Detailed job description and main responsibilities

Key results from the job holder

• Support the division in the implementation of defined national and organisational standards, demonstrating their effective application at all levels.
• Lead on the monitoring/implementation of effective processes to achieve relevant quality targets.
• To support the Divisional Head of Governance, Quality and Risk in providing expert advice and leadership on governance and assurance issues.
• Support the implementation of the risk management strategy and policy in the division, including the effective maintenance and application of the risk register.
• Support the development and maintenance of policies and procedures relevant to the services provided by the Division.
• Contribute to any external accreditation processes by ensuring the division is compliant with standards and coordinating the compilation of relevant evidence.
• To support the Divisional Head of Governance, Quality and Risk to ensure that there is local and organisational learning following all types of incidents, complaints, and claims, actively disseminating lessons learned throughout the Division.

Planning and Organisational Duties

• To investigate and analyse issues arising from all types of Governance data including Dr Foster, incidents, SUIs, audits, complaints and claims and develop actions to address issues and trends in order to ensure divisional learning and planning.
• Utilise computer software to develop/produce reports and other relevant documents within required deadlines.
• Produce reports as required by Divisional Director of Operations and Performance, Divisional Director of Nursing & AHP, Divisional Head of Governance, Quality and Risk and Divisional Medical Director.
• Monitor quality and safety standards through audit, observation and analysis of trends and contribute to the implementation of effective performance management processes.
• Support the Divisional Quality Executive Group (DQEG), ensuring the timely production of reports.
• Facilitate the editing and reviewing process for policies and procedures generated within the division ensuring the same are approved at the relevant level in the organisation.
• Support members of the divisional management team in the development and progress of divisional governance meetings.
• Support the response to the results of patient satisfaction surveys and other patient feedback, developing /implementing action plans to improve services in response to findings.
• To participate with the divisional risk assessment process and to ensure that the risk register is effectively populated, to analyse and identify trends and actions arising, and to monitor on a regular basis to ensure that risks are controlled.
• To coordinate the overall day-to-day delivery of the divisional governance agenda (including national guidance relating to Governance and Risk Management requirements), through the development and implementation of procedures, policies and processes across the Division.
• To review procedures and practice in relation to Governance plans, strategic developments and Risk Management (including risk assessments and risk register maintenance) ensuring actions are developed and implemented, escalating issues as the needs arise.
• To support clinical leads to develop and implement clinical guidance and policies in line with best practice nationally and locally.
• To provide help and support for staff in the development of guidelines / patient information and give assistance with the submission process.
• To monitor and investigate incidents and ensure that that Datix is completed correctly and in a timely manner by divisional leads and investigators.
• To investigate serious incidents when directed assimilating very confidential and sensitive information as part of the investigation and manage the outcome communications with diplomacy and professionalism.
• To provide support to staff for incident monitoring/investigation where appropriate.
• To support lead investigators for serious adverse incidents within the care group.
• To ensure that Duty of Candour is being implemented actioned consistently as required.
• To facilitate shared learning from incidents across the Division.
• To support the management of the complaints process in Division, identifying trends, ensuring learning from experience and that action plans are followed through, acting as case manager for specific cases.
• To be an active core member of key Divisional groups, including DQEG, Patient Safety and Risk group, DPARG and Health and Safety Group.
• Provide specialist advice and actively support staff within the clinical environment to achieve evidence-based care and CQC compliance for patient safety and quality agenda.
• To support the collation of required documentary evidence is collated for CQC and other inspections and assessments and ongoing monitoring for compliance required at all levels.
• To co-ordinate the evidence required for the assessments, ensuring the evidence is gathered and collated in a timely manner.
• If deficiencies are identified through the monitoring of compliance to the standards the post holder will support the development of an action plan to address these deficiencies that actions are implemented, and improvements occur to ensure the required standard is achieved.
• Follow up on external inspections, develop action plans and verify the completion of corrective actions as required.
• To support the management of the Divisional Risk Register, supporting individuals and teams in ensuring that risks are identified at all levels and action plans developed for the minimisation and management of those risks.

 Communications and Key Working Relationships

Key Relationships:

Divisional Director of Operations and Performance / Divisional Medical Director / Divisional Head of Nursing & AHP / Divisional Head of Governance, Quality and Risk / Heads of Adult Services / Heads of Children’s services / Operations and Performance Managers / Clinical Leads / Service Managers / Team Managers / Corporate and other Divisions’ Governance Teams / Admin Support Team.

• Support the development and maintenance of effective communication systems within the Division and between the Division and other areas of the Trust specifically ensuring that learning from experience is shared.
• Leading by personal example, to establish a high profile for Governance within the Division, working with others to ensure good practice, communicate lessons learned and celebrate success.

 Responsibility for Finance

• Ensure the effective and efficient use of Trust resources.
• Generate ideas for cost improvement schemes and bring to the attention of the Divisional ‘Savi’ lead and / Director of Operations.
• Support the CIP process by conducting Risk Assessments linked to specific schemes when required.

 Responsibility for Human Resources

• Line management of the Governance administrator in accordance with Human Resource policies.
• Undertake performance development review (PDR) and support staff in meeting objectives identified in personal development plans.
• Provide mentorship, coaching, supervision and shadowing opportunities to individuals in order to support their development.
• Participate in the recruitment and selection process as required.
• Participate in own PDR, identifying appropriate development opportunities and evaluating same.
• Act as investigator in disciplinary actions, assimilating very confidential and sensitive information and managing the outcome communications with diplomacy and professionalism.

Responsibility for Health & Safety

Compliance with the Health & Safety at Work Act 1974 – the post holder is required to fulfil a proactive role towards the management of risk in all of their actions. This entails the risk assessment of all situations, the taking of appropriate actions and reporting of all incidents, near misses and hazards, and a statutory duty of care for their own personal safety and that of others who may be affected by their acts or omissions. 

• o lead on Health and Safety issues within the Division
• To ensure that health & safety standards are maintained and be involved in improvement programmes as required by external accrediting bodies and in line with legislation.
• To be a core member of the Division’s Health and Safety Group.
• Complete regular Health & Safety inspections in accordance with the Divisional programme.
• To represent the Division at corporate committees.
• To lead on supporting Service Led managers to support COSHH compliance within the Division.

Responsibility for Teaching

• To maintain own competence and up to date knowledge of Governance developments and drivers.
• Support the development and organisation of governance awareness activities throughout the division in accordance with best practice standards / evidence-based care, considering national policy / standards / guidance.
• Participate as required; in the provision of Trust led Clinical Governance related education and training initiatives.
• Advise staff within the division on quality and safety as required.
• To develop Governance and Risk Management information materials and participate in education and training programmes.

Work Circumstances & on-call

• Working hours are 37.5 /week Monday to Friday.
• There is no on-call requirement.