Clinical Excellence Lead

Job Description

Purpose of the Role

The Clinical Excellence Lead is the senior on‑site clinical leader, responsible for ensuring safe, evidence‑based, person‑centred and well‑being‑focused clinical care across the home.

They provide visible clinical leadership, deliver hands‑on practice, oversee governance and risk management, and ensure exceptional clinical communication every day.

They directly line‑manage Registered Nurses, lead the clinical handover structure, drive the #Find Your Evelyn ACB programme, reduce avoidable hospital admissions, embed medication safety, uphold documentation standards in Nourish, and ensure all residents—regardless of whether they are nursing or residential—receive timely, appropriate and well‑communicated clinical oversight.

This role is a cornerstone of CHG’s clinical governance model and operates as the clinical anchor for the home.

About The Role

Key Responsibilities

• 1. Clinical Leadership & Daily Standards
• Deliver visible, proactive clinical leadership every day.
• Lead safe, high‑quality clinical practice aligned with CHG standards and external professional frameworks.
• Provide structured, accurate daily nursing handovers to ensure clarity, risk awareness and prioritisation.
• Role‑model professionalism, clinical judgement, empathy and accountability.
• 2. Direct Clinical Practice ("In the Numbers")
• Work directly alongside nurses and care partners delivering clinical and personal care.
• Complete wound care, clinical reviews, monitoring, interventions and long‑term condition management.
• Ensure clinical care is consistent, dignified and aligned with personalised goals and wellbeing outcomes.
• 3. Line Management of Registered Nurses
• Provide direct line management, supervision, capability oversight and pastoral support.
• Ensure clinical competence, safe administration practices and consistent professional standards.
• Complete “Our Suite” HR processes for all direct reports, including support, progression and accountability.
• 4. Embedding #Find Your Evelyn (ACB Programme)
• Lead the #Find Your Evelyn Anticholinergic Burden (ACB) pathway, ensuring:
• completion of ACB assessments
• identification of moderate/high ACB scores
• timely follow‑up reviews
• GP and pharmacy involvement
• evidence‑based reduction planning
• clear documentation of all decisions, rationale and outcomes in Nourish
• involvement of families where appropriate
• Ensure ACB data feeds into the Governance Workbook and drives improvement.
• Use ACB findings to actively reduce clinical risk and avoid preventable hospital admissions.
• 5. Specialist Clinical Pathway Oversight

• Provide oversight of core clinical pathways including

• diabetes
• MUST assessments and nutrition
• hydration and fluid balance
• wound care and pressure injury prevention
• continence and catheter care
• respiratory conditions and oxygen
• pain management and PRN reviews
• behaviour support and ABC monitoring
• Ensure pathways are evidence‑based, clearly documented and reviewed routinely.
• 6. Clinical Governance, Risk Management & Safety
• Lead clinical governance and ensure all risks are identified, escalated, documented and tracked.
• Ensure compliance with MCA, Do LS and Court of Protection frameworks, embedding best‑interest processes.
• Maintain accurate oversight of clinical risks within the Governance Workbook.
• Lead or support internal governance meetings as required.
• 7. Deterioration Management & Escalation
• Ensure effective use of NEWS2, RESTORE2 or equivalent tools.
• Lead sepsis escalation approaches and ensure staff recognise triggers.
• Ensure escalation plans are understood by the full MDT.
• Maintain low avoidable hospital admissions through timely intervention and monitoring.
• 8. Safeguarding & Root Cause Analysis
• Identify safeguarding concerns and elevate them without delay.
• Undertake Root Cause Analysis (RCA) for clinical incidents and embed actions.
• Support safeguarding investigations as directed by senior leadership or external agencies.
• Disseminate learning to improve practice across teams.
• 9. Behaviour, Mental Capacity & Do LS Compliance
• Oversee behaviour plans and ensure consistent monitoring of distressed presentations.
• Ensure mental capacity assessments are completed, reviewed and appropriate.
• Lead best‑interest decision making with full rationale documented.
• Ensure Do LS conditions are actioned, monitored and communicated daily.
• 10. Medication Safety, Homely Remedies & Covert Administration

• Lead impeccable medication governance including

• ordering
• stock control
• storage
• reconciliation
• controlled drugs
• destruction
• Ensure Homely Remedies documentation, authorisation and recording is complete and compliant.

