Royal Surrey NHS Foundation Trust

Patient Safety Midwife B7

The closing date is 11 February 2026

Job summary

Band 7 Patient Safety Midwife

Maternity Leave Fixed Term

37.5 hrs a week

The Women and Children's Division is seeking to recruit an experienced practicing midwife who will support the Clinical Governance Lead midwife in delivering the governance agenda for maternity services. This will include leadership and oversight of incidents, guidelines and audit processes within the service.

The post holder will be responsible for defined work within the governance agenda and this will include leading on key quality improvement projects identified as a result of incident investigation. The post will support with all key assurance processes within the maternity service and include oversight of data entry and submission on local and regional reporting portals.

The post holder will support delivery by the senior leadership team of key work within the maternity governance agenda including the national delivery plan to be rolled out in 2026.

The post holder will support the governance midwife in delivery of all governance meetings and incident investigations as well as supporting external agencies such as MNSI, NHSR and MBRACCE.

For further information about this post please contact Clare Cardu via her email address ccardu@nhs.net

Details of closing date and interview will be outlined on NHS Jobs

Main duties of the job

To act as the patient safety midwife within the maternity department, focusing on undertaking audit, managing the guideline and document review process, incident management and other related clinical governance activities. This may include engaging with or leading change management and quality improvement projects.

This role will deputise for the Clinical Governance midwife in her absence leading the governance agenda for the maternity service.

Monitor the completion of actions from a number of sources including action plans arising from meetings, incident investigation and audit. Attend and contribute to disseminating learning from a variety of meetings, including perinatal mortality and morbidity meeting.

Use a number of data sources to share feedback with staff regarding the effectiveness of their clinical area and coordinate the creation and effectiveness of action plans.

Work with a multidisciplinary team and the obstetric lead for clinical governance to ensure clinical guidelines and procedural documents are reviewed and meet locally agreed standards.

Lead the process of reviewing mortality using the Perinatal Mortality Review Tool. This includes working with a multidisciplinary team to prepare the cases, lead the review, write the report and work with the bereavement midwife to engage with the patient and family.

Undertake other clinical governance activities as required, including responding to complaints, patient feedback, providing documents.

About us

Royal Surrey is a compassionate and collaborative acute and community Trust. Recognising that our 5000 colleagues are our greatest strength, we offer a comprehensive health and wellbeing program along with a commitment to developing and advancing your career. Our diverse and welcoming Royal Surrey family will ensure you that you feel valued from your initial interview through your entire tenure.

We are clinically led and provide joined up care by bridging the gap between hospital and community services alongside regional specialist cancer care. Our main acute hospital site is in Guildford with community hospital sites at Milford, Haslemere and Cranleigh. We provide adult community health services in homes across Guildford and Waverley.

The Care Quality Commission (CQC) have given us an overall rating of Outstanding.

Royal Surrey has a strong reputation and history to build on. We are proud of our achievements and we are investing in our colleagues through our commitment to supporting professional development as well as investing more than £45 million in our physical environment and new equipment in the next few years. There has never been a better time to join us.

Although it isn't the Trusts normal practice, adverts may close early, so you are encouraged to submit an application as soon as possible.

