Quality & Governance Lead

Job description

Job responsibilities

Governance, assurance and regulatory compliance

Lead day-to-day delivery of quality governance systems, ensuring structured oversight of compliance requirements, evidence collation and reporting cycles across services.

Maintain organisational readiness for external scrutiny by ensuring governance artefacts are current, complete, traceable and accessible.

Support the CEO & Senior Management Team (SMT) with assurance reporting, action tracking and governance development activity.

External inspection and accreditation readiness

Coordinate preparation and evidence portfolios for external inspection and accreditation activity e.g. CQC and other relevant framework standards as applicable.

Maintain inspection readiness trackers, action logs and evidence sets, ensuring timely closure of action with clear audit trails.

Support CEO and SMT during visits/reviews including briefings, evidence retrieval and follow-up action coordination.

Audit programme and quality improvement

Coordinate and deliver the internal audit programme across the Hospice, ensuing audits are scoped, scheduled and completed to deadline using standardised tools/templates.

Ensure audit findings translate into SMART actions, tracked to completion with evidence based closure and measurable improvement.

Lead continuous improvement by promoting learning, standardisation and effective governance routines across teams.

Risks, incident, complaints and learning

Lead effective incident, complaint and feedback governance, including logging oversight, investigation support, thematic reviews and tracking learning/actions to closure.

Lead on the Risk module on Vantage

Contribute to risk management processes (risk registers, risk assessments), ensuring mitigation actions are tracked and evidenced.

Promote a just culture and leaning approach to safety and quality improvement.

Training, engagement and stakeholder working

Build effective working relationships with the Senior Management Team, clinical leads, operational managers and wider staff groups to enable sustained compliance.

Represent the Quality & Governance functions at internal meetings and where appropriate, external stakeholder discussions.

Professional and organisational responsibilities

Maintain confidentiality and comply with information governance requirements, GDPR and organisational IG policies, ensuring secure handling and appropriate access controls for governance evidence.

Maintain up to date knowledge of relevant quality, governance and assurance frameworks applicable to the Hospice.

Take responsibility for the management, development and improvement of systems supporting your role e.g. Vantage modules or other systems as required.

Undertake other duties consistent with the post as required to support organisational priorities.

Become an active member and participant in any Hospice UK quality initiatives / groups.

Network with similar post holders both regionally and nationally in order to support benchmarking for Willow Wood Hospice Services and also keep up to date with quality agenda in healthcare.

To adhere to all Willow Wood Hospice standards, policies and procedures.

To take responsibility for own personal learning and development, and to support the learning and development of others and the organisation as a whole; a commitment to completing all training required and refreshing training as appropriate.

To conduct all work in a manner reflective of the organisational values and behaviours.

Additional Notes

a) This document is a guideline to the general scope of duties involved and will be reviewed at regular intervals. It is not intended as a rigid inflexible specification.

b) The employer shares with the employee the dual responsibility for suggestions to alter the scope and content of this document in order to improve the working situation.

c) There is a duty to be aware and adhere to all professional governing body rules and any particular Acts or statutory requirements, which may vary from time to time.

d) Willow Wood Hospice operates a no smoking policy

e) This post requires a satisfactory enhanced disclosure from the Disclosure Barring Service (DBS).

Person Specification

Qualifications

Essential

• Degree or equivalent experience/qualification.
• Evidence of continued professional development.

Desirable

• Clinical or Risk Management Qualification.
• Professional qualifications in management, quality, project management or governance.
• Root cause analysis/serious incident training / qualification.

Personal Attributes and qualities

Essential

• A naturally collaborative team player.
• High personal integrity and commitment.
• Empathy with the aims and values of the Hospice.
• An understanding of corporate responsibilities.
• Ability to work under pressure.
• Proven track record at managing resources effectively.
• Demonstration of strong assertiveness and interpersonal skills.
• Demonstrate flexibility both within the Hospice and across organisational boundaries with credibility and integrity.

Experience

Essential

• An understanding of the General Data Protection Regulation and the importance of confidentiality.
• An understanding of the meaning of and responsibility for Safeguarding.
• Experience working in a quality/compliance role.
• Proven track record of planning and facilitating service change in response to risk management issues.
• Ability to produce high quality comprehensive reports to senior management level.
• Ability to analyse and condense highly complex information to produce concise briefings and summaries.
• Ability to interpret and apply national and local policy.
• Excellent communication, negotiating, influencing, organisation and interpersonal analytical, interpretive and conflict management skills.
• Good presentation skills and the ability to present complex and sensitive information to senior managers where there may be barriers to acceptance.
• Practical experience of quality and governance principles, systems and processes.
• Detailed knowledge of risk management, clinical and corporate governance and its impact on the organisation.
• Knowledge of computer skills for use of power point presentations, reports statistical analysis e.g. PowerPoint, excel and work programmes.

Desirable

• Management experience within a healthcare organisation.
• Knowledge and experience in clinical audit.
• Evidence of collaborative working across a wider health/social care economy.
• NHS Standards Framework.
• Vantage (Sentinel) risk management software (or equivalent e.g. Datix, Ulysses Safeguard).
• Evidence of carrying out complex investigations RCA, serious incidents, division reviews etc.
• Evidence of collaborative working across a wider health/social care economy.
• Good working knowledge of the national agenda around health reforms.
• Good understanding of the key national initiatives/Trust priorities around: -
• oPatient safety.
• oNPSA, MHRA & CQC.
• oDuty of Candour.
• oSerious incident and complaints management.

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.

Employer details

Employer name

Willow Wood Hospice

Address

Willow Wood Close

Ashton under Lyne

Lancashire

OL6 6SL

Employer's website

https://www.willowwood.info/ (Opens in a new tab)