Ashford & St. Peter's Hospitals NHS Foundation Trust

Divisional Governance Lead (FIXED TERM 6 MONTHS)

The closing date is 15 April 2026

Job summary

We are seeking an experience nurse/ registered practitioner to support the medical division with governance. The general and specialist Medical division is a busy division with eleven inpatient wards, four ambulatory units/ services and a busy outpatient delivery service.

The person will support the governance framework and patient experience for the division alongside the leadership and ward teams.

the post is currently being offered as a six month fixed term contract and we welcome interested individuals to get in contact with either Janet McAuley Divisional Chief Nurse 01932 72190 or janet.mcauley@nhs.net or Emma Reed Head of Nursing on 07729 079906

Main duties of the job

Take a lead in the Quality Governance Assurance Framework ensuring that the quality of care in the division, patient experience, patient safety and clinical effectiveness is of the highest standard, meeting national and local outcomes

Provide information relating to the divisional compliance with CQC ensuring that Health Assure is updated in a timely way

Ensure that the Quality, Safety and Risk Management Framework is embedded in the division

Co-ordinate clinical and non-clinical risk management activities across the division

To report regularly and liaise with Divisional Chief Nurse and Associate Director of Nursing on developments within the division and organisation, learning from incidents, risk management, audit and in-service education

To monitor incidents/events recorded via the Trust reporting system relating to the division in order to co-ordinate and communicate actions taken locally and disseminate appropriately any issues that could promote organisational learning

Prepare reports for discussion relating to the division

To keep abreast of the National Agenda in regards to Patient Safety. Ensure dissemination of the Patient Safety Alerts from the NPSA and co-ordinate the responses to ensure that appropriate action plans are in place and actione

Take a lead on co-ordinating Patient Experience , PALs and complaints

About us

Ashford and St. Peters Hospitals NHS Foundation Trust serves a population of more than 410,000 people living in North-West Surrey, parts of Hounslow and beyond.

Over 3,700 highly trained doctors, nurses, midwives, therapists, healthcare scientists and other support staff make up our workforce, providing a wide range of services across our two hospital sites, Ashford, Surrey and St Peter's, Chertsey, Surrey.

We also run many specialist clinics in the community and local community hospitals and other healthcare facilities.

Our vision is to be one of the best healthcare Trusts in the country. There has never been a better time to join us in the NHS at ASPH. We are committed to providing continuous professional development and flexibility to shape our workforce around our patient care.

We are expanding our theatres at Ashford Hospital and moving towards this becoming our dedicated elective centre. We want to create a state-of-the-art centre for excellence for planned surgical procedures.

We can offer you the full range of NHS benefits/discounts and in addition:

  • Excellent pension scheme and annual leave entitlement
  • On-site Nurseries
  • On-site staff cafes
  • On-site parking
  • Support in career development
  • Salary Sacrifice schemes including wage stream, lease cars, Cycle to Work schemes and home electronics

Adverts may close early, so applicants are encouraged to submit an application as soon as possible.

For more information about a career at ASPH please visit:www.asph-careers.org

Details

Date posted

10 April 2026

Pay scheme

Agenda for change

Band

Band 8a

Salary

£59,798 to £67,020 a year pa, inc. HCAS

Contract

Fixed term

Duration

6 months

Working pattern

Full-time, Flexible working

Reference number

323-NM4469-MH-A

Job locations

ashford and st peters nhs trust

guildford road

chertsey

KT160PZ


Job description

Job responsibilities

Internally the post holder will develop effective working relationships with:

Clinicians and Nursing Staff

Admin & Clerical Staff

Quality Department

1. MAIN DUTIES AND RESPONSIBILITIES OF THE POST:

Quality Responsibilities:

In conjunction with the Divisional Chief Nurse, Head of Nursing, Matrons , Lead Nurse for Stroke, Associate Director Operations and Divisional Director assess and review compliance with governance and CQC standards.

Lead and maintain the PSIRF dashboards and co-ordinate the investigative process supporting wards and leadership team to carry out appropriate meetings.

