Job summary Following a recent departure, Independent Health Group have an incredibly exciting opportunity for an exceptional individual to join as our Head of Quality and Governance. As a member of the senior management team, accountable for ensuring all relevant healthcare, CQC regulations, clinical governance, and all other applicable compliance and governance standards are understood and adhered to within Independent Health Group. Responsible for being the subject matter expert for the organisation on all relevant Healthcare regulations, legislation and compliance, and the successful application and adherence to these across the organisation. Working in a collaborative and matrixed way, closely with our Medical Director, CNO, CFO and CEO. This position is open to those interested in a full time as well as a part time (minimum 25 hours) position Main duties of the job You will provide support, guidance, and development of robust clinical governance frameworks, ensuring we can deliver and evidence the very best practice, safety and quality standardised care across all sites. You will champion our values and culture of excellence creating a culture where continuous improvement and learning are the norm. You will lead the organisational Risk, Patient Safety, Quality and Governance strategy and related performance activities to ensure compliance with all applicable regulations. You will provide assurance to the organisation and other stakeholders that the highest standards of quality and patient safety are maintained. You will review, develop, maintain and monitor systems of clinical governance, Patient Safety and Quality Improvement. You will work in partnership with the Matrons and Senior Clinical and operational staff, to ensure services are delivered in a safe and effective way. About us IHG were set up in 2004 by Dr Matthew Wordsworth with the aim of offering patients the choice of being treated out of hospital, closer to home. Matt wanted to create a new health care organisation in which like-minded health care professionals could deliver truly patient centred care. Our aim was to bea leading provider of community-based diagnostic and treatment services of the highest quality, where patients always come first. In the summer of 2022 we have proven this, with our Outstanding CQC rating We work in a different kind of environment to that of an acute hospital setting. Our patients see the same clinician and are offered specific appointment times. Our staff work within small teams with plenty of time for patient contact. We provide services Monday to Friday, so there is no evening working, and nor do we operate on bank holidays. We pride ourselves on being a flexible employer. If your working hours need to be juggled round for you to achieve a good work-life balance, we will try to meet your needs. We offer our staff an innovative, alternative way to delivering health care, have a very patient-centred approach with short waiting times for our patients, and you will have the opportunity to contribute to the development of a fantastic organisation, as well as the opportunity to develop your skills and knowledge in a surgical setting. Date posted 11 February 2025 Pay scheme Other Salary £65,000 to £75,000 a year Contract Permanent Working pattern Full-time, Part-time, Flexible working, Home or remote working Reference number U0043-136 Job locations 8 The Office Village Bath Business Park Peasedown St John BA2 8SG Job description Job responsibilities Quality and governance framework: Accountabilities and Deliverables: Lead and advise all areas of the organisation on the understanding and application of all relevant healthcare governance and compliance, including, but not limited to the CQC, Health and Social Care Act 2008, Clinical and general governance. Lead the Governance team to drive and ensure strict adherence to all such compliance and governance standards. Assess, mitigate, monitor, measure, and report on risks impacting the business Analyse and coordinate the management of potential risks arising from changes in legislation, regulation, or business practice. Lead the process to raise risk awareness among employees. Lead and be responsible for the Governance team. Monitor the implementation and effectiveness of associated company policies and procedures. Report to the Board through the chief nurse and Medical Director and SMT on all aspects of risk, compliance and governance. Responsibility to conduct risk assessments of new business proposals in line with healthcare requirements. Responsibility to ensure quality impact assessments are conducted for any changes within the business Manage specific risk and compliance projects. Seeking out external best practice and applying to the business where appropriate. Own the implementation of the Quality Strategy To ensure there is a framework of policies and standard operational procedures in place and they are applied consistently to ensure services are safe and effective. Maintain the organisations Risk Register, specifically ensuring clinical/operational risks are recorded and actions are taken within services to mitigate these risks. Interpret statutory legislation and guidance for the development and monitoring of Governance policies, procedures, protocols and safe systems of work and support managers in the implementation of these. Exercise expert judgement involving highly complex facts, statistical data and multifaceted situations that require the analysis, interpretation and comparison of a range of options, which support improved risk management, embed governance and improved patient services across the Service. Maintain and monitor services Work with senior operational and clinical staff to ensure standard operating procedures and other guidelines or protocols are communicated, reflect best practice and ensure we have safe systems of work. Under the leadership