Deputy Head of Governance

The Division of Medicine is looking for a resilient, motivated and engaging individual to support the leadership of the Divisional Governance Team in the role of Deputy Head of Governance.

The primary focus of the Deputy Head of Governance is to oversee the operational delivery of the Divisional clinical governance agenda, maintain efficient delivery of governance outputs and to ensure the smooth running of the team.

This is a permanent, full-time role working a 37.5 hour week with hours being worked Monday-Friday and with a mix of office and home-based working.

The successful candidate will work closely with the Division's Medical, Nursing and Operational management teams and in collaboration with Corporate Governance functions.

Candidates will be required to present original certificates for qualifications at interview stage.

This vacancy may close earlier than the specified closing date if a high volume of suitable applications are received.

Main duties of the job

The successful post holder will:

• Possess sound knowledge of the relevant legislative and regulatory body requirements (CQC), relevant policy and key recognised sources of evidence-based practice and guidelines. In addition, you will demonstrate knowledge and understanding of contemporary clinical risk management strategies that are effective in promoting and ensuring high-quality patient care.
• Be educated to Degree level or with equivalent experience, you will have a sound understanding of clinical governance and excellent communication, influencing and analytical skills.
• Provide comprehensive leadership in all aspects of patient safety, incidents, complaints, risk and governance issues, promoting a culture of embracing learning whilst ensuring there is robust methodology in place to monitor quality standards to demonstrate that learning is embedded.
• Support the Head of Governance in ensuring that systems and processes are implemented and monitored in order to achieve governance, assurance and quality objectives within the Division of Medicine, dealing with highly complex complaints and data of a sensitive nature.
• Act using their own experience and knowledge, achieving best practice and results, guided by Trust policies and principles.

About us

Choose Well - Choose WWL

Wrightington, Wigan and Leigh NHS Foundation Trust are the proud providers of acute hospital and community services to the people of the Wigan Borough and surrounding areas. At WWL, we value our staff believing that 'happy staff makes for happy patients'. We have a recognised track record in staff engagement and living our values 'the WWL Way'.

WWL are committed to placing the patient at the heart of everything we do, and in the provision of safe, effective care that acknowledges and ensures dignity. With this in mind, we are seeking to recruit people who share our values and beliefs.

Job description

Job responsibilities

Duties and Responsibilities

Key results from the job holder

• Actively support the division in the implementation of defined national and organisational standards, demonstrating their effective application at all levels.
• Lead on the monitoring and implementation of effective processes to achieve relevant quality targets.
• Support the Head of Governance in providing expert advice and leadership on governance and assurance issues to the division and wider Trust.
• Support the implementation of the risk management strategy and policy in the division, including the effective maintenance and application of the risk register.
• Actively contribute to the development 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 ensuring the compilation of relevant evidence.
• Support the Head of Governance to ensure that there is local and organisational learning following all types of incidents, complaints and claims, actively disseminating lessons learned throughout the Division.
• Support the management of the complaints process in the division, identifying trends, ensuring learning from experience and that action plans are followed through, acting as case manager for specific cases.
• Assist the directorate to develop, set, and implement action plans relating to their clinical governance agenda and support changes in working practices, in line with governance-related reviews, inquiries, or recommendations.
• Responsible for providing clinical governance information for the directorate management team, including incident, complaints, and claims information. Ensure that directorate plans take these into account and any action points are addressed, through the delivery of governance plans and their regular review.
• Responsible for collating statistics and information to produce succinct, coherent governance-related reports for the directorate and Trust-wide forums.
• Provide the directorate with timely and accurate reports and relevant progress updates for directorate and specialty governance action plans, audit programmes, and to assist in the management of risk.
• Ensure effective systems are in place to support evidence collation of evidence to support compliance with the CQC Fundamental Standards.