Lead on closing and supporting actions and learning across the division

Identify and cascade to senior leadership team any immediate risk or actions which occur as part of the incident reporting system

Support the completion of Duty of Candour statutory letters through the division

In conjunction with the Divisional Chief Nurse, Head of Nursing, Matrons, Lead Nurse for Stroke, Associate Director Operations and Divisional Director take responsibility for tracking all complaints relating to the division

In conjunction with the Divisional Chief Nurse and Patient Experience Team

assist with investigation and actions as a result of complaints

Contribute to the development of effective strategies, policies and processes across the Division

Develop and implement systems to identify opportunities for learning and sharing good practice creating learning opportunities for the division

Work with senior clinicians to monitor the implementation of NICE guidelines, National Service Frameworks and NCEPOD recommendations

Support report writing for EPSIP meetings and governance meetings

Work with all divisional teams to ensure speciality governance meetings are taking place and feed into the divisional governance meetings

Monitor PSIRF training and compliance

Risk Management responsibilities:

In conjunction with the leadership team, be responsible for delivering the Quality, Safety and Risk Management Strategy

Lead and collate the evidence/information required from the division regarding the NHSLA risk management standards

Be responsible for following up any events causing concern with the appropriate nurse/clinician

Take the lead in reporting incident events to the Divisional Governance Group, contributing to any action planning as a result of an event and supporting staff to implement the identified actions

Advise and support staff to undertake Root Cause Analysis Training investigation process

Facilitate a proactive approach to risk management through support of risk assessment process in helping to populate the Trust risk register and ensuring regular reviews and updates are maintained

Ensure recommended action is taken as a result of risk management investigations

Education responsibilities:

Take a lead role in the provision of governance training within the division

To ensure all staff are aware of their governance responsibilities

Oversee achievement of the Trusts mandatory training requirement across the division

Work with teams to ensure compliance with incident reporting is taking place and support with any educational needs that may arise

Ensure all learning and actions are being discussed and disseminated from floor to Board

Audit Responsibilities:

Work in conjunction with a designated group of clinicians and specialist nurses to make recommendations designed to eliminate or reduce risk and help facilitate the identified changes in practice

To foster and encourage an environment of clinical audit, acting as a facilitator for audits in conjunction with the clinical leads across the Division

Take the lead on producing reports for the local governance and quality meetings

Work with the divisional team to ensure CENARG audits and guidelines are reviewed

Professional Responsibilities:

Maintain own professional registration

Act as a role model, maintaining and upholding high standards of professional behaviour

Be an effective leader of change, embedding a culture of continuous quality improvement, innovation and use of technology that meets the changing needs of patients

Maintain a flexible approach to working

General responsibilities

To support the department and organisation by carrying out any other duties that reasonably fit within the broad scope of a job of this grade and type of work.

Job description

Job responsibilities

Internally the post holder will develop effective working relationships with:

Clinicians and Nursing Staff

Admin & Clerical Staff

Quality Department

1. MAIN DUTIES AND RESPONSIBILITIES OF THE POST:

Quality Responsibilities:

In conjunction with the Divisional Chief Nurse, Head of Nursing, Matrons , Lead Nurse for Stroke, Associate Director Operations and Divisional Director assess and review compliance with governance and CQC standards.

Lead and maintain the PSIRF dashboards and co-ordinate the investigative process supporting wards and leadership team to carry out appropriate meetings.

Lead on closing and supporting actions and learning across the division

Identify and cascade to senior leadership team any immediate risk or actions which occur as part of the incident reporting system

Support the completion of Duty of Candour statutory letters through the division

In conjunction with the Divisional Chief Nurse, Head of Nursing, Matrons, Lead Nurse for Stroke, Associate Director Operations and Divisional Director take responsibility for tracking all complaints relating to the division

In conjunction with the Divisional Chief Nurse and Patient Experience Team

assist with investigation and actions as a result of complaints

Contribute to the development of effective strategies, policies and processes across the Division

Develop and implement systems to identify opportunities for learning and sharing good practice creating learning opportunities for the division

Work with senior clinicians to monitor the implementation of NICE guidelines, National Service Frameworks and NCEPOD recommendations

Support report writing for EPSIP meetings and governance meetings

Work with all divisional teams to ensure speciality governance meetings are taking place and feed into the divisional governance meetings

Monitor PSIRF training and compliance

Risk Management responsibilities:

In conjunction with the leadership team, be responsible for delivering the Quality, Safety and Risk Management Strategy

Lead and collate the evidence/information required from the division regarding the NHSLA risk management standards

Be responsible for following up any events causing concern with the appropriate nurse/clinician

Take the lead in reporting incident events to the Divisional Governance Group, contributing to any action planning as a result of an event and supporting staff to implement the identified actions

Advise and support staff to undertake Root Cause Analysis Training investigation process