of the Chief Nurse and Medical Director ensure clinical practice and clinic standards are up to date by cascading updates, safety alerts and notices to staff and ensuring they are actioned (e.g. CAS, health and safety, NICE guidance etc) Provide a framework for auditing services, and ensure a programme of audits are undertaken by operational services, and actions taken in response hose audits Provide the quality visit framework, ensure the service lead undertakes safety audits, and follow up actions are completed. To manage and lead the organisations PSIRF and Electronic Risk and event management system, undertaking, monitoring and coordinating internal and external investigations and ensuring improvement actions are identified and taken including reporting of significant events. Own the complaints and concerns process, ensuing all complaints and concerns are handled in a timely and considerate manner in line with policy and process, and support the management of any legal claims. Reporting Produce high quality, monthly, quarterly, and annual reports for both internal and external requirements that highlight successes and opportunities for improvement and development, this includes leading on the creation of the annual quality account, supporting quality priorities and operational delivery and achievement of agreed quality targets. Maintain complete and timely records of actions to support governance and quality. Undertake regular thematic analyse of all key Quality Metric such as, patient safety events, patient feedback, reporting on trends and highlighting risks or issues. In partnership with the Medical Director, ensure that Independent Health Group adheres to all relevant aspects of the Medical Practitioners Assurance Framework. Management and leadership As a senior member of the Senior management team, ensure that IHG meets its business objectives and operates to the highest standards of corporate and clinical governance. Responsible for ensuring that the culture of incident reporting is embedded across the organisation. This includes management of the incident reporting system, identifying trends and providing assurance and learning from incidents to the Integrated Governance and Business committee / clinical & non-clinical teams. Hold direct line management responsibilities for the Quality and Governance Assistant and new team members as the organisation grows - To undertake all direct line management functions including Recruitment, Appraisals / Performance reviews, Sickness reviews, ensuring all mandatory, statutory and competency training is undertaken and staff who report to you comply with relevant HR policies. Job description Job responsibilities Quality and governance framework: Accountabilities and Deliverables: Lead and advise all areas of the organisation on the understanding and application of all relevant healthcare governance and compliance, including, but not limited to the CQC, Health and Social Care Act 2008, Clinical and general governance. Lead the Governance team to drive and ensure strict adherence to all such compliance and governance standards. Assess, mitigate, monitor, measure, and report on risks impacting the business Analyse and coordinate the management of potential risks arising from changes in legislation, regulation, or business practice. Lead the process to raise risk awareness among employees. Lead and be responsible for the Governance team. Monitor the implementation and effectiveness of associated company policies and procedures. Report to the Board through the chief nurse and Medical Director and SMT on all aspects of risk, compliance and governance. Responsibility to conduct risk assessments of new business proposals in line with healthcare requirements. Responsibility to ensure quality impact assessments are conducted for any changes within the business Manage specific risk and compliance projects. Seeking out external best practice and applying to the business where appropriate. Own the implementation of the Quality Strategy To ensure there is a framework of policies and standard operational procedures in place and they are applied consistently to ensure services are safe and effective. Maintain the organisations Risk Register, specifically ensuring clinical/operational risks are recorded and actions are taken within services to mitigate these risks. Interpret statutory legislation and guidance for the development and monitoring of Governance policies, procedures, protocols and safe systems of work and support managers in the implementation of these. Exercise expert judgement involving highly complex facts, statistical data and multifaceted situations that require the analysis, interpretation and comparison of a range of options, which support improved risk management, embed governance and improved patient services across the Service. Maintain and monitor services Work with senior operational and clinical staff to ensure standard operating procedures and other guidelines or protocols are communicated, reflect best practice and ensure we have safe systems of work. Under the leadership of the Chief Nurse and Medical Director ensure clinical practice and clinic standards are up to date by cascading updates, safety alerts and notices to staff and ensuring they are actioned (e.g. CAS, health and safety, NICE guidance etc) Provide a framework for auditing services, and ensure a programme of audits are undertaken by operational services, and actions taken in response hose audits Provide the quality visit framework, ensure the service lead undertakes safety audits, and follow up actions are completed. To manage and lead the organisations PSIRF and Electronic Risk and event management system, undertaking, monitoring and coordinating internal and external investigations and ensuring improvement actions are identified and taken including reporting of significant events. Own