Interim Head of Governance

Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust; Oswestry; On-site; GBP 125,000 - 150,000; Full time

Job summary

A leading orthopaedic hospital in the UK is seeking an Interim Head of Governance to oversee clinical governance and patient safety. The successful candidate will manage the Clinical Governance and Clinical Audit Team, drive quality improvement initiatives, and work closely with senior operational and clinical colleagues. Candidates should hold a master's degree and have a strong background in healthcare. The role involves collaboration with various departments to enhance patient safety and quality care across the organization.

Benefits

Outstanding professional development opportunities

Access to state-of-the-art facilities

Strong links with universities

Qualifications

• Current clinical registration with a UK professional body.
• Considerable management competency at a senior level in healthcare.
• Experience delivering objectives within a senior quality governance role.

Responsibilities

• Lead clinical governance and patient safety agenda across the Trust.
• Implement quality improvement initiatives.
• Manage and develop the Clinical Governance and Clinical Audit Team.

Skills

Excellent communication skills

Analytical and problem-solving skills

Education

Master's degree or equivalent experience

Post Graduate patient safety qualification

Job description

Overview

Interim Head of Governance ACN at Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust. The closing date is 18 February 2026.

A fixed term opportunity has arisen for a suitably experienced clinical registrant who will be accountable for delivering and managing the clinical governance service and patient safety agenda across the Trust.

You will drive accountability, improvement and innovation and provide compassionate and collaborative senior leadership, visibility and expert support to the patient safety work within the organisation.

This role supports the development of a patient safety culture and safety systems and requires sufficient seniority to engage directly with the Executive Team, Managing Directors, Clinical Chairs, Assistant Chief Nurses and other senior leaders across the organisation and external partners.

Reporting to the Chief Nurse and Patient Safety Officer acting as an expert advisor on all issues relating to integrated governance and risk.

Main duties of the job

Take the lead role to develop a proactive partnership with the senior operational clinical team and key external senior governance leads to ensure robust, effective and flexible governance arrangements are in place across the Trust that delivers a consistent, positive, patient, service user and Carer experience.

This role will have accountability for implementing the most effective approaches to improving patient safety understanding, involvement and improvement activity and ensuring that systems thinking, human factors understanding and just culture principles are embedded in all processes. This includes ensuring that the Trust has effective processes in place that link effectively to national safety systems. This role includes supporting the organisation to ensure that the patient is at the centre of all patient safety activity.

In addition, the post holder will be responsible for leading and managing the Clinical Governance and Clinical Audit Team. The post holder will also support the Deputy DIPC and IPC team to ensure effective Governance systems and processes are in place to monitor the performance of IPC across the Organisation.

About us

The Robert Jones and Agnes Hunt Orthopaedic NHS Trust (RJAH)is one of the leading orthopaedic hospitals in the country, with some of the highest levels of staff and patient satisfaction, as well as a strong reputation for research and innovation.

In the National Staff Survey, 74% of our staff would recommend the Trust as a place to work and 92% would recommend the hospital to a friend or relative for treatment.

Joining RJAH is more than just a job - we want our people to have the best opportunities to thrive in their role.We have a range of fantastic staff benefits on offer to everyone who joins RJAH and you\'ll have access to outstanding professional development opportunities and state-of-the-art facilities - including our recently-opened £6 million Headley Court Veterans\' Orthopaedic Centre (the first unit of its kind in the UK).RJAH has strong links with a range of universities including Staffordshire, Keele, Glyndwr, Chester and Birmingham.The hospital is located on a site outside Oswestry in Oswestry, just off the A5. The nearest train station is in Gobowen, approximately two miles from the hospital. The station is part of the Chester to Birmingham line.We are based in North Shropshire, close to the border with North and Mid Wales. It is one of the most attractive parts of the country, with a rich historic culture and excellent transport links. It offers outstanding opportunities for anyone who enjoys an outdoor lifestyle or is looking to raise a family.

