Head of Governance, Quality and Patient Safety

Safety is a senior leadership role within the Care Directorate. The post holder

provides strategic and operational leadership for governance, quality

assurance, patient safety, risk management, clinical effectiveness and

regulatory compliance across Haven House Childrens Hospice. The post holder will lead the organisations

governance and quality systems, ensuring robust processes are in place to

support the delivery of safe, effective, caring, responsive and well-led

services. They will provide assurance to the Director of Clinical Services, who

is the executive lead for quality and safety, and through the Director to the

Executive Team, Board Committees and Board of Trustees. The post holder will act as the organisational

lead for CQC readiness under the Single Assessment Framework, maintaining

continuous preparedness and oversight of evidence, compliance and improvement

activity. Deputise

for the Director of Clinical Services, as required, in relation to governance,

quality, patient safety, regulatory assurance and CYP/family experience within

agreed delegated authority. There is scope for the post holder to take on

Registered Manager responsibilities in future, subject to organisational

requirements, mutual agreement and CQC registration.

Key ResponsibilitiesGovernance and QualityOwn the organisational governance

and assurance framework, with individual service leads remaining accountable

for the delivery and reporting of safe practice, compliance and improvement

within their areas. Identify and escalate gaps in assurance to the Director of

Clinical Services.Ensure the voice and experience of

children, young people and families is embedded within quality governance and

assurance, with feedback, experience data, complaints, compliments and

co-production used to identify themes, drive improvement and evidence impact.Maintain oversight of governance

structures, terms of reference and reporting arrangements, ensuring clear lines

of accountability to Board.Develop and maintain quality,

patient safety and experience dashboards and metrics to support organisational oversight and

assurance.Produce regular governance, quality,

safety and experience reports for the Director of Clinical Services, SLT, Board

Committees and Trustees.Lead the production of the annual

Quality Account in partnership with the Director of Clinical Services.Own the organisational governance

assurance action tracker, actively drive delivery with responsible leads,

escalate slippage and provide evidence of closure and sustained improvement.Patient Safety and LearningAct as the organisational lead for

patient safety and incident managementLead implementation of the Patient

Safety Incident Response Framework (PSIRF), including the Patient Safety

Incident Response Plan, proportionate learning responses and patient safety

incident investigations.Ensure incidents are recorded

through the Learn from Patient Safety Events (LFPSE) service and that local

reporting systems are effective.Lead the Duty of Candour framework

and provide assurance regarding compliance.Maintain strategic oversight of

complaints, concerns and compliments, ensuring responses are timely and

learning is captured.Lead thematic reviews and ensure

learning from incidents, complaints, audits, safeguarding reviews, child death

reviews and family feedback is embedded into practice.Establish and maintain systems to

verify that actions arising from incidents, audits, complaints, regulatory

reviews and investigations have been implemented effectively, embedded in

practice and resulted in sustained improvement.Support the organisations

contribution to child death review processes, including Child Death Overview

Panel (CDOP) and National Child Mortality Database (NCMD) requirements. Maintain oversight of medicines

safety governance, working with the Director of Clinical Services and pharmacy

partners. Ensure learning from Freedom to

Speak Up concerns is reflected in governance reporting, working with the

Freedom to Speak Up Guardian.CQC and Regulatory AssuranceLead organisational readiness for

assessment and inspection under the CQC Single Assessment Framework Maintain oversight of compliance

with relevant legislation, CQC regulations, national standards and professional

guidance. Develop and maintain a comprehensive

evidence repository and compliance platform demonstrating quality outcomes.Coordinate organisational responses

to inspections, regulatory enquiries, statutory notifications and assurance

reviews.Deputise

for the Director of Clinical Services/Registered Manager as required, within

agreed delegated authority, and support the discharge of Registered Manager

responsibilities.Lead mock inspections and internal

assurance reviews and develop action plans to address gaps.Monitor developments in legislation,

regulation, national

policy and guidanceand advise on their implications and recommended actions. Support senior leaders and Trustees

in understanding regulatory requirements, including Well-Led expectationRisk Management, Audit and AssuranceLead the clinical risk management

framework and maintain the clinical risk register, ensuring alignment with

organisational and strategic risk registers.Ensure effective systems for risk

identification, assessment, mitigation and escalation.Lead the development and delivery of

the annual clinical audit and assurance programme.Ensure audit findings and assurance reviews result in measurable,

sustained improvements, with completed actions tested to confirm that changes

are embedded in practice and effective over time.Oversee service evaluation, quality

assurance and performance monitoring activity.Clinical Effectiveness and Quality ImprovementLead the organisational Quality

