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1. To be competent in the trust governance processes and effectively communicate and embed those across the Place and services.

2. To monitor quality and governance processes across Place and to work closely with other Governance and Quality Supports to ensure standardisation.

3. To maintain a good knowledge of Place services and functions.

4. Support all relevant Place services and departments in ensuring compliance with core NHS standards including but not limited to Care Quality Commission (CQC) guidance, National Institute for Health and Care Excellence (NICE) and the Department of Health (DoH).

5. Co-ordinate the compilation of the regular Place governance reports and provide support in the compilation of other governance related reports including for example: Infection Control report and Safer Staffing reports and ensure timely submission.

6. To deputise as chair, where needed, at the local risk, quality and governance meetings and to act as the Place representative at trust meetings where appropriate.

7. Collate all required information and ensure timely submission of accurate data to inform the internal and external assurance frameworks.

8. Initiate the investigation of incidents and complaints in a timely manner and manage incident reporting system and appropriate escalation of incidents. To support staff in the collation and submitting of After Action Reviews and Duty of Candour responses within timescales as per trust policy.

9. To support the local subject matter experts (SMEs) in the review of raised incidents ensuring they are finally approved in the organisational incident reporting system.

10. To support the central governance team in the quality checking of finally approved incidents as per a planned quality checking programme, ensuring improvements and actions are implemented where necessary and staff are supported in learning and development related to finally approving incidents.

11. Promote and encourage an open reporting and learning culture within the trust.

12. Develop own knowledge and practice and actively assist others to continually professionally develop.

13. Demonstrate and support a working environment and culture that actively improves health, safety and security.

14. Support and enable equality, diversity and rights.

15. Prioritise and communicate key issues to the Quality Matron, Clinical Quality Director or Senior Management Team in line with needs of the trust.

16. To continually review established processes and inform process owners of potential improvements and changes as and where necessary to support the trust in delivery of objectives in the most efficient manner.
Clinical Governance

17. Assess, monitor and review performance to ensure full compliance both nationally set and locally set standards and targets.

18. Together with the Quality Matron, support the preparation for assessments from NHS regulators such as CQC and local commissioners as and where necessary

19. To work closely with the Quality Matron in leading the accurate and timely reporting and provision of information as and when requested by NHS regulators such as CQC and local commissioners.

20. Support the efficient co-ordination of the clinical governance related meetings and forums to ensure they function effectively, according to an annual plan and in line with trust assurance framework.

21. To support the implementation of changes to ensure compliance with national and local standards.

22. In collaboration with the Quality Matron, review and update relevant strategies, policies and procedures as required.

23. Support local SMEs with the update of specific policies and associated documentation (such as but not limited to, care plans, patient leaflets, intranet pages, website information etc.

24. Proactively manage the incident reporting system, ensuring all incidents are investigated in a timely manner and the lessons learnt are shared with all relevant teams and team members.

25. To deliver work supporting local and organisational quality improvement, offering advice and support to others, whilst ensuring continuous governance compliance throughout the trust.

26. Responsible for effective dissemination and central reporting of all issued alerts and collation of actions required

27. Manage and co-ordinate clinical and non-clinical risk activities ensuring compliance with relevant regulatory bodies including where needed creation of action plans and mitigation proposals to support organisational management of identified risks.

28. Ensure appropriate reporting, investigation and management of incidents is undertaken in accordance with documented processes and requirements and where necessary develop and devise procedures/processes and local policies, as necessary.

29. Co-ordinate the dissemination, integration and implementation of corporate and local policies and procedures. Support colleagues to contribute to appropriate policies where appropriate, and ensure they are reviewed within the required time frames.

30. Adopting a multi-disciplinary approach, in conjunction with colleagues, work to develop an organisational culture which encourages professionals to review practice, report untoward incidents and share lessons learnt without fear of recrimination or censure.

31. Ensure that the views of patients and customers are used to guide and inform the provision of services through patient forums, engagement with patient representative groups, dissemination of feedback form questionnaires, complaints etc.

32. Ensure that relevant and appropriate information, advice and support is available to all service users and stakeholders.

33. To support the Place in improving Friends and Family Test (FFT) scores and feedback through implementation of actions and learning as and when identified. This will include close working with the Lived Experience and Co-Production Manager and associated roles ensuring organisational learning and development is implemented where necessary and appropriate.

34. To support the local escalation of PALS enquiries where appropriate.
Health & Safety

35. Support the Place in the delivery of local health and safety objectives with an aim to reduce organisational risk.

36. Work closely with the Quality Matron to ensure that appropriate and necessary audit activity is completed in line with both the annual corporate and local plan, prioritising audits against key performance indicators.

37. Ensure that the local annual audit plan is devised and delivered, and actions and outcomes are implemented and where appropriate monitored through a robust action plan.

38. Oversee audit activity to ensure compliance within the clinical departments throughout the Place.

39. Engage with National Audit Programmes as and where necessary and ensure timely submission of data as relevant to hospital practices.

40. To inform and advise the trust and its employees about their obligations to comply with local and national standards set by organisations such as but not limited to the Care Quality Commission and Department of Health.

41. To be the first point of contact for employees regarding governance and quality matters within the Place, seeking support where required.

42. To support compliance with NHS legislation and codes of practices providing guidance and advice where necessary influencing conversations (following multi-faceted scenarios and applying the relevant advice).

43. To process complex situations and scenarios, analysing and interpreting the information from multiple sources, producing and presenting reports on a regular basis including options appraisals and making recommendations for a range of meetings both internal and external to the organisation including but limited to Risk Group and relevant commissioner led service review meetings.

44. Responsible for advising on complex governance and quality compliance, incident, patient safety or risk management matters, ensuring appropriate and timely escalation where required to subject matter experts across the trust to support with the provision of advice and guidance.

45. To communicate with patients, carers and stakeholders to support complaint resolution and investigations as well as to gather feedback to embed learning.

46. Using analytical skills and subject knowledge, to work within trust policy and national and local guidance, to support the trust to remain compliant with the relevant guidance and best practice.

47. Responsible for accessing information from a range of internal and external sources, and including risks, incidents, complaints and patient feedback, interpreting and applying best practice to make recommendations to the trust. This will include preparing and presenting reports.

48. Responsible for supporting the creation of reports and information data sets into standard organisational meeting templates to support the governance agenda and demonstrate Place compliance with set standards.

49. The effective use of SystmOne and Datix systems to support with the management of complaints, investigations and external information requests.