Job responsibilities

Patient Safety Specialist

Working with senior operational and clinical colleagues, lead on the delivery of quality assurance across the Trust, by providing significant challenge and support within the delivery units, to help them demonstrate the delivery of high quality, safe patient care, or to develop improvement plans where gaps are identified.

To source, collate and analyse relevant, highly complex and sensitive information to the relevant Trust Committees and relevant Executives and other strategic groups and committees (where appropriate) to support and inform decision making and delivery across all aspects of the quality, safety and governance of patient care.

Accountable to the Chief Nurse and Patient Safety Officer for the implementation of the NHS England Patient Safety Strategy across the Organisation.

Support the Chief Nursing Officer in the implementation, monitoring and review of the Quality Strategy, Quality & Governance Framework and Quality plans in line with trust objectives and priorities ensuring that they reflect changing legislation and regulations.

In collaboration with the Delivery Units and corporate services, lead/support the development of a trust wide work programme for quality improvement, including quality priorities and metrics and ensure timely delivery and monitoring for effectiveness and impact on standards of patient and service user care and treatment.

Ensure quality improvement and clinical governance techniques and tools are embedded in trust decision making, planning and performance management processes.

Ensure there are appropriate Trust wide systems in place to monitor quality and safety and identify areas for improvement.

Ensure that there is a comprehensive strategy for clinical audit and effectiveness, incorporating a robust clinical audit programme, across the Trust therefore ensuring that there are also mechanisms in place to audit the adoption of NICE guidance, NICE Quality Standards and Patient Safety Alerts issued nationally.

Ensure there is a programme of effective clinical audit to support emerging clinical risks and the programme is aligned with the Trusts strategic and annual objectives.

Support the integration learning outcomes from complaints, claims, incidents, and patient feedback using reports, data and root cause analysis as appropriate to identify and recommend changes to ways of working and compliance, formulating long term strategic plans and corporate policies as necessary to achieve the agenda.

Ensure effective use of the Ward to Board reporting mechanisms in creating a climate of support and accountability rather than blame.

Provide clinical assurance and management to incidents, and provide clinical support to the Trust Risk processes

Build and maintain strong, effective working relationships with a range of external organisations and stakeholders, including the ICS and Care Quality Commission.

Support the systems for all external assessments of the Trust in relation to quality, including the Care Quality Commission, and Clinical Commissioning Groups.

Act as a subject expert in incident investigations, providing advice and guidance to other Trust staff undertaking the role of investigations lead.

Support the continual development of an open and honest safety culture; encourage staff to actively report incidents, recognise and acknowledge process and systems failures, recognise human factors and review, reflect and engage in multidisciplinary learning.

Implement robust systems and processes that will reduce clinical risk, reduce levels of harm and reduce hospital mortality

Ensure that all incidents are reported, investigated appropriately, and reviewed in accordance with regulatory requirements and that resultant actions and lessons learned are acted upon.

Develop divisional and departmental key performance indicators (KPIs) and associated dashboards, to ensure the timely delivery of duty of candour, the timely investigation of serious incidents and the continuous improvement of quality of investigations and investigation reports

Provide support to the relevant Executive Directors and Delivery Units who have a designated lead responsibility for ensuring the trust meets required standards

Monitor and review progress against the agreed action plans in support of the CQC Fundamental standards.

Provide regular patient safety reports to the appropriate assurance committees and sub committees of the Board of Directors.

Monitor and review all safety / risk policies, procedures and guidelines on a regular basis ensuring that the trust complies with statutory and local obligations

Develop appropriate education and training opportunities for Trust staff in conjunction with Executive Directors and Senior Managers

Ensure the continual integration between the components of safety including complaints, litigation, clinical incidents/adverse events, health and safety and clinical effectiveness.

Monitor compliance with the Trusts Incident Reporting Procedures including Serious Incidents

Assist in the investigation and reporting of Serious Incidents and other high risk / significant incidents

Ensure best practice with regards to adverse event reporting, monitoring, trend analysis, action plans and changes in practice

Quality

Support the Chief Nurse and Patient Safety Officer and the Chief Medical Officer in coordinating and contributing to the authorship of the Trusts annual Quality Account and contribute to the Trusts Annual Report.

