Head of Governance, Quality and Patient Safety in Woodford Green

You will lead the Governance and Education Team, with responsibility for patient safety, risk management, clinical audit, quality improvement, policy oversight and regulatory assurance. You will provide clear reporting to the Director of Clinical Services and, through the Director, to senior leaders and Trustees. You will also deputise for the Director of Clinical Services within agreed responsibilities and participate in the senior on-call rota. There is scope to take on Registered Manager responsibilities in future, subject to organisational requirements, mutual agreement and CQC registration.

The Head of Governance, Quality and Patient 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 Children’s Hospice. The post holder will lead the organisation's 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.

About us: At Haven House, we 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.

Key Responsibilities

• Own 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.
• Act as the organisational lead for patient safety and incident management.
• Lead 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 organisation's 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.
• Lead 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 guidance and advise on their implications and recommended actions.
• Support senior leaders and Trustees in understanding regulatory requirements, including Well-Led expectation.
• Lead 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.
• Lead 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.
• Lead 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.
• Support 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.
• Provide 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.
• Provide 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.
• Work 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.

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.