Head of Governance, Quality and Patient Safety

Salary: £57528.00 to £60417.00

You will lead the
Governance and Education Team, with responsibility for patient safety, risk
management, clinical audit, quality improvement, policy oversight and
regulatory assurance. You will provide clear reporting to the Director of
Clinical Services and, through the Director, to senior leaders and Trustees.
You will also deputise for the Director of Clinical Services within agreed
responsibilities and participate in the senior on-call rota. There is scope to
take on Registered Manager responsibilities in future, subject to
organisational requirements, mutual agreement and CQC registration.

The Head of Governance, Quality and Patient
Safety is a senior leadership role within the Care Directorate. The post holder
provides strategic and operational leadership for governance, quality
assurance, patient safety, risk management, clinical effectiveness and
regulatory compliance across Haven House Childrens Hospice. The post holder will lead the organisations
governance and quality systems, ensuring robust processes are in place to
support the delivery of safe, effective, caring, responsive and well-led
services. They will provide assurance to the Director of Clinical Services, who
is the executive lead for quality and safety, and through the Director to the
Executive Team, Board Committees and Board of Trustees. The post holder will act as the organisational
lead for CQC readiness under the Single Assessment Framework, maintaining
continuous preparedness and oversight of evidence, compliance and improvement
activity. Deputise
for the Director of Clinical Services, as required, in relation to governance,
quality, patient safety, regulatory assurance and CYP/family experience within
agreed delegated authority. There is scope for the post holder to take on
Registered Manager responsibilities in future, subject to organisational
requirements, mutual agreement and CQC registration.

Key Responsibilities
Governance and Quality
Own the organisational governance
and assurance framework, with individual service leads remaining accountable
for the delivery and reporting of safe practice, compliance and improvement
within their areas. Identify and escalate gaps in assurance to the Director of
Clinical Services.Ensure the voice and experience of
children, young people and families is embedded within quality governance and
assurance, with feedback, experience data, complaints, compliments and
co-production used to identify themes, drive improvement and evidence impact.Maintain oversight of governance
structures, terms of reference and reporting arrangements, ensuring clear lines
of accountability to Board.Develop and maintain quality,
patient safety and experience dashboards and metrics to support organisational oversight and
assurance.Produce regular governance, quality,
safety and experience reports for the Director of Clinical Services, SLT, Board
Committees and Trustees.Lead the production of the annual
Quality Account in partnership with the Director of Clinical Services.Own the organisational governance
assurance action tracker, actively drive delivery with responsible leads,
escalate slippage and provide evidence of closure and sustained improvement.
Patient Safety and Learning
Act as the organisational lead for
patient safety and incident managementLead implementation of the Patient
Safety Incident Response Framework (PSIRF), including the Patient Safety
Incident Response Plan, proportionate learning responses and patient safety
incident investigations.Ensure incidents are recorded
through the Learn from Patient Safety Events (LFPSE) service and that local
reporting systems are effective.Lead the Duty of Candour framework
and provide assurance regarding compliance.Maintain strategic oversight of
complaints, concerns and compliments, ensuring responses are timely and
learning is captured.Lead thematic reviews and ensure
learning from incidents, complaints, audits, safeguarding reviews, child death
reviews and family feedback is embedded into practice.Establish and maintain systems to
verify that actions arising from incidents, audits, complaints, regulatory
reviews and investigations have been implemented effectively, embedded in
practice and resulted in sustained improvement.Support the organisations
contribution to child death review processes, including Child Death Overview
Panel (CDOP) and National Child Mortality Database (NCMD) requirements. Maintain oversight of medicines
safety governance, working with the Director of Clinical Services and pharmacy
partners. Ensure learning from Freedom to
Speak Up concerns is reflected in governance reporting, working with the
Freedom to Speak Up Guardian.
CQC and Regulatory Assurance
Lead organisational readiness for
assessment and inspection under the CQC Single Assessment Framework Maintain oversight of compliance
with relevant legislation, CQC regulations, national standards and professional
guidance. Develop and maintain a comprehensive
evidence repository and compliance platform demonstrating quality outcomes.Coordinate organisational responses
to inspections, regulatory enquiries, statutory notifications and assurance
reviews.Deputise
for the Director of Clinical Services/Registered Manager as required, within
agreed delegated authority, and support the discharge of Registered Manager
responsibilities.Lead mock inspections and internal
assurance reviews and develop action plans to address gaps.Monitor developments in legislation,
regulation, national
policy and guidanceand advise on their implications and recommended actions. Support senior leaders and Trustees
in understanding regulatory requirements, including Well-Led expectation
Risk Management, Audit and Assurance
Lead the clinical risk management
framework and maintain the clinical risk register, ensuring alignment with
organisational and strategic risk registers.Ensure effective systems for risk
identification, assessment, mitigation and escalation.Lead the development and delivery of
the annual clinical audit and assurance programme.Ensure audit findings and assurance reviews result in measurable,
sustained improvements, with completed actions tested to confirm that changes
are embedded in practice and effective over time.Oversee service evaluation, quality
assurance and performance monitoring activity.
Clinical Effectiveness and Quality Improvement
Lead the organisational Quality
Improvement Strategy and promote the use of quality improvement methodology
across services.Maintain oversight of clinical
effectiveness programmes and the implementation of NICE and other national
guidance.Ensure service development is driven by outcome measures, audit findings and feedback
from children, young people and families.Champion innovation and improvement
initiatives that enhance care and experience for children, young people and
families.
Policy and Information Governance
Lead the organisational policy
management framework, including development, consultation, review, ratification
and implementation. Maintain document control and
version management systems, ensuring policies are compliant, current and
accessible.Support information governance
arrangements, including completion of the Data Security and Protection Toolkit
(DSPT).Act as Caldicott Guardian as
designated by the organisation.
Safeguarding
Support the Designated Safeguarding
Lead and team in the governance and assurance of safeguarding arrangements. Ensure safeguarding learning, audit
findings and assurance activity are integrated into the wider governance and
quality framework.
Education and Workforce Development
Provide strategic oversight of
clinical education, training and competency frameworks delivered by the
Education and Governance Team.Ensure education programmes respond
to learning from incidents, audits, complaints and regulatory findings.Maintain oversight of mandatory and
clinical training compliance and report on it through governance structures.Lead the development of governance
and quality improvement capability across the organisation.
Leadership and Management
Provide professional leadership and
line management to the Education and Governance Team, including supervision,
appraisal, wellbeing and professional development. Foster a culture of openness, accountability,
psychological safety, learning and continuous improvement.Support workforce development and
succession planning within the governance function.Address performance, conduct and
capability concerns in line with organisational policies.Participate in the senior on-call
rota and deputise for the Director of Clinical Services where delegated,
including governance decision-making, incident escalation, regulatory matters
and quality and patient safety assurance within agreed authority.
Collaborative Working
Work collaboratively with clinical,
operational and corporate leaders to improve governance, quality and safety. Hold leads to account for delivery
of governance and assurance actions and escalate failures of assurance to the
Director of Clinical Services. Build strong relationships with
external partners, including NHS organisations, the Integrated Care Board,
regulators and professional networks. Provide specialist governance advice
to service developments, transformation programmes and strategic projects. Represent Haven House at internal
and external meetings relating to governance, quality, patient safety and
regulatory matters.