Clinical governance Quality and Assurance Facilitator

NHS; Rotherham; On-site; GBP 34,000; Part time

Job summary

The NHS is looking for a dedicated Clinical Governance Officer at Rotherham Hospice. This essential role involves ensuring compliance with regulatory standards, supporting clinical governance initiatives, and developing training programs. The successful candidate will exhibit strong interpersonal skills, empathy, and commitment to providing high-quality care, thereby improving health outcomes for patients.

Qualifications

• Experience in health and social care management.
• Understanding of clinical governance and quality improvement.
• Evidence of ongoing professional development.

Responsibilities

• Supports clinical governance and regulatory compliance.
• Develops and delivers governance training sessions.
• Administers governance systems to assure quality standards.

Skills

Empathy

Integrity

Communication

Teamwork

Education

Degree level education or equivalent experience

Tools

Microsoft 365 Suite

Job description

Job summary

This role is an essential part of the application of the Hospices clinical governance framework, quality improvement and regulatory assurance in line with agreed processes. Supporting the Director of Quality & Assurance and the Director of Clinical Services in administering and monitoring regulatory compliance and clinical governance.

The post holder will, as directed by the Caldicott Guardian, facilitate and administer the Hospice response, for the management of patient information in line with Caldicott regulations/requests, support compliance with data protection regulations and act as the SystmOne privacy officer.

They will take work across Hospice services in actively promoting clinical governance, the provision of advice and support and will participate in the development/delivery of governance, quality and assurance training packages as required to all service areas.

They will lead on quality/continuous improvement initiatives where delegated, support the delivery of the clinical audit/effectiveness programme embedding clinical governance/effectiveness across all areas, and ensure the hospice meets its regulatory, ethical, and operational standards.

Closing Date 13th July 2025

Interviews 29th July 2025

Main duties of the job

• Supports the delivery of clinical governance/regulatory monitoring and compliance. Participates in the preparation, co-ordination and delivery of mock CQC inspections within the Hospice.
• Liaise and communicate with all staff to provide governance/assurance advice and support in line with the Hospice frameworks, policies and procedures.
• Provides expert administrative support to clinical forums, working closely with the forum Chairs.
• Attends and actively participates in clinical governance, quality and assurance meetings, providing relevant updates and information. This includes supporting the Clinical Services Directors to prepare required reports and documents for the Clinical Quality Sub-committee. Attends and participates in the sub-committee meetings as required, provides administrative support in the absence of the Hospice PA.
• Develops and delivers education and training sessions related to clinical governance, quality/continuous improvement and assurance supporting staff understanding and compliance with required standards and delivery.
• Operationally administers and monitors governance systems for the evaluation and assurance of quality standards, safety, outcomes and the management of risk. This includes the tracking of progression of incident reports, delivery of associated action plans, regular review of risks by risk holders co-ordination of the Hospice response to MHRA/other alerts received.

About us

Rotherham Hospice is a charity dedicated to the people of Rotherham, offering specialist palliative and end of life care to our community since 1996.

We provide comprehensive, compassionate care through two primary patient services:

• 24-hour, 14-bed Inpatient Service
• 24-hour Hospice at Home Service

Additionally, we offer wider support to patients and their families through:

• Complementary therapies & hairdressing
• Counselling and Bereavement Support for adults, children and teenagers
• Day services with individual and group sessions
• Family memory events
• Occupation therapy and physiotherapy
• Social work
• Spiritual care
• Tailored experiences for patients and loved ones

