Head of Quality and Governance

Job description

Job responsibilities

Job Purpose

As the Head of Quality and Governance, you will champion a culture of excellence and collaboration throughout the organisation, particularly with the Clinical Service Director. Your primary focus will be to spearhead the advancement of governance and quality initiatives within the Hospice, ensuring meticulous implementation and monitoring of systems and processes to uphold the highest standards. This pivotal role entails driving compliance with regulatory requirements, fostering continuous quality improvement, and safeguarding the welfare of our patients and their families.

Key Performance Areas

Quality

• Develop and oversee robust systems to fulfil statutory obligations across all facets of quality and governance.
• Maintain systems ensuring ongoing compliance with Care Quality Commission (CQC) standards, utilising effective monitoring and self-assessment methodologies.
• Facilitate the collection of evidence for pre- and post-CQC assessments, collaborating with departmental leaders to ensure comprehensive documentation.
• Lead, motivate, and support staff to achieve optimal quality outcomes, emphasising adherence to best practices and regulatory standards.
• Direct the organisational audit program, providing guidance to drive sustained quality enhancement and ensuring meticulous documentation and reporting of findings.

Governance and Compliance

• Act as the Safeguarding Lead, overseeing policy development, staff training, and coordination with external agencies to ensure the safety and well-being of all individuals under our care.
• Provide integral support to governance assurances, actively contributing to the organisation's risk management framework.
• Propel the quality improvement agenda by overseeing audit processes, thereby validating service quality and identifying avenues for enhancement.
• Collaborate with stakeholders to integrate risk and governance practices seamlessly into Hospice operations.
• Manage the risk assessment process, maintaining an up-to-date organisational risk register, analysing trends, and implementing mitigation strategies.
• Champion a culture of learning and accountability, ensuring critical incidents and near misses are thoroughly investigated, with lessons learned informing continuous improvement efforts.
• Cultivate a deep understanding of the governance framework among the leadership team, fostering compliance with regulatory standards and promoting a safety-centric environment.
• Uphold information governance policies and procedures to ensure adherence to regulatory requirements, providing guidance and support across the organisation.
• Actively engage in collaborative endeavours with external agencies and partners to advance shared objectives.

Professional Responsibilities

• Collaborate closely with key stakeholders to ensure compliance with regulatory requirements and the delivery of high-quality services aligned with strategic objectives.
• Serve as the Information Governance Lead, ensuring adherence to legislative and best practice standards regarding patient information management.
• Demonstrate professionalism and uphold respectful relationships with colleagues while adhering to organisational policies and procedures.
• Manage time effectively, maintain punctuality and attendance, and utilise hospice resources responsibly.
• Serve as an ambassador for the East Lancashire Hospice, embodying its vision and values in all interactions.

Personal Development

• Engage in mandatory training pertinent to the role and seize opportunities for personal growth through participation in the hospice appraisal system and relevant training initiatives.
• Contribute to the education and training of others as appropriate.

Managing Services

• Prioritise safety by promptly addressing hazards, conducting risk assessments, investigating incidents, and implementing risk mitigation measures.
• Ensure efficient resource utilisation within allocated budgets.

Managing People

• Participate in recruitment and induction processes in accordance with hospice policies.
• Contribute to staff development initiatives to enhance service delivery and monitor staff engagement with the performance review process.

Statutory Duties

• Maintain compliance with data protection regulations, health and safety protocols, and safeguarding policies.
• Uphold infection control measures and promote individual rights, diversity, and equality.

Working Hours37.5 hours per week, across 5 days flexibly to meet the needs of the hospice.

Notes This job description may evolve to reflect the evolving needs of the hospice and will be subject to annual review during the performance review process.

Equality and Diversity We are committed to fostering an inclusive working environment and encourage applications from individuals of all backgrounds.

Person Specification

Experience

• E1 Substantial experience within a quality/ governance role
• E2 Risk management
• E3 Clinical audit
• E4 Project Management
• E5 Provision of credible advice and support related to role for staff across departmental boundaries
• E6 Leading and facilitating role related change
• E7 Complex investigations for example RCA, serious incidents
• E8 Scoping, interpreting and applying national and local policy and regulatory requirements

• E9 Experience within a health care setting

Qualifications

• Q1 Professional Qualification in a related field
• Q2 First degree or equivalent experience/
• qualification
• Q3 Risk Management Qualification / equivalent
• Q4 Root cause analysis /serious incident
• investigation training
• Q5 Evidence of continued professional
• Development
• Q6 Professional qualifications(s) in governance,
• quality, project management/related field
• Q7 Masters Level qualification / experience in
• related field

• Q4 Root cause analysis /serious incident investigation training
• Q6 Professional qualifications(s) in governance, quality, project management/related field
• Q7 Masters Level qualification / experience in related field

Knowledge

• K1 Patient Safety agenda
• K2 Detailed working knowledge of national and regulatory requirements related to quality, health and safety, risk management
• K3 CQC Regulatory framework
• K4 Information Governance and GDPR

Skills

• S1 Ability to analyse and condense highly complex information in order to produce concise informative reports and effectively communicate to individuals and groups
• S2 Ability to interpret and apply national and local policy
• S3 Well developed communication, and interpersonal skills with the ability to engage, negotiate and influence for positive outcomes
• S4 Excellent organisational skills with ability to Prioritise/reprioritise to deliver work to the required standard by agreed deadlines
• S5 Attention to detail with ability to absorb a broad range of information quickly and make decisions/recommendations
• S6 Well developed computer skills and ability to work with a range of IT programmes/ packages
• S7 Car driver with access to a vehicle for work Purposes

Personal Attributes

• PA1 Demonstrates personal integrity, trust and respect for others
• PA2 Calm and professional and can remain so in challenging situations
• PA3 Punctual with a good attendance record
• PA4 Collaborative working style with ability to engage and motivate others
• PA5 Team player with ability to work alone

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

East Lancashire Hospice

Address

Park Lee Road

Blackburn

BB2 3NY

https://eastlancshospice.org.uk