trust (NMUH) is one of London's busiest healthcare providers, providing hospital care and community services for the 350,000 people living in Enfield, Haringey and beyond. Our specialist services include HIV, cardiology, blood disorders, diabetes, fertility, sickle cell and thalassemia. In addition to a full range of cancer diagnosis and treatment services, the Helen Rollason Cancer Support Centre is based on-site and provides services to support cancer patients' wellbeing. We also provide community services and have a dedicated 0-19 service for children and young people in Enfield so that they can get the best possible start in life. This includes health visitors and school nurses who are delivering the national Healthy Child Programme, which provides a structured framework for the delivery of key interventions to support the health and wellbeing of children and families from 0 to 5 and school aged children from 5-19. The 0-19 service aims to improve pathways and partnerships with services in the hospital and deliver excellent care for the children and families. For more information, please access the following link:

Job description

Job responsibilities

Duties and Responsibilities:

Audit and Guidelines
  • Facilitate the development, implementation and monitoring of clinical guidelines across the Womens Directorate.
  • To ensure the Directorate is aware of National and Regional guideline changes in practice that may influence local guideline development, to ensure practice remains up to date & evidence based
  • To ensure a robust repository of guidelines within the Directorate is monitored and maintained, to provide assurance to the Division that the guidelines are up to date and in line with current practice.
  • Work with the audit midwife to facilitate the clinical audit programme within the Directorate incorporating local and national audit requirements that support clinical effectiveness.
  • work with the audit midwife in the facilitation of the development of Clinical Audit & Effectiveness activity plans, assisting the Trust Clinical Audit 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 and CQC outcomes and regulations.
  • Consult and provide advice to clinical staff on the design and development of proposed audit projects. This may include advice on selecting topics to audit, carrying out literature searches, advising on the appropriate audit methodology in order to promote the completion of the clinical audit cycle.
  • Work with the audit midwife and create appropriate systems and processes for the collection of the data for the audit projects.
  • Provide written and verbal reports and presentations of completed audit projects and current status of guidelines to the relevant multi-professional groups.
  • Support the Governance Team in its work plan to demonstrate compliance with CQC, CNST, Ockenden and other regulatory bodies requirements.
  • To summarise completed audit reports for presentation to relevant meetings within the department and directorate.
  • Support audit project leads in the monitoring of action implementation.
  • Provide support to staff in development of new guidance and alteration to existing guidelines to meet requirements.
  • Communicate with Departmental Managers on clinical issues related to practice.
  • Support line managers in the effective and efficient use and management of resources.
  • Contribute to dissemination of information relating to audit and quality governance across relevant staff groups.
  • Evaluate the clinical audit training and education needs across the organisation, in conjunction with the Governance Team.
  • Work with the Trust library and the Academy to ensure research and clinical effectiveness material is accessible locally to clinical staff and team members.
  • Liaise with other agencies for the purpose of information exchange on audit and related quality activities.
  • Maintain confidentiality at all times.
  • Promote an evidence-based learning culture through the use of clinical audit and up to date guideline used in clinical practice.

Undertake delegated activities relating to Quality Governance including but not limited to:
  • Participation and record keeping of governance meetings and activities
  • Maintain governance databases
  • Participate in service improvement projects.
  • Ensure clinical governance encompasses continuous quality improvement.
  • Demonstrate ability to access /generate information from Trust IT systems as required.
  • Remain up to date with changing practice/research and maximise the use of all training, education and IT facilities.