A video about the Royal Surrey - https://www.youtube.com/watch?v=R96pMboIYdo

Details

Date posted

28 January 2026

Pay scheme

Agenda for change

Band

Band 7

Salary

£50,008 to £56,908 a year per annum pro rata includes high cost area supplements

Contract

Fixed term

Duration

12 months

Working pattern

Full-time

Reference number

384-CH-EMF19900-B7

Job locations

Royal Surrey NHS Foundation Trust

Guildford

GU2 7XX


Job description

Job responsibilities

  • To conduct local and nationally required audits taking place in the maternity department. This includes the creation of audit standards and audit tools, analysing data generated, writing audit reports and presenting the findings to a variety of staff through a variety of methodologies.
  • To monitor the completion of action plans related to serious incident investigations and national improvement work.
  • To provide support and guidance to other healthcare professionals undertaking audit
  • To work in close collaboration with the Clinical Governance Team and the Clinical Governance Lead Midwife providing a robust and resilient service to support the maternity teams
  • To provide feedback and updates on all governance activityto the Maternity Quality and Safety Meeting as required
  • To lead key clinical governance activities, including research, by obtaining from a number of systems, including BagerNet (Matenrity EPR) and analysing data as required. Use the data and data analysis to assess clinical effectiveness
  • To collate evidence as required to demonstrate compliance with external inspections and other national requirements such as CNST and key national improvement plans led by NHSE. Ensure accuracy of data published for internal and external use with Surrey heartlands LMNS and NHSE/I.
  • To support the incident management process by investigating incidents
  • To manage the process of Perinatal Mortality Review Tool process. This includes identifying and preparing cases, leading the multidisciplinary review, identify recommendations and actions and monitoring the effectiveness of the actions.
  • Provide information for the Maternity Safety Board report regarding the Perinatal Mortality Review Tool activities
  • Manage the review of guidelines, this includes identifying guidelines and documents due to be reviewed and working the obstetric clinical governance lead to allocate guidelines to appropriate staff for review.
  • Reviewing appropriate guidelines and procedural documents for effectiveness and ensuring they meet national and local standards.
  • Managing guidelines and procedural documents through the review and ratification process
  • Support the implementation of guidelines and clinical procedural documents within the maternity department utilising a quality improvement approach as required
  • To maintain an up-to-date and comprehensive knowledge of local and national clinical effectiveness issues, including the interpretation of national health policies relevant to maternity to ensure that goals and standards are achieved
  • Collate and provide evidence to demonstrate compliance with NICE, CNST, CQC and any other national organisation as required
  • Respond to Freedom of Information Requests as required by the department
  • Support the clinical governance lead midwife in reporting key activities related to incident investigation
  • This post holder will be required to support clinical activity as a practicing midwife in times of escalation and also to participate in the midwifery on call rota as all practicing midwives do.

Project and Change Management

  • Provide methodological support to clinical teams, including stakeholder analysis, user involvement, sampling, data collection, data analysis, data reporting, dissemination, action planning and change management necessary for the improvement of clinical practice
  • Undertake and provide support to quality improvement projects within the maternity department
  • Explore opportunities in determining the most appropriate action through analysis and comparison

Education and Training

  • Support on-going training regarding documentation and documentation standards for clinicians within maternity
  • Assist in coordinating the maintenance of high quality standards in documentation amongst all staff group
  • To teach and support staff to ensure compliance with clinical guidelines and to adhere to The Code: professional standards for practice and behaviour for nurses and midwives (NMC 2015).
  • To present audit findings and recommendations to staff through meetings and clinical audit days
  • To achieve and maintain compliance with statutory and mandatory training requirements
  • Present the results of incident investigation to support learning and staff development

Job description

Job responsibilities

  • To conduct local and nationally required audits taking place in the maternity department. This includes the creation of audit standards and audit tools, analysing data generated, writing audit reports and presenting the findings to a variety of staff through a variety of methodologies.
  • To monitor the completion of action plans related to serious incident investigations and national improvement work.
  • To provide support and guidance to other healthcare professionals undertaking audit
  • To work in close collaboration with the Clinical Governance Team and the Clinical Governance Lead Midwife providing a robust and resilient service to support the maternity teams
  • To provide feedback and updates on all governance activityto the Maternity Quality and Safety Meeting as required
  • To lead key clinical governance activities, including research, by obtaining from a number of systems, including BagerNet (Matenrity EPR) and analysing data as required. Use the data and data analysis to assess clinical effectiveness
  • To collate evidence as required to demonstrate compliance with external inspections and other national requirements such as CNST and key national improvement plans led by NHSE. Ensure accuracy of data published for internal and external use with Surrey heartlands LMNS and NHSE/I.
  • To support the incident management process by investigating incidents
  • To manage the process of Perinatal Mortality Review Tool process. This includes identifying and preparing cases, leading the multidisciplinary review, identify recommendations and actions and monitoring the effectiveness of the actions.
  • Provide information for the Maternity Safety Board report regarding the Perinatal Mortality Review Tool activities
  • Manage the review of guidelines, this includes identifying guidelines and documents due to be reviewed and working the obstetric clinical governance lead to allocate guidelines to appropriate staff for review.
  • Reviewing appropriate guidelines and procedural documents for effectiveness and ensuring they meet national and local standards.
  • Managing guidelines and procedural documents through the review and ratification process
  • Support the implementation of guidelines and clinical procedural documents within the maternity department utilising a quality improvement approach as required
  • To maintain an up-to-date and comprehensive knowledge of local and national clinical effectiveness issues, including the interpretation of national health policies relevant to maternity to ensure that goals and standards are achieved
  • Collate and provide evidence to demonstrate compliance with NICE, CNST, CQC and any other national organisation as required
  • Respond to Freedom of Information Requests as required by the department
  • Support the clinical governance lead midwife in reporting key activities related to incident investigation
  • This post holder will be required to support clinical activity as a practicing midwife in times of escalation and also to participate in the midwifery on call rota as all practicing midwives do.