Details Date posted

24 June 2025

Pay scheme

Other

Salary

£33,223.68 a year 33,223.68 FTE

Contract

Permanent

Working pattern

Part-time

Reference number

B0109-25-0000

Job locations

Broom Road

Rotherham

South Yorkshire

S60 2SW

Job description Job responsibilities

• Supports the delivery of clinical governance/regulatory monitoring and compliance. Participates in the preparation, co-ordination and delivery of mock CQC inspections within the Hospice.
• Liaise and communicate with all staff to provide governance/assurance advice and support in line with the Hospice frameworks, policies and procedures.
• Provides expert administrative support to clinical forums, working closely with the forum Chairs.
• Attends and actively participates in clinical governance, quality and assurance meetings, providing relevant updates and information. This includes supporting the Clinical Services Directors to prepare required reports and documents for the Clinical Quality Sub-committee.
• Attends and participates in the sub-committee meetings as required, provides administrative support in the absence of the Hospice PA.
• Develops and delivers education and training sessions related to clinical governance, quality/continuous improvement and assurance supporting staff understanding and compliance with required standards and delivery.
• Operationally administers and monitors governance systems for the evaluation and assurance of quality standards, safety, outcomes and the management of risk. This includes the tracking of progression of incident reports, delivery of associated action plans, regular review of risks by risk holders co-ordination of the Hospice response to MHRA/other alerts received.
• Operationally manages the Hospice complaint/concern tracking system ensuring that responses to complaints are completed within the required timescales.
• Operationally supports Hospice staff to complete incident reporting recording of complaints and to undertake risk assessments ensuring high quality data content.
• Supports investigating officers to complete PSIRF investigations. Undertakes complaint/incident investigation as delegated within role scope.
• Co-ordinates the completion and sending of templates to escalate concerns regarding other providers raised through the incident reporting system.
• Works with the Clinical Heads of Service to develop and produce a monthly governance infographic, attending clinical governance meetings as required to provide feedback on learning, themes and trends.

Has oversight and administers the repository of clinical policies monitoring that thoseidentified lead the development, review or implementation of clinical policies within required timescales and escalating breaches to the appropriate Director.

• Provides agreed regular governance reporting to individual Directors/Senior Leadership Team on a bi-monthly basis.
• Provides regular reporting on the Hospice levels of compliance on regulatory assurance.
• Escalates any potential serious incidents/governance issues to the relevant Head of Service, Director or CEO.
• Undertakes research, collates and prepares information as requested by the Director of Quality & Assurance (routine and ad-hoc requests)
• Participates in external clinical governance forums, engages with external partners in sharing learning and best practice in clinical governance.
• Participates in stakeholder engagement working closely with patients and families to gather feedback and insights to shape and improve the quality of care. Provides regular reporting of the feedback received.

Job description Job responsibilities

• Supports the delivery of clinical governance/regulatory monitoring and compliance. Participates in the preparation, co-ordination and delivery of mock CQC inspections within the Hospice.
• Liaise and communicate with all staff to provide governance/assurance advice and support in line with the Hospice frameworks, policies and procedures.
• Provides expert administrative support to clinical forums, working closely with the forum Chairs.
• Attends and actively participates in clinical governance, quality and assurance meetings, providing relevant updates and information. This includes supporting the Clinical Services Directors to prepare required reports and documents for the Clinical Quality Sub-committee.
• Attends and participates in the sub-committee meetings as required, provides administrative support in the absence of the Hospice PA.
• Develops and delivers education and training sessions related to clinical governance, quality/continuous improvement and assurance supporting staff understanding and compliance with required standards and delivery.
• Operationally administers and monitors governance systems for the evaluation and assurance of quality standards, safety, outcomes and the management of risk. This includes the tracking of progression of incident reports, delivery of associated action plans, regular review of risks by risk holders co-ordination of the Hospice response to MHRA/other alerts received.
• Operationally manages the Hospice complaint/concern tracking system ensuring that responses to complaints are completed within the required timescales.
• Operationally supports Hospice staff to complete incident reporting recording of complaints and to undertake risk assessments ensuring high quality data content.
• Supports investigating officers to complete PSIRF investigations. Undertakes complaint/incident investigation as delegated within role scope.
• Co-ordinates the completion and sending of templates to escalate concerns regarding other providers raised through the incident reporting system.
• Works with the Clinical Heads of Service to develop and produce a monthly governance infographic, attending clinical governance meetings as required to provide feedback on learning, themes and trends.

Has oversight and administers the repository of clinical policies monitoring that thoseidentified lead the development, review or implementation of clinical policies within required timescales and escalating breaches to the appropriate Director.

• Provides agreed regular governance reporting to individual Directors/Senior Leadership Team on a bi-monthly basis.
• Provides regular reporting on the Hospice levels of compliance on regulatory assurance.
• Escalates any potential serious incidents/governance issues to the relevant Head of Service, Director or CEO.
• Undertakes research, collates and prepares information as requested by the Director of Quality & Assurance (routine and ad-hoc requests)
• Participates in external clinical governance forums, engages with external partners in sharing learning and best practice in clinical governance.
• Participates in stakeholder engagement working closely with patients and families to gather feedback and insights to shape and improve the quality of care. Provides regular reporting of the feedback received.