Patient Experience
  • To develop and maintain a co-produced maternity user experience improvement plan.
  • To co-ordinate the completion of all patient experience projects within the directorate as per service improvement plan
  • To present findings of patient experience projects undertaken at MVP and directorate meetings
  • To attend and participate in maternity directorate meetings as appropriate
  • Act as a resource for staff in both the hospital and community setting
  • Contribute to the directorates Effective Handover Huddles, sharing feedback on patient experience projects undertaken, progress on the compliance with guidelines, quality improvement plan and changes in practice resulting from audit.
  • Prepare monthly progress reports for the maternity services directorate team to ensure compliance with guidelines
  • Provide monthly progress information for inclusion in the directorates maternity safety report to be presented to Trust Board.
  • Develop IT systems and spreadsheets to maintain accurate records of all patient information leaflets, undertaken within the directorate and with service users
  • Communicate with key leads to maximise the potential for the successful implementation of the evidence based guidelines reflecting National Standards & recommendations.
  • Provide timely, accurate progress reports to all stakeholders in relation to guideline & audit activity across the maternity Directorate.
  • In collaboration with other senior midwives/ nurses, managers and clinical leads, contribute to providing oversight of guideline and audit recommendations to improve the safety of women/birthing people, and babies.
  • Work closely with the Governance Lead, Governance Manager, Director and Associate Director of Midwifery, Deputy Head of Midwifery, Matrons, the LMNS, MVP, Clinical Lead and Midwives prioritising workloads which may include undertaking training, audit and guideline development to aid implementation of key national projects for example Saving Babies Lives and attend relevant study days as required.
  • Work closely with the Divisional Governance Lead, Governance Manager the Midwifery/ Nursing Clinical education team for Education and Development.
  • Demonstrate clear, effective extended communication skills with colleagues and other agencies to ensure effective implementation of objectives.
  • Use every opportunity to facilitate teaching, learning and reflection within the clinical area.
  • To communicate highly sensitive and complex information to women and their families clearly explaining the benefits and risks of different care approaches and the alternatives available recognising barriers to acceptance. To uphold these standards and support midwives/ nurses in achieving them.
  • Represent the directorate on external professional groups and network with colleagues from other organisations as appropriate.
  • Ensure that the womans voice is clear within any service developments, seeking opinion and views on any changes.
  • Work collaboratively with other professional groups to maximise development opportunities and interprofessional learning opportunities.
  • Maximise opportunities to share good practices and innovations with colleagues locally and nationally.
  • Contribute to the development of a learning organisation, alerting the appropriate parties to resource issues which may affect this.
  • Identify own training and professional development needs to maintain clinical credibility.
  • Influence and nurture positive attitudes and behaviours within the teams and wider multidisciplinary team. Education and Development
  • Participate in curriculum development and joint professional development activities with other agencies e.g. Learning and Development Department, Universities, CCGs and the Local Maternity System to maximise learning opportunities.
  • Participate in regular performance and personal development reviews and work to achieve agreed objectives.

Research and Practice Development
  • Promote research/evidence based practice and audit outcomes to inform clinical practice and set clinical standards.
  • Instigate or contribute to research initiatives and clinical audit programmes as appropriate. Management of Resources
  • Promote a culture where staff are valued supported and deliver high quality care
  • Understand, manage and be accountable for the use of resources in a cost effective way
  • Actively support the Improving Working Lives initiatives within the Department and across the Trust. Quality Management
  • Facilitate the development implementation, monitoring, evaluation and audit of nursing/midwifery policies, protocols, guidelines and standards ensuring that they meet current practice and professional regulations.
  • Act as a resource for staff to access and raise awareness of national and local policies that will impact upon them and affect the delivery of patient care

Ensure that quality standards are set and monitored and that clinical risk management and clinical audit are an integral part of practice developments.
  • Establish effective communication and good working relationships with multi-professional colleagues within the Trust to support effective service delivery.

Other Duties
  • Provide cover for colleagues as appropriate.
  • Assist in producing ad hoc reports and in project work.
  • Undertake any other duties requested as appropriate to the banding eg Unit Co-ordinator

Person Specification

Qualifications and Training


  • oRegistered Midwife with current registration.
  • oEducated to degree level or equivalent experience
  • oTeaching qualification or equivalent / Mentorship Qualification/ Practice Assessor


  • oIT qualification
  • oPrevious IT or data quality experience



  • oDeveloping, implementing and monitoring guidelines
  • oAudit of guidelines and compliance
  • oA good understanding of current and emerging issues relating maternity and the NHS.
  • oKnowledge of specialist areas, e.g.: CQC standards and regulatory requirements, CNST Maternity Incentive Scheme, NHSLA, Ockenden, Better Births etc
  • oAbility to lead on quality improvement projects and compliance
  • oAbility to prepare and deliver presentations to a group of people.
  • oAbility to work as part a multidisciplinary team
  • oAbility to store data/information safely and correctly
  • oAbility to evaluate effectiveness

Skills and Knowledge


  • oAbility to work within set timeframes working to priorities and deadlines
  • o Ability to monitor the quality of own and others work
  • oAble to recognise own limits and work within those limits of competence
  • oReport Writing Skills
  • oPresentation Skills
  • oIT Literate (MS WP/Excel & PowerPoint)
  • oChange Management
  • oInnovative Practice
  • oResearch and Audit
  • oAbility to communicate effectively at all levels across the Department and Trust.
  • oAbility to communicate effectively, both written and oral

Personal Qualities


  • oAbility to demonstrate enthusiasm towards teaching and sharing knowledge.
  • oUnderstanding of own knowledge and skills
  • oFramework
    Any attachments will be accessible after you click to apply.


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