Improvement Strategy and promote the use of quality improvement methodology

across services.Maintain oversight of clinical

effectiveness programmes and the implementation of NICE and other national

guidance.Ensure service development is driven by outcome measures, audit findings and feedback

from children, young people and families.Champion innovation and improvement

initiatives that enhance care and experience for children, young people and

families.Policy and Information GovernanceLead the organisational policy

management framework, including development, consultation, review, ratification

and implementation. Maintain document control and

version management systems, ensuring policies are compliant, current and

accessible.Support information governance

arrangements, including completion of the Data Security and Protection Toolkit

(DSPT).Act as Caldicott Guardian as

designated by the organisation.SafeguardingSupport the Designated Safeguarding

Lead and team in the governance and assurance of safeguarding arrangements. Ensure safeguarding learning, audit

findings and assurance activity are integrated into the wider governance and

quality framework.Education and Workforce DevelopmentProvide strategic oversight of

clinical education, training and competency frameworks delivered by the

Education and Governance Team.Ensure education programmes respond

to learning from incidents, audits, complaints and regulatory findings.Maintain oversight of mandatory and

clinical training compliance and report on it through governance structures.Lead the development of governance

and quality improvement capability across the organisation.Leadership and ManagementProvide professional leadership and

line management to the Education and Governance Team, including supervision,

appraisal, wellbeing and professional development. Foster a culture of openness, accountability,

psychological safety, learning and continuous improvement.Support workforce development and

succession planning within the governance function.Address performance, conduct and

capability concerns in line with organisational policies.Participate in the senior on-call

rota and deputise for the Director of Clinical Services where delegated,

including governance decision-making, incident escalation, regulatory matters

and quality and patient safety assurance within agreed authority.Collaborative WorkingWork collaboratively with clinical,

operational and corporate leaders to improve governance, quality and safety. Hold leads to account for delivery

of governance and assurance actions and escalate failures of assurance to the

Director of Clinical Services. Build strong relationships with

external partners, including NHS organisations, the Integrated Care Board,

regulators and professional networks. Provide specialist governance advice

to service developments, transformation programmes and strategic projects. Represent Haven House at internal

and external meetings relating to governance, quality, patient safety and

regulatory matters.

Designated Lead Roles - PLEASE REFER TO THE JOB DESCRIPTION FOR MORE INFORMATION.

.Controlled Drugs Accountable Officer -PLEASE REFER TO THE JOB DESCRIPTION FOR MORE INFORMATION.

This job description is not a definitive or exhaustive list of

responsibilities but identifies the key responsibilities and tasks of the post

holder. The specific objectives of the post holder will be subject to review as

part of the individual performance process.Haven House is

committed to Equal Opportunities in Employment and therefore it is our aim to

ensure that no applicant or employee receives less favourable treatment on

grounds of gender, disability, religion, race, colour, sexual orientation, and

nationality, ethnic or national origins or is placed at a disadvantage by

conditions or requirements which cannot be shown to be justifiable.Haven House is

responsible under the existing equality and diversity legislation to ensure

equality issues are promoted and you are expected to work with Haven House to

fulfil these obligations, policies and codes of good practice.Employees must take reasonable care and be aware of the responsibilities

placed on them under the Health & Safety at Work Act (1974) and to ensure

that agreed safety procedures are carried out to maintain a safe environment

for employees, patients and visitors.Haven

House is committed to safeguarding and promoting the welfare of children and

young people and expects all staff to share this commitment. Employment is

subject to receipt of satisfactory references and an enhanced DBS check.

PLEASE REFER TO THE JOB DESCRIPTION FOR MORE KEY RESPONSIBILITIES.

support children and young people with life-limiting and life-threatening

conditions, alongside their families. We are looking for an experienced nurse

or allied health professional to lead our governance, quality and patient

safety work, helping us deliver the best possible care. This is a senior

leadership role within our Care Directorate, working closely with the Director

of Clinical Services and teams across the hospice. You will lead our governance

and assurance systems, support continuous CQC readiness and ensure that

learning leads to meaningful, lasting improvements in practice. The voices and

experiences of children, young people and families will be central to your

work. You will bring together feedback, incident learning, audit findings and

service outcomes to understand where we are doing well, where we need to

improve and whether our actions are making a difference.

Qualifications

Desirable: - Masters degree or equivalent experience

Skills and Abilities

Experience

Knowledge

Essential: - Strong knowledge of the CQC Single Assessment Framework

Desirable: - Knowledge of information governance, including the DSPT

Personal Qualities