Person Specification Personal Qualities Essential

• Empathy and a deep commitment to providing compassionate care
• Integrity and a strong sense of ethical responsibility
• A patient/family/focused approach to care and clinical governance
• Committed to supporting a learning culture

Desirable

• Strong advocacy for palliative care and end-of-life care services
• An ability to inspire and motivate others to achieve high standards of care and safety
• A full UK Driving license

Skills and Abilities Essential

• Understanding of the CQC regulatory framework
• High quality written and verbal communication
• The ability to work independently to deliver set objectives
• Delivery of operational clinical governance and delegated projects consecutively
• The ability to work independently and as part of a team
• Effectively manages time, workload and delegation
• Exceptional interpersonal skills, with the ability to build relationships with a wide range of stakeholders.

Desirable

• Strong understanding of healthcare quality frameworks and patient safety models, or willingness to complete training to develop
• Operational experience of using data analytics to inform decision-making and quality improvements
• Ability to develop and deliver presentations or reports as required

Qualifications Essential

• Educated to degree level (and/ or equivalent level/transferable experience within quality or safety environment)
• Experience of working in a Health and Social Care management role
• Understanding of clinical governance, risk management and quality/continuous improvement methodologies and their application
• Experience of regulatory standards and frameworks that are applicable to care providers
• Experience of data inputting, analysis/extraction and developing reports Proficiency in the use of the Suite of Microsoft 365packages
• Evidence of ongoing professional development
• Understanding of clinical audit/clinical effectiveness

Desirable

• Experience working in a palliative care or end-of-lifecare setting
• Understanding of the local and national approaches to palliative & end of life care
• Previous operational work-based experience of clinical governance
• Project management experience qualification or experience
• Advanced certificate in Health Service Governance or equivalent Training in root cause analysis and incident investigation
• Training in Caldicott Guardian roles/responsibilities

Person Specification Personal Qualities Essential

• Empathy and a deep commitment to providing compassionate care
• Integrity and a strong sense of ethical responsibility
• A patient/family/focused approach to care and clinical governance
• Committed to supporting a learning culture

Desirable

• Strong advocacy for palliative care and end-of-life care services
• An ability to inspire and motivate others to achieve high standards of care and safety
• A full UK Driving license

Skills and Abilities Essential

• Understanding of the CQC regulatory framework
• High quality written and verbal communication
• The ability to work independently to deliver set objectives
• Delivery of operational clinical governance and delegated projects consecutively
• The ability to work independently and as part of a team
• Effectively manages time, workload and delegation
• Exceptional interpersonal skills, with the ability to build relationships with a wide range of stakeholders.

Desirable

• Strong understanding of healthcare quality frameworks and patient safety models, or willingness to complete training to develop
• Operational experience of using data analytics to inform decision-making and quality improvements
• Ability to develop and deliver presentations or reports as required

Qualifications Essential

• Educated to degree level (and/ or equivalent level/transferable experience within quality or safety environment)
• Experience of working in a Health and Social Care management role
• Understanding of clinical governance, risk management and quality/continuous improvement methodologies and their application
• Experience of regulatory standards and frameworks that are applicable to care providers
• Experience of data inputting, analysis/extraction and developing reports Proficiency in the use of the Suite of Microsoft 365packages
• Evidence of ongoing professional development
• Understanding of clinical audit/clinical effectiveness

Desirable

• Experience working in a palliative care or end-of-lifecare setting
• Understanding of the local and national approaches to palliative & end of life care
• Previous operational work-based experience of clinical governance
• Project management experience qualification or experience
• Advanced certificate in Health Service Governance or equivalent Training in root cause analysis and incident investigation
• Training in Caldicott Guardian roles/responsibilities

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Employer details Employer name

The Rotherham Hospice

Address

Broom Road

Rotherham

South Yorkshire

S60 2SW

Employer's website

https://www.rotherhamhospice.org.uk/ (Opens in a new tab)

Employer details Employer name

The Rotherham Hospice

Address

Broom Road

Rotherham

South Yorkshire

S60 2SW

Employer's website

https://www.rotherhamhospice.org.uk/ (Opens in a new tab)