• Ensure Covert Medication applications are fully completed with

• best‑interest decisions
• GP/pharmacy authorisation
• risk assessments
• care plans and supporting documentation
• Complete daily MAR chart sampling for accuracy and safe practice.
• Ensure self‑administering residents are competency assessed and monitored.
• Ensure thickening agents are stored safely yet accessible as required.
• 11. Infection Prevention & Antibiotic Stewardship
• Sustain low infection rates through strong IPC practice and oversight.
• Complete IPC audits, walk‑rounds and escalation actions.
• Track antibiotic usage and promote antimicrobial stewardship.
• Ensure infection control updates and safety notices are actioned.
• 12. Documentation & Nourish Excellence
• Ensure care plans and risk assessments are robust, personalised and clinically accurate.
• Ensure all clinical documentation is updated in real‑time and inspection‑ready.
• Audit documentation routinely and provide targeted feedback.
• 13. Reporting, KPI Monitoring & Governance
• Prepare clinical reports as requested by the Head of Clinical Excellence.

• Track and act on all clinical KPIs including

• falls
• wounds
• hydration
• nutrition
• behaviours
• infections
• medication errors
• hospital admissions
• Ensure all KPI actions and data feed into the Governance Workbook with evidence of improvement.
• 14. Digital Clinical Intelligence
• Monitor digital alerts, weight trends, hydration prompts, bowel monitoring and other clinical indicators within Nourish.
• Identify emerging patterns early and escalated proactively.
• Use digital dashboards to influence care planning and risk management.
• 15. Education, Coaching & Capability Building
• Provide clinical coaching, education sessions and reflective learning.
• Identify training needs and escalated for formal training where required.
• Build confidence and capability across the nursing and care workforce.
• 16. External Liaison (for ALL Residents)
• Engage with GPs, district nurses, mental health teams, therapists, discharge teams, tissue viability and external specialists.
• Ensure every resident benefits from timely clinical review and appropriate referrals.
• 17. End‑of‑Life Care Leadership
• Deliver exceptional, compassionate end‑of‑life care.
• Ensure anticipatory medications, comfort plans and symptom management.
• Provide emotional support to families during decline and at critical moments.
• 18. Dining Experience & Clinical Alignment
• Ensure safe, consistent IDDSI levels, swallow guidance, fluid consistency and nutritional risk management.
• Liaise with the Resident Experience Manager to ensure mealtime safety and dignity.
• 19. Emergency Preparedness & Response
• Oversee emergency equipment and emergency planning.
• Lead clinical responses during urgent incidents and embed learning.
• 20. Medicines Governance Reviews
• Lead quarterly medication governance reviews with pharmacy partners.
• Ensure findings and action plans feed into the Governance Workbook.
• 21. Admission & Discharge Clinical Safety
• Ensure new residents receive complete clinical onboarding including baseline observations, risk assessments and ACB scoring.
• Ensure safe clinical discharge processes, including medication reconciliation and transfer summaries.
• 22. Clinical Representation in Complaints & Investigations
• Provide accurate clinical information for complaints, safeguarding enquiries, coronial investigations and CQC feedback.
• Ensure all findings are documented with clarity, evidence and professionalism.
• 23. Outcome‑Focused Clinical Reviews (OCRs)
• Complete structured clinical outcome reviews for complex cases, repeated incidents or deterioration concerns.
• Ensure learning informs care planning and team practice.
• 24. Workforce Planning Input
• Provide clinical insight for workforce planning, skill mix reviews and development needs.
• Work collaboratively with the Culture & Engagement Manager to ensure clinical and cultural priorities align.
• 25. Transformation, Innovation & Best Practice
• Act as an ambassador for CHG’s clinical strategy and transformation agenda.
• Support group‑wide improvement programmes led by the Head of Clinical Excellence.
• Share best practice and clinical learning across CHG.
• #J-18808-Ljbffr