Job Description

Job title

Director of Quality Governance

Reports to

Chief Executive


Based at the Hospice buildings in Pembury, Kent, and Five Ashes, East Sussex, with potential requirement to work at other locations within West Kent and East Sussex.

Direct Reports

To be confirmed, but likely to include:

  • Head of Safeguarding (to include DoLS/LPS and MCA compliance)
  • Head of Quality Assurance

Scope and Job Purpose

  • Member of the Executive Leadership Team, required to develop and provide leadership to the organisation regarding healthcare governance, in particular in relation to healthcare (especially quality) governance and risk management. Instrumental in continually improving systems and processes to spot the early warning signs of failure and to provide verifiable evidence and assurance regarding the quality of health and care services within the hospice, in order to inform quality improvement. This will include cultivating relationships with a wide network of colleagues internal and external to Hospice in the Weald.
  • Responsible for the provision of governance, compliance, assurance, risk, and patient safety leadership, overseeing the assessment of compliance with the requirements of the CQC.
  • Responsible for the systems and processes in place to deliver strategic objectives in order to meet regulatory requirements and will lead on the delivery of improvement programmes, budgets and staff relevant to integrated governance.
  • Provide specialist and professional advice to the organisation on all matters relating to integrated governance to ensure Hospice in the Weald is meeting its legal and statutory duties laid out by the CQC.
  • As part of the executive team, create an environment which promotes and supports safety for patients, staff and visitors and contribute to the development of an open, learning, and safe culture.
  • Ensure that there are effective monitoring processes in place and integrated reporting that promotes effective escalation of risks and concerns that have the potential to affect quality or compliance standards.
  • With the executive leadership team and Board of Trustees, ensure an integrated governance strategic approach is formulated, understood by all stakeholders, and is delivered utilising all available resources efficiently and effectively.
  • The post holder is expected to provide compassionate, value-based leadership in implementing, operating and continuously improving systems and processes to facilitate and assure the Hospice’s successful compliance with CQC standards and wider regulatory obligations including best healthcare governance practice. This will include the development and implementation of assurance and audit strategies, including the Boad Assurance Framework, and updating of risk management and governance strategies and policies, in line with the organisation’s overall strategies and regulatory expectations of best practice.
  • The post holder will engender the development of processes and capability in, and a culture of, continuous improvement both within their portfolio and, working collaboratively across professional disciplines, with other departments in the wider organisation and with its partners, including patients, families, and service users as part of our co-design and co-production, in order to deliver the organisation’s strategic objectives.
  • In particular, the post holder will lead the transformation of governance and assurance processes and procedures within the organisation so that we can make decisions based on strong intelligence.
  • The post holder will provide expert advice to the Board, Executive and regulators on quality assurance and compliance matters and will participate on all matters, including in meetings with the Board, Board Committees, Executive, Associate Directors, regulators, and other stakeholders.
  • The post holder will work closely and collaboratively with those within the organisation who also have governance and assurance responsibilities.
  • As executive lead for Safeguarding (Children and Adults), lead the development and implementation of safeguarding strategies and procedures, ensuring safeguarding issues are adequately addressed through the healthcare governance framework. Provide professional advice and support to staff specialising in safeguarding.
  • Be the Director for Infection Prevention and Control to ensure there is an integrated approach to the management of infection control, practising at all times in accordance with the infection control standards specified in Hospice policies and procedures and with the current codes of practice for the prevention and control of health care associated infections. Provide leadership to the Infection Control and Prevention lead to deliver their work programme.
  • Executive lead on patient safety incident response systems and processes, ensure robust incident reporting and patient complaint management arrangements are in place and operating effectively, and processes for acting on findings and recommendations are robust. This includes education and training.
  • Executive lead for the implementation of PSIRF (patient safety incident response framework), work collaboratively with the Director of Clinical Excellence and Director of Care Services and heads of care services to ensure arrangements are robust for the Hospice. Monitor learning responses and foster a learning culture across the organisation.
  • Ensure systems are in place to record and monitor compliance with the organisation’s statutory responsibilities for Duty of Candour. Provide expert advice and ensure Duty of Candour training is in place. Monitor and regularly report on compliance, and work with the Director of Clinical Excellence and Director of Care Services to identify areas for improvement in the delivery of the Duty.
  • Executive lead for the Hospice’s assurance framework, with responsibility for ensuring a robust Board Assurance Framework is in place in order to provide the Board of Trustees accurate and comprehensive information in respect of risks to the achievement of its strategic objectives.
  • Ensure sound systems and processes are in place for the oversight and assurance of NICE guidance, safety alerts and clinical audits. This will include the provision of education and training, policies, monitoring, and reporting.
  • Ensure a robust Clinical Audit strategy and programme is in place, which responds appropriately to risks and non-compliance, as well as forming a comprehensive part of the assurance framework for the organisation.
  • Executive for the systems and processes relating to policy management, ensuring there is development and ongoing review of all policies, procedures, and guidelines, and that these are understood and that there are mechanisms in place to ensure they are followed. This will include ensuring they are in line with best practice guidance and regulations, and working with the executive team, ensure that appropriate audits and other reviews are undertaken to monitor compliance.
  • Executive lead for Freedom to Speak Up (FTSU), champion and support the Freedom to Speak Up Guardian, and be a credible role model of the behaviours that encourage speaking up. Drive the improvements in the organisation’s speaking up culture, fostering a psychologically safe environment and openness, honesty, and transparency in own and others’ approach. Lead the strategic arrangements for FTSU in the Hospice and the evaluation of speaking up arrangements.
  • Participate in the HLT on-call rota.

Key Responsibilities

Person Specification