Prepare for regulatory enquiries and visits, for example: CQC enquiries / inspections, NHSE/I enquiries and implementation of guidance.

Support the Chief Nurse and Patient Safety Officer and Chief Medical Officer in relation to responding to Coroners enquiries and any actions required and following receipt of any Regulation 28 Reports

The post holder will be required to liaise closely with the complaints and claims leads to facilitate triangulation of incidents with complaints and claims

You will be required to work with Unit teams to investigate complaints and meet with complainant when appropriate.

Support the effective management of all complaints, working with clinical teams to respond and resolve complaints, whilst ensuring deadlines are met and auditable trails are evident.

To review and sign off all complaint responses, ensuring a robust response with clear improvements identified, prior to being authorised by the Trusts Chief Executive Officer

Governance

To implement sustainable and effective systems of clinical governance within across the Organisation, which meet core and developmental standards, set for the organisation by the CQC and other regulatory bodies.

Accountable to the Chief Nurse and Patient Safety Officer in establishing a comprehensive approach to governance across all teams within the Organisation Ensure all Governance work and Trust wide information is cross referenced to core standards and provide ongoing evidence of compliance through both streams of work.

Assist the Chief Nurse and Patient Safety Officer to set priorities for audit across the Organisation that complements the Trusts objectives as well as National requirements.

Flag and action risks around deficiencies in resources, equipment, and staffing across the service.

Monitor compliance and improvement action plans within the service areas and ensure effective communication of evidence against all CQC outcomes.

Promote a patient safety culture ensuring that lessons are learnt from serious untoward incidents and clinical incidents thereby preventing reoccurrence. Ensure that the lessons learned are effectively shared across a defined clinical area as well as Trust wide where required.

Lead and promote the implementation of changes and improvements to practice and systems in support of the national patient safety and complaints agenda

Provide advice on evidence-based practice and research to support changes required in clinical and professional practice.

Ensure safety improvement actions and programmes integrate the research evidence base for effective clinical approaches (e.g. NICE guidance) wherever this is established

Work in partnership with systems providers to ensure continuous patient safety improvement and best practice, establishing and using relevant surveys as needed.

Enable the organisation to benefit from relevant innovations in patient safety by drawing from experience and expertise in other academic fields and industries

Maintain and continue professional development and keep up to date with national developments and best practice in specialist areas.

To ensure that the Clinical Audit Plan is aligned with Trust strategic objectives and is a key mechanism to further develop a learning organisation

Responsible for promoting a culture of enhanced patient safety including the reporting of an agreed range of key clinical indicators relevant to the defined clinical area (i.e., leading on the High Impact Interventions and CQUINS where appropriate).

To co-ordinate and oversee the management of external incident investigations.

Please refer to the job description and person specification for further information.

Person Specification

Qualifications

• Current clinical registration with UK professional body
• Educated to Master\'s degree level or equivalent experience
• Post Graduate patient safety qualification or extensive expert specialist knowledge of the patient safety agenda as it applies to the NHS

Experience & Knowledge

• Considerable management competency at a senior level in a healthcare setting, including staff management
• Proven track record of consistently achieving high standards and delivering objectives within a senior quality governance role
• Competency and ability to interpret, analyse and use highly complex, sensitive and contentious information in order to detect themes/trends and drive continuous improvement

Skills and Competencies

• Excellent communication skills with the ability to liaise influence and negotiate effectively at all levels
• Highly developed analytical and problem solving skills; capable of interpreting and evaluating complex, multi-faceted information; ability to summarise complex information; ability to make judgements and advise on the best course of action

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.

Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust

Address

The Robert Jones and Agnes Hunt Orthopaedic Hospital

The Robert Jones and Agnes Hunt Orthopaedic Hospital