Planning and Organisational Duties

• Investigate and analyse issues arising from all types of Governance data including Dr Foster, incidents, corporate risk, 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.
• Responsible for producing management reports as required by the Divisional Director of Nursing, Head of Governance, Divisional Medical Director or Divisional Director of Operations & Performance.
• Monitor quality and safety standards through audit, observation and analysis of trends and contribute to the implementation of effective performance management processes.
• Support Divisional Governance Meetings, ensuring the timely scheduling, efficient production of reports and following up on agreed actions.
• Oversee the editing and review process for policies and procedures generated within the division ensuring the same are approved at the relevant level in the organisation.
• 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.
• Maintain the Divisional risk register and ensure that it is effectively populated, to analyse and identify trends and actions arising, and to monitor on a regular basis to ensure that risks are controlled.
• Be responsible for the co-ordination of 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.
• 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.
• Monitor and investigate incidents and ensure that Datix is completed correctly and in a timely manner by divisional leads and investigators.
• Investigate patient safety incidents when directed, assimilating very confidential and highly sensitive information as part of the investigation and manage the outcome communications with diplomacy and professionalism.
• Ensure that Duty of Candour is being implemented within the division and actioned consistently as required.
• Be an active core member of key divisional committees, including Quality, Risk, Patient Experience, Patient Safety and Health & Safety as a minimum.
• 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.
• Support the collation of required documentary evidence for CQC and other inspections and assessments and ongoing monitoring for compliance required at all levels.
• 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.
• 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.
• Support the Divisional Head of Governance to ensure systems and processes in place to promote and embed learning as a result of complaints, concerns and results of patient engagement projects.
• Ensure complaints are processed within the division in accordance with Trust policy.
• Support formulation of responses to complaints and actively participate in the Divisional Patient Experience process and meetings.
• Provide reports on trends analysis as a result of concerns and complaints received.
• Ensure that improvement plans as a result of concern or complaint are monitored and delivered with non-compliance escalated to the Divisional Leadership Team.
• Collate, accurately analyse and present data to support and maintain a positive patient experience.

Communications and Key Working Relationships

• Communicate sometimes highly complex and sensitive information to patients, relatives and staff in what can be highly charged situations particularly in relation to complaints, ensuring that difficult questions are handled effectively and with care.
• Build and maintain effective working relationships with all colleagues across the division and Trust, this also applies to patients when they are making a complaint which needs to be handled sensitively and with empathy.
• Work with the trust Research & Development lead to advise and support colleagues in relation to the Trust Research Approvals Process and Research Governance Framework.
• Follow up on external inspections, develop action plans and verify the completion of corrective actions as required.
• Support members of the divisional management team in the development and progress of specialty governance meetings.
• Promote the Trust's strategic direction across specialty teams with the appointed governance leads.
• Support clinical leads to develop and implement clinical guidance and policies in line with best practice nationally and locally.
• Provide help and support for staff in the development of guidelines/patient information and give assistance with the submission process.
• Support the Trust Patient Engagement Lead and Divisional Head of Governance to encourage patient engagement and evaluate the patient/service user experience to improve service delivery.
• Provide support to staff for incident monitoring/investigation where appropriate and support lead investigators for serious adverse incidents within the care group.

Responsibility for Finance

• Ensure the effective and efficient use of Trust resources.
• Support the CIP process by conducting Risk Assessments linked to specific schemes when required.

Responsibility for Human Resources

• Work within the parameters of all Trust policies and procedures.
• Manage the direct reports in line with all Trust Policies and procedures, set and monitor work programme in relation to governance.
• Undertake appraisals/PDRs for members of the team.
• Actively participate in recruitment and selection process.
• Contribute their skills to enable teams to deliver safe effective services.

Responsibility for NHSLA

Adhere to and demonstrate NHSLA standards and outcomes and CQC essential standards of quality and safety.

Responsibility for Teaching

• Facilitate shared learning from incidents across the Division.
• Participate in the induction and subsequent training of new staff members or students.
• Participate in the development of governance educational programmes for use across the division.
• Ensure own credibility by maintaining own professional development and completion of mandatory training sessions.
• Act as a positive role model at all times.
• Any other duties appropriate to the grade.

Person Specification

Qualifications

Essential

• Degree level qualification/or equivalent experience.
• Demonstrable evidence of continuing professional development.
• Management/Leadership qualification.

Experience

Essential

• Experience in a leadership or management level post or equivalent.
• Working with sensitive/confidential information.
• Experience of providing training.
• Experience of managing multiple projects, deadlines and fluctuating workloads.
• Use of governance management systems/databases.

Skills

Essential

• Excellent report writing skills.
• Demonstrable negotiation skills to ensure challenging groups work together.
• Track record of successful policy, procedures and guideline development.
• Able to use Microsoft Office software.
• Teaching skills in formal and informal settings.
• Excellent organisational and planning skills.
• Excellent verbal, written and interpersonal communication skills.
• Ability to interpret highly complex and sensitive data and present to all levels of staff.
• Able to work effectively under pressure, manage constantly conflicting priorities and meet deadlines.

Knowledge

Essential

• Professional and specialist knowledge.