the complaints and concerns process, ensuing all complaints and concerns are handled in a timely and considerate manner in line with policy and process, and support the management of any legal claims. Reporting Produce high quality, monthly, quarterly, and annual reports for both internal and external requirements that highlight successes and opportunities for improvement and development, this includes leading on the creation of the annual quality account, supporting quality priorities and operational delivery and achievement of agreed quality targets. Maintain complete and timely records of actions to support governance and quality. Undertake regular thematic analyse of all key Quality Metric such as, patient safety events, patient feedback, reporting on trends and highlighting risks or issues. In partnership with the Medical Director, ensure that Independent Health Group adheres to all relevant aspects of the Medical Practitioners Assurance Framework. Management and leadership As a senior member of the Senior management team, ensure that IHG meets its business objectives and operates to the highest standards of corporate and clinical governance. Responsible for ensuring that the culture of incident reporting is embedded across the organisation. This includes management of the incident reporting system, identifying trends and providing assurance and learning from incidents to the Integrated Governance and Business committee / clinical & non-clinical teams. Hold direct line management responsibilities for the Quality and Governance Assistant and new team members as the organisation grows - To undertake all direct line management functions including Recruitment, Appraisals / Performance reviews, Sickness reviews, ensuring all mandatory, statutory and competency training is undertaken and staff who report to you comply with relevant HR policies. Person Specification Personal Competencies Essential Able to lead, influencing and communicating effectively with all key stakeholders Ability to make decisions effectively and prioritise workload Collaborative and willing to work with/through others. Committed to the highest standards of care and continuous improvement Experience Essential Leading a quality or governance service in the health or care sector Preparing and presenting quality data to stakeholders Planning, implementing and analysing audits Clinical governance and risk management. Lead the management of serious incidents, including their investigation and action planning. Staff management Initiating and implement changes that improve the patients experience. Desirable Operating in a dispersed, multi-site setting Working in an organisation providing surgery. Knowledge and Skills Essential Regulatory knowledge e.g CQC Experience of managing and overseeing a Risk and Incident Management System Knowledge of clinical and corporate governance, regulatory frameworks, and service improvement mechanisms Excellent understanding of the importance of delivering high quality clinical care and the factors that influence it. Able to communicate effectively with patients and colleagues in a variety of settings and with differing levels of understanding Good analytical/critical reasoning skills. Able to present written and verbal information clearly and concisely Self-motivated and able to work autonomously Willing and able to challenge Qualifications Essential Degree in relevant field, or equivalent experience Patient Safety and investigation qualification/s or equivalent experience Quality Improvement qualification or equivalent experience Desirable A registered health care professional with evidence of continuous professional development Medico-legal qualification or equivalent experience Health and Safety qualification or equivalent experience Person Specification Personal Competencies Essential Able to lead, influencing and communicating effectively with all key stakeholders Ability to make decisions effectively and prioritise workload Collaborative and willing to work with/through others. Committed to the highest standards of care and continuous improvement Experience Essential Leading a quality or governance service in the health or care sector Preparing and presenting quality data to stakeholders Planning, implementing and analysing audits Clinical governance and risk management. Lead the management of serious incidents, including their investigation and action planning. Staff management Initiating and implement changes that improve the patients experience. Desirable Operating in a dispersed, multi-site setting Working in an organisation providing surgery. Knowledge and Skills Essential Regulatory knowledge e.g CQC Experience of managing and overseeing a Risk and Incident Management System Knowledge of clinical and corporate governance, regulatory frameworks, and service improvement mechanisms Excellent understanding of the importance of delivering high quality clinical care and the factors that influence it. Able to communicate effectively with patients and colleagues in a variety of settings and with differing levels of understanding Good analytical/critical reasoning skills. Able to present written and verbal information clearly and concisely Self-motivated and able to work autonomously Willing and able to challenge Qualifications Essential Degree in relevant field, or equivalent experience Patient Safety and investigation qualification/s or equivalent experience Quality Improvement qualification or equivalent experience Desirable A registered health care professional with evidence of continuous professional development Medico-legal qualification or equivalent experience Health and Safety qualification or equivalent experience Employer details Employer name Independent Health Group Address 8 The Office Village Bath Business Park Peasedown St John BA2 8SG Employer's website https://www.ihg.org.uk/ (Opens in a new tab)