Project and Change Management

  • Provide methodological support to clinical teams, including stakeholder analysis, user involvement, sampling, data collection, data analysis, data reporting, dissemination, action planning and change management necessary for the improvement of clinical practice
  • Undertake and provide support to quality improvement projects within the maternity department
  • Explore opportunities in determining the most appropriate action through analysis and comparison

Education and Training

  • Support on-going training regarding documentation and documentation standards for clinicians within maternity
  • Assist in coordinating the maintenance of high quality standards in documentation amongst all staff group
  • To teach and support staff to ensure compliance with clinical guidelines and to adhere to The Code: professional standards for practice and behaviour for nurses and midwives (NMC 2015).
  • To present audit findings and recommendations to staff through meetings and clinical audit days
  • To achieve and maintain compliance with statutory and mandatory training requirements
  • Present the results of incident investigation to support learning and staff development

Person Specification

Qualifications

Essential

  • Practising registered midwife with significant experience in all aspects of midwifery
  • Mentorship qualification (or alternative)

Desirable

  • Quality Improvement training and experience of undertaking QI work
  • Leadership qualification or willingness to undertake development in this area.

Skills, Knowlede & Experience

Essential

  • Demonstrate ability to prioritise workload, adapt effectively to changing priorities and work without supervision
  • Presentation skills with an ability to present information to a variety of audiences
  • Able to problem solve
  • Able to analyse datasets
  • Have an awareness of audit and the audit process
  • Ability to make decisions autonomously, when required, working to tight and often changing timescales

Desirable

  • Previous experience of audit, clinical governance or risk management
  • Ability to process conflicting, controversial or sensitive information and cope with challenging situations
Person Specification

Qualifications

Essential

  • Practising registered midwife with significant experience in all aspects of midwifery
  • Mentorship qualification (or alternative)

Desirable

  • Quality Improvement training and experience of undertaking QI work
  • Leadership qualification or willingness to undertake development in this area.

Skills, Knowlede & Experience

Essential

  • Demonstrate ability to prioritise workload, adapt effectively to changing priorities and work without supervision
  • Presentation skills with an ability to present information to a variety of audiences
  • Able to problem solve
  • Able to analyse datasets
  • Have an awareness of audit and the audit process
  • Ability to make decisions autonomously, when required, working to tight and often changing timescales

Desirable

  • Previous experience of audit, clinical governance or risk management
  • Ability to process conflicting, controversial or sensitive information and cope with challenging situations

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

Royal Surrey NHS Foundation Trust

Address

Royal Surrey NHS Foundation Trust

Guildford

GU2 7XX


Employer's website

https://www.royalsurrey.nhs.uk/ (Opens in a new tab)


Employer details

Employer name

Royal Surrey NHS Foundation Trust

Address

Royal Surrey NHS Foundation Trust

Guildford

GU2 7XX


Employer's website

https://www.royalsurrey.nhs.uk/ (Opens in a new tab)


Employer contact details

For questions about the job, contact:

Head of Midwifery

Clare Cardu

01483571122

Details

Date posted

28 January 2026

Pay scheme

Agenda for change

Band

Band 7

Salary

£50,008 to £56,908 a year per annum pro rata includes high cost area supplements

Contract

Fixed term

Duration

12 months

Working pattern

Full-time

Reference number

384-CH-EMF19900-B7

Job locations

Royal Surrey NHS Foundation Trust

Guildford

GU2 7XX


Supporting documents

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