Deputy Director Of Clinical Governance

Quality Strategy In conjunction with the Director of Nursing, AHP and Quality and Medical Director, oversee the implementation of the Trust Quality Strategy, ensuring that the quality priorities for improvement - Informed, Timely and Safe Care are informed via integrated reporting. Ensure that the Quality Strategy priorities are aligned to the Trust Vision, Values, planning cycle and quality accounts. To work in collaboration with the Associate Director of Quality Improvement in ensuring that the Quality Strategy and Quality Improvement plans fully align to the delivery of the Trusts overall clinical strategy. Lead the development and delivery of the Trust annual quality account report. Support the Director of Nursing, AHP and Quality and Deputy Director of Nursing in the oversight of contractual arrangements regarding including the CQUIN framework for the Trust. Support the Trusts Quality Committee (sub Board Committee) (Clinical) Governance Develop and maintain effective systems and processes for managing incidents, investigations, risk and complaints and ensure compliance with Trust policies, procedures and guidelines, by taking action or alerting the senior management team if practice appears to contravene policy or have a detrimental impact on patient care. Deputise for the Director of Nursing, AHP and Quality as required on matters of assurance, compliance and Quality Governance. Work in partnership with the Director of Nursing, AHP and Quality to provide clear management and leadership of assurances. Oversee the development of Quality Governance in line with the expectations of the Board of Directors, ensuring that the expectations of the CQC, NHS Improvement and the commissioners are met or exceeded. Ensure that governance functions are included in the annual Quality Improvement Programme and the findings acted upon. Be responsible for advising Board Directors, including the Medical Director and the Director of Nursing, AHP and Quality, managers and other Trust employees as necessary, on complex matters such as legislation, regulations, orders and codes of practice which have a direct impact on clinical and quality governance within the Trust. Provide expert advice and support on Clinical Governance in order to influence improvements in patient care through the development of improved performance and service delivery across the organisation. To ensure timely submission of reports for the Trust Board, Quality Committee, Quality Review Group and other committees as appropriate. In conjunction with the Director of Nursing, AHP and Quality, Deputy Director of Nursing and Medical Director lead the preparation for Care Quality Commission inspection including co-ordination of the PIR return, preparation of key lines of enquiry evidence and Trust level action planning in response to the inspection. Develop systems and processes to ensure that the Trust complies with CQC, NHSI and other regulatory frameworks. Responsible for ensuring that all the regulated activity for the Trust is registered appropriately with the CQC. Act as the primary contact for the CQC and respond to concerns and enquiries raised by the CQC. Oversee the implementation of the CQC action plan. Provide an educational programme on Regulation to support staff to deliver care and treatment in line with the Regulations as outlined in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Support the Divisions in developing their quality assurance frame works in relation to the investigation process for clinical incidents and patient complaints, ensuring lessons are learnt and practice changed as appropriate. Patient Safety / Risk Management Ensure that the Trust has effective process for incident reporting and managing investigations, to ensure compliance with all relevant Fundamental Standards, for example: Regulation 12 (safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Ensure that the Trust is compliant with Duty of Candour under Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Ensure that the principles outlined in the Management of Incidents, Incorporating Serious Incidents (SIs) policy are adhered to and that the policy is reviewed on a periodic basis. Ensure there are appropriate systems in place for learning from incidents and serious incidents within the Trust, as part of a co-ordinated lessons learned framework. Ensure external reporting systems are in place STEIS, NRLS. Ensure appropriate systems are in place to manage safety alerts within the Trust and that appropriate distribution, monitoring, assurance and evidence of adoption and implementation is achieved. Oversee the organisation of the Trust Executive Patient Safety Panel ensuring that SI reports are completed to a high standard, on time and robust action plans are developed and monitored. Responsible for the development of the Trust Emergency Preparedness, Resilience and Response (EPRR) Develop a robust risk management function, ensuring that the Trusts risk management system provides a dynamic, high quality proactive service that enables divisions and the corporate functions to manage and maintain effective risk registers and report on risk compliance and performance. Ensure the Trust complies with relevant statutory and mandatory risk management requirements, in line with Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Ensure a programme of risk management activities are undertaken and owned within the divisions and that robust reporting structures are in place to support this. Ensure there is a risk training programme embedded within the organisation. Chair the Risk Assurance Committee to seek assurance of adherence to good risk management of all functions within the Trust and report relevant matters or issues to the Executive Team. Patient Experience Complaints and PALS. To ensure that the Trust has policies and procedures in place for complaints management that is in line with national guidance and aligned to best practice. To ensure learning from complaints is identified, shared and monitored. To support the Trusts Complaints Review Panel. To support the patient experience team function in developing strategies to engage with patients using all methods of real time feedback and the programme of local and national patient surveys. Health and Safety To be responsible for the Health and Safety Function and Security management function. Responsible for the development and oversight and implementation of the Trusts Health & Safety Strategy. Lead for ensuring the Trust has in place policies, procedures & systems to comply with Health & Safety legislation. Establish and test assurance processes to demonstrate the Trust complies with Health & Safety legislation. MANAGERIAL RESPONSIBILITIES: To provide expert advice to Executive Directors on all clinical and quality governance issues. To line manage staff within the clinical and quality governance directorate including oversight of recruitment, work flows, performance monitoring, appraisal and HR matters. To role model the Trust Values and the expected behaviours of a Trust manager. To develop and maintain effective working relationships with internal and external stakeholders. Effectively manage the delegated service budget ensuring that budgetary control is achieved. To participate in the Director On Call rota. PERFORMANCE REVIEW: Objectives for the post will be subject to the overall agreement and regular review between the post holder and the Executive Director of Nursing & Quality.