Facilitate a proactive approach to risk management through support of risk assessment process in helping to populate the Trust risk register and ensuring regular reviews and updates are maintained

Ensure recommended action is taken as a result of risk management investigations

Education responsibilities:

Take a lead role in the provision of governance training within the division

To ensure all staff are aware of their governance responsibilities

Oversee achievement of the Trusts mandatory training requirement across the division

Work with teams to ensure compliance with incident reporting is taking place and support with any educational needs that may arise

Ensure all learning and actions are being discussed and disseminated from floor to Board

Audit Responsibilities:

Work in conjunction with a designated group of clinicians and specialist nurses to make recommendations designed to eliminate or reduce risk and help facilitate the identified changes in practice

To foster and encourage an environment of clinical audit, acting as a facilitator for audits in conjunction with the clinical leads across the Division

Take the lead on producing reports for the local governance and quality meetings

Work with the divisional team to ensure CENARG audits and guidelines are reviewed

Professional Responsibilities:

Maintain own professional registration

Act as a role model, maintaining and upholding high standards of professional behaviour

Be an effective leader of change, embedding a culture of continuous quality improvement, innovation and use of technology that meets the changing needs of patients

Maintain a flexible approach to working

General responsibilities

To support the department and organisation by carrying out any other duties that reasonably fit within the broad scope of a job of this grade and type of work.

Person Specification

Qualifications

Essential

  • Registered qualification ie. RN AHP
  • Governance training ie. PSIRF
  • bsc Healthcare
  • working towards a MSC

Desirable

  • Management or risk qualification

Experience

Essential

  • oSignificant post registration experience.
  • experience of chairing safety reviews
  • Experience of PSIRF framework and fundamentals of governance and patient experience

Desirable

  • worked in governance role previously

attitudes and behaviours

Essential

  • oFlexible in their attitudes and behaviours to support team working and delivery of objectives
  • take pride in their team
  • passion for excellence
  • patients first

Knowledge and skills

Essential

  • oStrong understanding of a responsiveness to the complexities and dynamics of the healthcare environment
  • oClear understanding of the current NHS issues and initiatives pertaining to Clinical Governance and practice
  • oUnderstanding and insight into the challenges of addressing the Clinical Governance/Quality agenda
  • oYou are able to communicate effectively to ensure high standards of care, treatment, service or support as appropriate to your role,
  • oPeople management skills, including leadership, decision making, negotiating, influencing and persuading skills
  • able to use complex data and databases and knowledge of datix process
Person Specification

Qualifications

Essential

  • Registered qualification ie. RN AHP
  • Governance training ie. PSIRF
  • bsc Healthcare
  • working towards a MSC

Desirable

  • Management or risk qualification

Experience

Essential

  • oSignificant post registration experience.
  • experience of chairing safety reviews
  • Experience of PSIRF framework and fundamentals of governance and patient experience

Desirable

  • worked in governance role previously

attitudes and behaviours

Essential

  • oFlexible in their attitudes and behaviours to support team working and delivery of objectives
  • take pride in their team
  • passion for excellence
  • patients first

Knowledge and skills

Essential

  • oStrong understanding of a responsiveness to the complexities and dynamics of the healthcare environment
  • oClear understanding of the current NHS issues and initiatives pertaining to Clinical Governance and practice
  • oUnderstanding and insight into the challenges of addressing the Clinical Governance/Quality agenda
  • oYou are able to communicate effectively to ensure high standards of care, treatment, service or support as appropriate to your role,
  • oPeople management skills, including leadership, decision making, negotiating, influencing and persuading skills
  • able to use complex data and databases and knowledge of datix process

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

Ashford & St. Peter's Hospitals NHS Foundation Trust

Address

ashford and st peters nhs trust

guildford road

chertsey

KT160PZ


Employer's website

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


Employer details

Employer name

Ashford & St. Peter's Hospitals NHS Foundation Trust

Address

ashford and st peters nhs trust

guildford road

chertsey

KT160PZ


Employer's website

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


Employer contact details

For questions about the job, contact:

divisional chief nurse

janet mcauley

janet.mcauley@nhs.net

01932722190

Details

Date posted

10 April 2026

Pay scheme

Agenda for change

Band

Band 8a

Salary

£59,798 to £67,020 a year pa, inc. HCAS

Contract

Fixed term

Duration

6 months

Working pattern

Full-time, Flexible working

Reference number

323-NM4469-MH-A

Job locations

ashford and st peters nhs trust

guildford road

chertsey

KT160PZ


Supporting documents

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