#WeAreTeamCRH

Job description
POST: Quality Governance and Risk Management Lead – Child Health & CAMHS
BASE: Chesterfield Royal Hospital NHS Foundation Trust
SALARY RANGE: Band 7
REPORTS TO: Divisional Head of Quality Governance
ACCOUNTABLE TO: Divisional Head of Quality Governance

Supporting our vision and values

Our vision: Exceptional patient care provided by exceptional people.
Our mission: To bring our people communities and partners together – providing patient care we can all be proud of., We
all play a part in achieving this, by living up to the values we promise to our patients and each other. As members of staff
we will always be guided by our Proud to CARE values:

 COMPASSION – treating everyone with kindness – welcoming diversity and inclusion, considering individual needs; and
challenging inappropriate behaviours outside of our values
 AMBITION – Aspiring to be the best – reaching high standards, providing exceptional care and services; and achieving
measurable improvements in people’s health and wellbeing
 RESPECT – Valuing and appreciating everyone – listening, learning and acting on their experiences, being open and honest; and
recognising that working with others brings benefits
 ENCOURAGEMENT– Opportunities for all – supporting education and development, helping people to bring their improvement
ideas to life and speak-up; and getting everyone involved in our future

Leading the Chesterfield Way

The Lead for Quality Governance/Risk Management is a (senior leadership) role within our organisation. Leading
the Chesterfield Way supports the Trust’s objectives and ambitions - and sets out the behaviours and characteristics
that leaders are expected to adopt and that all staff can role model, to make the Trust an even better place to work;
and to support the best possible care for patients. It provides a framework for leadership and supports individual
progression through appraisal, career progression and personal development. As a governance lead you will use
Leading the Chesterfield Way and its principles to:

 Inspire a shared sense of purpose – encouraging your team to take pride in what they do, improve the care and
services they provide; and enable them to understand how they contribute to the success of the organisation
 Lead with care - showing colleagues compassion and care by listening - and offering empathy and understanding to
help create a supportive workplace
 Evaluate and use information - be alert to what is happening around you; and evaluate the information you hear,
receive or discover to take actions and decisions that improve both patient and staff experience
 Work with others to connect services – using the opportunity to link up with different colleagues, leaders and partners,
building relationships that can help everyone to deliver effective and efficient healthcare and services
 Engage with your team - respecting every member of staff, valuing their diversity and making sure that every member
of your team feels that their contribution is appreciated and valued
 Hold yourself and others to account - be clear about what’s expected at work, giving honest feedback and acting
quickly and fairly to support others who are struggling to meet expectations
 Develop capability – take opportunities to develop your own skills, take-up training and education that will help you in
your role and keep up-to-date with the essential training that applies to you
 Influence what happens – by acting as an ambassador for the Trust, sharing good news and good practice with your
team, contributing to debates, having a say and leading improvement – all ways of influencing what happens to our
services in the future
Job purpose
The post holder will, in collaboration with the Divisional Head of Quality Governance, Quality Governance and
Risk management lead for Maternity and Gynaecology and the Divisional Quality Governance Team, co-ordinate,
maintain and monitor the quality governance/ risk management processes for, Family care Division, in line with
the overarching Trust quality governance framework, working to create a positive organisational safety and
learning culture.

The post holder will provide education and training for staff within the Division, related to quality governance
and risk management issues, and ensure learning from clinical incidents, complaints and investigations is
cascaded to all relevant staff groups.

The post holder will cross cover with Quality governance Lead for Maternity and Gynaecology where required

The Quality Governance team

The Team

Dvisonal Head of Quality

Governance and risk managment

Quality Governance coordintaor

Quality Governance facilitator
x2

Maternity and Gynaecology Care unit

care unit Quality governance and Risk
Quality governance and Risk management
management Lead
Lead
This Post

Key Result Areas

These are the key areas that support the purpose of the job

Quality Governance/Risk Management

 Promote a positive safety culture throughout Family care Division, reflecting the NHS Constitution
key safety culture performance indicators.
 Co-ordinate the collection of data required for quality assurance across the Division and ensure databases
are maintained where required.
 Undertake ‘spot checks’ of clinical practice in the family Care Division for quality assurance.
 Ensure all clinical incidents are reported, investigated and escalated in line with the Trust Incident
Reporting Policy.
 Monitor the review of clinical incidents in Child Health and CAMHS Care Units, and in conjunction with
the Head of Quality governance and care unit leadership teams, finally approve incidents on Datix.
 Liaise with the Patient Safety Team to ensure all serious incidents are reported and escalated in line with
Trust guidance.
 Lead and co-ordinate investigations following serious incidents, near misses and accidents, including RCA
investigations where indicated, and ensure these are reviewed at the appropriate Divisional/Trust

