Clinical Quality and Governance Lead

Job responsibilities

Overview of general responsibilities. Within the Hospice to:

• Follow policies and guidelines as per the Staff Employees Handbook and ensure the team also work within this guidance.
• Oversee and support the caseload reviews of the Clinical Teams including Hospice at Home, Wellbeing Service, Complimentary Therapies, Befriending, Family Support and Community Service..
• Provide practical support for clinical teams to cover planned and unplanned absences within the clinical leads to ensure a robust provision is in place..
• To provide the CQC with monitoring information required to keep Great Oaks risk profile rated as a low risk.
• To produce regular reports which demonstrate service quality, clinical outcome measures and statutory compliance in support of the Quality Committee processes and external stakeholders.
• To analyse incident reporting, using root cause analysis, identifying trends and making recommendations for improving practice, ensuring lessons are learned are shared with the organisation to reduce likelihood of repetition.
• To keep up to date with national and local funding policies and initiatives. To identify, evaluate and progress potential funding streams/mechanisms in relation to provision of charitable activities.
• Monitor and follow up outstanding actions with those responsible to ensure closure against matters arising or the forward planner as appropriate.
• Provide evidence of gaps in meeting compliance, and devise plans to meet any such gaps.
• Support the Registered Manager in preparation of evidence and documentation for CQC inspections and engagement meetings.
• Complete the Data Security Protection Toolkit (DSPT) with advice and input from the senior management prior to submission.
• Support the Chief Executive with the compilation of regular statutory reports and Board/Committee reports.

Strategic:

• Provide Monthly, Quarterly reports and governance assurances to the Quality Committee and if required present them to the Board of Trustees and external stakeholders.

• Keep up to date with Quality Improvement agenda within healthcare, making recommendations for the hospice to adopt.

• Create, implement and monitor governance and compliance across the hospice including action, planning and support.

• Contribute to the strategic development of the hospice services with an emphasis on governance and compliance.

• Assist in the risk management arrangements and the planning and delivery of business continuity processes in the hospice.

• Review and adapt the monitoring system on CQC compliance, including clinical health and safety, and support and guide the change management process to achieve these.

• Advise and guide in collaboration with the Caldicott Guardian and SIRO on organizational compliance with Information Governance and GDPR.

• Advise, maintain and develop the hospices compliance with CQC regulations regarding legislation and best practice.

• Work with the Chief Executive to develop a rolling programme of service outcome measures which captures the effectiveness of Hospice services, and which supports the requirements of the CQC and other Statutory Bodies.

• To manage contracts and funding operations within the clinical service and lead our understanding of relevant public sector funding/commissioning processes and any government and national initiatives.

• Take the lead in creatively communicating with service users and stakeholders to gain information and feedback, with which to support the evaluation and development of services.

Managerial:

• Support the senior management team to manage and investigate complaints in accordance with the Great Oaks complaints procedures.
• Provide clinical support to all clinical staff and support the Chief Executive in line managing the clinical team leads as requested.
• Review of training needs analysis, ensuring role profiles are up to date, ensuring compliance and sourcing of external training as identified by services as needed.
• To contribute upon request to Committee and Board meetings, in particular relating to compliance requirements, potential funding and clinical operational effectiveness.
• To support the clinical team leaders in analysing incidents, accidents, using root cause analysis and feedback to ensure Great Oaks has a robust action and training plan to support learning and strive for excellence.
• To support and collaborate with the Fundraising Team by providing clinical activity data where needed for cases for support and profile raising.

Recognise that this job description is not restrictive and needs to be flexible to cope with the changing needs of the job and the changing needs of Great Oaks.

Managerial Knowledge

Essential

• Ability to support and nurture the development of clinical team

Experience

Essential

• Proven experience of a senior position within a health/social care environment.
• Proven experience of working with people with palliative or End of Life care needs.
• Experience of working in quality/compliance role
• Demonstrable experience of dealing effectively with matters of a highly sensitive and confidential nature
• Experience of planning and implementing service change in response to risk management issues
• Experience of communicating and engaging effectively with internal staff and external agencies/stakeholders
• Demonstrable experience of working with CQC guidelines
• Evidence of writing strategies, policies, procedures and guidelines
• Evidence of report writing and the ability to produce high quality comprehensive reports to senior management level
• Demonstrable experience of managing risk
• Knowledge and experience of audit
• Track record of leading and facilitating change, meeting strict deadlines, working under pressure and dealing with conflicting priorities.

Desirable

• Senior management experience within a healthcare organisation
• Evidence of leadership and accountability for performance management
• Some understanding and knowledge of the workings and challenges faced within healthcare environment
• Experience of working with volunteers
• Evidence of Information Governance management

Knowledge and Attributes

Essential

• Practical experience of quality and governance principles, systems and processes
• Detailed knowledge of risk management and governance and its impact on the organisation
• Knowledge of current symptom management
• Professional knowledge of CQC requirement
• Practical working knowledge of Systm1

Desirable

• Knowledge and understanding of Information Governance and the responsibilities associated with it.

Personal Skills and Attributes

Essential

• Excellent organisational skills, including the ability to manage time and prioritise workload effectively
• Excellent interpersonal and relationship-building skills with the ability to communicate effectively at all levels
• Ability to make decisions and implement changes, following detailed analysis and interpretation of data and statistics
• Project management skills with an ability to think analytically, anticipate obstacles and think ahead using analytical techniques to identify several solutions
• Excellent IT skills across a broad range of platforms
• An ability to provide, receive, convey and present information in a clear way
• Insight into the needs of the patient group
• Ability to work collaboratively and network
• Supportive, calm, approachable manner
• Emotionally resilient and intelligent
• Proactive and innovative
• A strong teamwork ethic

Desirable

• Proven track record as a motivational leader, with the ability to negotiate and provide empathy, reassurance and support

Other Requirements

Essential

• Willing to travel
• Willingness to support occasional on call out of hours including evenings and weekends to cover absence
• Occupational health clearance
• Enhanced DBS
• A full driving licence and access to a vehicle insured for business use

Qualifications

Essential

• Registered Nurse with the Nursing and Midwifery Council or Registered Band 6 or above
• Educated to degree in relevant subject or equivalent level qualification or significant experience of working at a similar level in specialist area supporting professional development

Desirable

• Clinical or risk management qualification
• Teaching/mentoring qualification
• Masters or equivalent level of experience working at senior level in specialist area
• Evidence of clinical specialist qualification in palliative care or oncology

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).