Compassion, Ambition, Respect, Encouragement

 Meetings, and shared with commissioners, within agreed timescales.
 Facilitate a seamless process for informing patients/ families whose care is subject to an internal
investigation, and for sharing the investigation report, ensuring that the Trust’s Duty of Candour
responsibilities are achieved.
 Develop systems to provide feedback to staff who have been involved in clinical incidents and
investigations.
 Ensure that improvement plans from investigations/ assessments/ audits are ‘SMART’, and that
outstanding actions are monitored through the Care Unit QGG meetings.
 Ensure that reports are produced for the Care Units as required.
 Facilitate learning opportunities for staff where themes and trends are identified from incident/ complaint
investigations.
 Ensure there is a robust process for the review, development and archiving of policies, guidelines,
protocols and patient information for services within the Family Care Division.
 Undertake risk assessments as indicated, ensuring they are presented at the Divisional Quality
Governance Group and entered on the Divisional and Trust Risk Register.
 Ensure there is process to ensure the timely review of risks within the Care Units, and that risk registers
are updated.
 Ensure the timely review of professional, NICE, other recommendations/ guidance relevant to the clinical
services within the family care unit is undertaken by the Child Health and CAMHS Care Unit, and that a
central database is maintained capturing this information, and areas of non-compliance are entered onto
the appropriate risk register.
 Maintain a plan of all internal/ external quality/ peer review/ accreditation requirements for the services
within the Division and monitor progress with preparation/ compliance.
 Undertake specific case reviews where indicated and where sub-optimal care is identified, liaise with the
relevant line manager/ clinical director, to ensure that the member of staff involved receives the
appropriate education and training.
 Participate in the Care Accreditation Scheme, nursing care and other quality assurance audits as required/
requested.
 Ensure data are entered onto national reporting systems, such as Each Baby Counts, in a timely manner.
 Review the agenda for the care unit QQG meetings prior to circulation.
 Provide direct support to the Care Unit’s Quality Governance Group Chair and attend their meetings.
 Assist the Care Units in the investigation of complaints as requested.

Management and Leadership

 Demonstrate effective leadership at all times, acting as an advocate for patient safety and an influential
role model.
 Contribute to the induction and competency programmes for clinical staff.
 Deputise for the Divisional Head of Quality governance and Risk
 Undertake annual appraisals for a defined group of staff, in line with Trust policy.

Audit
 Provide a point of contact for matters relating to audit, representing the Division at relevant meetings and
liaising with the Audit Department and working closely with the Care Unit audit leads.
 Ensure Care Unit annual audit plans are reflective of incidents, investigations and complaints.
 Ensure a central audit plan is maintained for the Division and that there is a process for monitoring the
completion and presentation of audits within the Care Units.
 Organise ‘spot check’ audits arising from investigations of clinical care, and ensure results are cascaded to
relevant staff.

Compassion, Ambition, Respect, Encouragement

Education and Training
 In partnership with the Lead for Clinical Education/Training, develop innovative methods of
disseminating learning opportunities identified from clinical investigations and complaints.
 Participate in education programmes and in-service training days as indicated.
 Implement initiatives to increase staff awareness and engagement with safety culture principles.
 Ensure a complete and accurate database of staff education and training is maintained.
 Develop a failsafe process for ensuring staff are informed of new and updated clinical policies, guidelines
and protocols.
 Contribute to development plans for individual staff where learning needs have been identified.

Personal/ Professional Responsibilities

 Participate in the evaluation of own effectiveness through the staff appraisal process, identifying and
acting upon development needs.
 Maintain personal professional status by ensuring that the requirements laid down by the relevant
professional body for maintaining registration and re-validation are complied with.
 Maintain a professional portfolio in accordance with PREP requirements.
 Undertake mandatory training in accordance with Trust/ Divisional requirements.
 Demonstrate the Trust’s Proud to Care values at all times.

Compassion, Ambition, Respect, Encouragement

 PERSON SPECIFICATION

Post Title: Lead for Quality Governance/Risk Management – Child Health & CAMHS

Assessment Criteria Essential Desirable How Assessed

Qualifications and Training  Registered Nurse or equivalent healthcare  Study at Masters Level Application
professional.
 Evidence of Study at Level 3.
 Evidence of continued CPD.

Experience  Extensive post registration experience.  Chairing meetings Application/ Interview

 Recent clinical experience in a senior role.
 Involvement in serious incident
investigations, for example Root
Cause Analysis.
 Review/ development of clinical guidelines
and policies.
 Working knowledge of the management of
complaints process.
Skills and Knowledge  Advanced IT skills  Knowledge of Datix system Application/ Interview
 Presentation skills  Knowledge National initiatives
 Excellent communication and interpersonal
relationship skills
 Review of national guidance related to
Child Health and CAMHS.

Personal Attributes  Resilient, organised and able to prioritise to Interview

meet deadlines
 Professional role model

Demonstrates Trust Values Compassion, Ambition, Respect, Encouragement Interview/ Selection Process
Proud to CARE